The health secretary, Andrew Lansley has sent (February 16) an email to the “leaders of all prospective clinical commission groups (CCGs)” reassuring them they’ll be fully in charge of commissioning health services in England once the primary care trusts are abolished in March 2013. This follows criticism from GPs that too many regulators are being put in place to oversee their new commissioning duties and that their freedom to commission will be much reduced.
As Marlborough News Online has reported, some local GPs have voiced this criticism and following our reports a copy of Mr Lansley’s email has been forwarded to us. It seems to reflect the government’s anxiety that they may be losing the argument over their NHS reforms.
The email opens: “I am writing to you to set out the important freedoms you can expect when the Health and Social Care Bill is passed into law and when CCGs take on their full statutory responsibilities. You will no doubt be aware of some of the interest the Bill’s return to the House of Lords is attracting in the media. This is not unusual for high-profile legislation, and I would like to reassure you that the Government remains fully committed to the successful passage of the Health and Social Care Bill.”
Mr Lansley then gives his reassurance to CCG leaders on three main counts:
“1. You will have the freedom, with your new powers and responsibilities, to commission services in ways that meet the best interests of your patients.” He tells the GPs: “It is a fundamental principle of the Bill that you as commissioner, not the Secretary of State and not regulators, should decide when and how competition should be used to serve your patients’ interests.”
This is a remarkable u-turn as from the general election onwards Mr Lansley and the Cooperation and Competition Panel have been telling commissioners when and how to put services in the hands of various kinds of private provider – what this government used to call ‘Any Willing Provider’ and then changed to the softer ‘Any Qualified Provider’.
“2. You will have the freedom to work with whoever you want to in commissioning health services.” This section of Mr Lansley’s email is all about the fears that the CCGs’ support services – such as payroll, record keeping and analysis, HR and financial control, all work previously done within the PCTs – will in future be carried out by large privatised companies which will to all intents and purposes take over the commissioning work.
This refers to the widely voiced criticism that the CCGs, sometimes clubbing together to pay for support services, will merely be reinventing PCTs, just on a slightly smaller scale.
Mr Lansley puts the onus firmly onto the GPs: “Whatever commissioning support arrangements you choose, you will always retain responsibility as a CCG for the commissioning decisions you make – the Bill does not allow these decisions to be made by other bodies.” This, of course, provides cover for other parties to put forward commissioning plans – so long as they are signed off by CCGs.
“3. You will be free from top-down interference.” Mr Lansley tells the GPs leading the CCGs that they “…will have the legal responsibility for the NHS budget entrusted to you from April 2013 onwards, and the legal power to use it in the interests of your patients.”
In fact the CCG leaders will not have responsibility for the NHS budget for England – as a quarter of it or about £20 billion will be kept back and used by the NHS Commissioning Board for, amongst other things, directly commissioning primary care and specialised services – and to create a system to ‘oversee ’ the CCGs.
Mr Lansley also tackles the criticism he’s heard from some CCGs that the clinical senates (which he writes without capital letters) being set up in response to last summer’s re-think on the Bill, will not be able to ‘second-guess the decisions you take.’ He reassures the GPs that these ‘senates’ will only “advise both CCGs and the NHS Commissioning Board on clinical issues at a broad strategic level.”
There are two elements of the coalition government’s policies for the NHS in England that are not mentioned in Mr Lansley’s email.
First, there is no mention of the local authority-based Health and Wellbeing Boards (H&WBs). These are supposed to be responsible for assessing the health needs of their whole area – rather than just the needs of the area covered by each CCG.
The policy in the coalition agreement was to elect people onto the PCTs to give, as the Lib Dems wanted, democratic legitimacy or accountability. When Lansley suddenly decided to abolish PCTs, the Lib Dems needed to find some other way of getting their democratic legitimacy. They chose the H&WBs. But as the Bill’s is written only one elected councillor has to serve on each of these Boards (this may be increased by amendment in the House of Lords.)
However, this appeased the Lib Dems’ demands for democratic input. The precise role of the H&WBs and their place in the new hierarchy of quangos is still not clear. It is well known that some councillors thought the H&WBs would allow them to commission NHS services.
Mr Lansley’s words of support for the CCGs make it quite clear the Boards will do no commissioning. And their omission from Mr Lansley’s email makes it unlikely they will ever be a threat to the ‘freedoms’ promised to GPs and their CCGs.
The other startling omission is that there is no mention at all of Mr Lansley’s mantra for patient power which featured so clearly in the White Paper that preceded the Bill: “No decision about me without me.” In the world of GP power that Mr Lansley portrays in his email, the role of the patient has disappeared.
This is almost certainly because some GPs in the CCGs had begun to see a nasty conflict of interests between what patients would want and what the GPs would want to commission.
In case GPs leading CCGs really were beginning to feel unloved, Mr Lansley has soothing words for them: “Your desire to improve services stands as testament to your dedication as public servants. In return, the Government will hold true our word to give you the powers and freedoms you need to deliver better services for patients.”
As one doctor expressed it to Marlborough News Online, some doctors feel they are being set up to take the blame when the money runs out for the NHS. Will they then be seen as ‘dedicated public servants’? Others believe there will be conflicts of interest with some GPs taking advantage of the reforms to bring more work into their surgeries, so earning themselves more money. Will they then be seen as ‘dedicated public servants’?
On Wednesday (February 8) the coalition government’s Health and Social Care Bill reappears in the House of Lords for its report stage. The government have tabled 136 amendments described as ‘concessions’ – but calls to stop the Bill are growing.
However, stopping the Bill is problematic. Prior to parliamentary approval, the Secretary of State for Health, Andrew Lansley has driven ahead with changes which would be hard to reverse.
In our area, NHS Wiltshire (the primary care trust or PCT) is already being split into three Clinical Commissioning Groups (CCGs) which are run mainly by GPs. The North East Wiltshire CCG (or NEW) covers the area from Ramsbury to Corsham.
In other areas these CCGs are already (before they’ve been fully approved) setting budgets and commissioning health care. Doctors in Wiltshire took a little longer to decide how to divide the county up, but members of the three CCGs are now working with the PCT and executive directors of the PCT are assisting the CCGs with governance issues.
The PCT itself has made the 45 per cent savings in admin costs that Lansley demanded and from March 1 will be ‘clustered’ with the Bath and North East Somerset (BANES) PCT. The regulations have been changed so these ‘clustered’ PCTs can merge their budgets – it’s not yet clear how far the Wiltshire-BANES ‘cluster’ will be a merger.
The merged or ‘clustered’ PCTs will only last till 31 March 2013. They are not statutory bodies, but they could be taken to judicial review over decisions they take.
Further up the chain, the south west strategic health authority has already merged to become part of NHS South of England – stretching from Dover to the Isles of Scilly.
To get a new view of the coalition government’s reorganisation of the NHS, Marlborough News Online contacted Dr Huw Williams who was a partner in a Trowbridge surgery for twenty-nine years. He retired two years ago and now works two or three days a week at the surgery mainly in its specialist cardiology unit which he helped set up.
As he is not part of a CCG Dr Williams can give his views on the Bill as an experienced yet disinterested doctor.
Dr Williams’ main fear is that there is no evidence that the new system for commissioning will work: “I’m against GPs being given a lot of commissioning – I don’t think they’re any good at it. No one’s suggested getting train drivers to run a city’s transport system. Just because GPs are near to the patient it doesn’t mean they’re expert at commissioning services. It’s a delusion.”
He looks back to the experiment of practice-based fundholding, when some doctors showed responsible corporatism while others proved very poor at controlling funds and some “rogue doctors” flourished: “Commissioning groups with a hundred GPs? No way they’re all going to agree – let alone behave in a sensible way.”
Dr Williams is worried by the “inevitable conflicts of interest” as many GPs will be providers of services at the same time as they commission services – whether it’s Dr Williams’ cardiology unit or a surgery that rents space to therapists.
One of the things he fears most is political interference: “Left to the politicians you’ll get examples of people misunderstanding the difference between needs and wants. It’ll be decision-making by decibel – he who bangs the desk loudest gets results.”
However, he does think that part of the trouble the government now faces has come from the concessions Mr Lansley has made after his Bill was first paused for alterations and then savaged by the Lords. It was “tokenism”, he says, to add one hospital doctor and one nurse onto each CCG: “What on earth is she or he going to be doing? It’s a bit of a dog’s dinner.”
However, Dr Williams says that once you’ve decided on a way to operate, “The more you dilute the less chance you have of getting people involved who can make a difference.”
Government ministers have dismissed the recent high decibel opposition from GPs – from both the doctors’ union, the BMA and from the Royal College of GPs. They do not seem to realise that many of the concessions they make to the plans simply alienate GPs.
As Marlborough News Online has been reporting (see items in August 2011 and this month), GPs do not like the way the initial promise of power to commission has been eroded with more and more bodies and duties inserted into the system to look over their shoulders and monitor them.
On the other hand, as Dr Williams puts it, “patients’ expectations have been raised” by such promises as “No decision about me without me” which was at the heart of the White Paper and is being strengthened in government amendments to be debated this week in the House of Lords.
The coalition government are pushing through Parliament reforms to the Disability Living Allowance. They want to take 500,000 people off this benefit by 2015 and cut the costs of assisting the most seriously disabled by twenty per cent.
Max Preston is a freelance journalist who lives in Lockeridge. A recent graduate of Leeds University’s broadcast journalism programme, he uses a wheelchair due to cerebral palsy and currently receives Disability Living Allowance. This is his personal view.
When the Tory-Lib Dem coalition took office in 2010, I – unlike a great many of my generation – held out some degree of hope. Under Labour, dealing with the various implementing entities for disability-related policy had been an unnecessarily bureaucratic chore made all the worse by startlingly frequent passive aggression on the part of their administrators.
It is still beyond me as to quite why I – with a diagnosis of quadriplegic cerebral palsy (CP) confining me to a wheelchair for life – needed to check in with these people on at least a semi-annual basis to reassure them that I was, indeed, still profoundly disabled and really-rather-put-out-about-it. Having said that, the Department of Work and Pensions (DWP) themselves have been – more often than not – courteous, helpful and disarmingly cognisant of how much of a pain-in-the-backside it is to have to deal with their paperwork.
After the election, I had hoped that the Lib Dems would provide a moderating influence on disability-related policy by offering a counterweight to Tory right-wingers, that efforts to cut back red tape would not be made merely for their own sake, and that David Cameron’s empathy thanks to his experiences with his own late son, Ivan (whose degree of CP was far more severe than mine), would win the day. Thus far, my optimism has not borne fruit.
Among other things, I use Disability Living Allowance (DLA) to fund a specially-adapted car which is driven for me to hospital appointments, grocery shopping excursions and – perhaps most importantly for a recent graduate – job interviews. In fact, it also pays for part of my food bills, as eating healthily (and therefore more expensively) is absolutely crucial for someone with as sedentary a lifestyle as mine.
Without DLA, I could not have gone to university and laid the foundations for what I hope will be a productive and fulfilling career in journalism.
Whilst I understand that the government wishes to substantially reduce the number of people in receipt of this type of benefit, a far more sensible course was suggested in the House of Lords by Baroness Tanni Grey-Thompson, formerly of Paralympic fame and now a steadfast crossbench advocate for the disabled.
In short, it was grossly irresponsible of peers to vote down her motion that DLA’s putative replacement – the Personal Independence Payment (or, unfortunately, PIP) – be extensively piloted before it is launched.
In its quest to make what are admittedly necessary cuts across many facets of British life, the government has lost sight of perhaps its most fundamental mandate, one to which every government is beholden: to take care of the most-vulnerable among us first. To invoke what is probably a well-worn cliché: this is not an issue of left-and-right, but of right-and-wrong.
People do abuse DLA, but this attempt to stamp out such wrongdoing appears to cut first and ask questions later, simply in order to appease the need for overall fiscal stability.
The coalition’s most fundamental mistake with regard to benefits policy precisely and dangerously mirrors that of recent Labour governments. Namely, there appears to be a presumption of guilt – that you’re trying to get one over on them – rather than innocence.
That mind-set starts from an unhelpful, even noxious place that makes staff unnecessarily hostile, gives recipients an unduly guilty conscience and renders politicians apathetic at best and cold-hearted at worst.
Admittedly, with a condition as severe as mine, one would like to believe that any reduction in my own benefits would be minimal. But having lost the support of even The Daily Mail on this issue, Messrs. Cameron and Clegg must pause to consider what they want their legacy to be.
They had an opportunity to take a commendable, non-partisan moral stand, just as they did alongside Joanna Lumley and the Ghurkhas, even as Gordon Brown refused to join them – and they have inexcusably failed to do so. Now, the DWP will have to screw up PIP before they can put it right, and hundreds of thousands of already disadvantaged people will find themselves even more marginalised and overburdened as a result.
It is worth remembering that while his premature death was undoubtedly a tragedy, Ivan Cameron was a child of privilege, and the support system that his parents rightly placed around him would have always ensured him the best-possible standard of care... because they could afford it.
The Prime Minister has, in the past, earnestly put himself forward as someone with first-hand experience of dealing with the travails of disability. As it stands, however, he has entirely abrogated the responsibility due to his own son’s memory - and he should be ashamed.