This blog gives my initial thoughts about the eagerly awaited bill presented by Andrew Lansley on Wednesday 19th January.
The Government’s plans for the reform of the NHS were generally well received last summer and during the public consultation period in the autumn. In the last few weeks a feeling of unease has replaced much of the initial enthusiasm expressed when the ideas in the White Paper “Equity and Excellence; Liberating the NHS” were new and fresh. The reality is that very little has changed apart from the political mood. Where should we go from here?
My blog “Liberating the NHS revisited” (October 19, 2010) welcomed the principles behind the proposed reforms but warned of the need to avoid pitfalls and to consider improvements. More of the suggestions made in my three submissions to the Department of Health as part of the public consultation process have ended up being in line with Government policy than I had expected. In general the Bill is to be commended.
The greatest challenge has in my view always been to win the whole-hearted cooperation of doctors. We have needed to avoid taking too much time away from the frontline care of patients and to ensure that enough doctors turn out to be able, willing and keen to take on the new proposed responsibilities.
With the benefit of hindsight, the greatest mistake has probably been not consulting doctors and their professional bodies more fully prior to publishing the original White Paper. The Government’s proposals are largely based on a belief that doctors and professionals in the NHS know best. At the same time some doctors feel that the Government is not fully respecting their views. This apparent inconsistency damages morale and has implications for working in a spirit of cooperation. A bottom-up decision-making process imposed unilaterally from the top has great potential for teething problems. It is a possible recipe for disaster. The top priority of Andrew Lansley should be to make every effort to get doctors firmly back on side without compromising on the important strategies underlying the proposals.
The range of responsibilities placed on doctors running commissioning consortia is at least as great as that placed on the directors of many major public companies. Apart from the general principle that the full support of doctors is important, the key to success is thorough planning and a focus on detail. Particular attention must be paid to areas where doctors alone may not have the skills required to get the best results. The main skill of most doctors is diagnosis of medical conditions, partly through experience and partly as a result of academic training. Other skills include, for example, recommending appropriate treatments and knowing when to seek a specialist opinion. People who have trained as doctors are not necessarily strong in business, finance, mathematics, economics, property management, negotiation or even medical research or surgery. More work is needed to determine what tasks doctors are willing and able to carry out and with what assistance. The Government must be seen to be on the same side as NHS professionals. In an undertaking as large and complex as the NHS wise principles and strategies are to no avail without skilled and careful management implementation. If the changes are to be made to a tight timetable, even more attention to detail is vital because there is little time to correct any mistakes.
Many potential pitfalls ahead, for example with respect to drug pricing policies and the exact role of NICE, are not addressed by the Bill because they do not require primary legislation. The Bill is a start rather than an end to all the detailed work that lies ahead if success is to be the reward.
Two details in the Bill do concern me. One is the wording of the statutory duty to pursue equality. Any major medical advance, for example a new surgical procedure, initially increases inequality because some patients must receive it first. Some doctors will be trained before others. My second concern is over commissioning consortia with only two doctors. Few public companies have only two directors. There are issues over holidays, illness, absence and workload. In addition, individual doctors often hold minority opinions. To impose such views on patients would increase inequality and introduce a postcode lottery. A commissioning consortium needs enough doctors to present a balanced professional view.