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July 9, 2010

Dr Phil’s Private Eye Column Issue 1267, July 7, 2010
Filed under: Private Eye — Tags: , — Dr. Phil @ 2:39 pm

Tory Health Policy

 ‘Health secretary Andrew Lansley has just spoken to more NHS managers than he will ever do again’. So observed the Health Service Journal after he told the NHS Confederation conference that management costs (i.e. jobs) would be ‘shaved’ by a minimum of £220 million this year. Redundancy packages and Brazillians all round.

 According to Lansley, we’ll need fewer managers because targets will be abolished, GPs will be in charge of the money and an independent NHS board will ensure fair play. If only it was that simple. Targets per se are not a bad thing. If you can prove they improve outcomes for patients and the staff are given a degree of flexibility in implementing them intelligently, they work. If you enforce them with a rod of iron, irrespective of the clinical context – as Labour did too often – then they lead to bullying and disillusionment,  and harm as many patients as they help.

 Too many targets are inevitably counter-productive, like squeezing a tube of toothpaste in ten places at once. Labour’s failing was to believe that the NHS was a linear system, easily controlled by central levers. Doctors have never have been easy to control but any central dogma that clearly isn’t helpful to patients breeds resentment. Lansley is right to focus on outcomes but to improve these, he will need some targets, whatever he chooses to call them. They just need to be relevant and evidence-based.

 As for GP commissioning, Lansley wants a ‘full system roll-out’ rather than the patchy adoption of budgets under the previous Tory administration,  where GP fund-holders negotiated much better care for their patients at the expense of patients who’s GPs weren’t interested or able to hold their own budget. This year’s model will require 500-600 ‘consortia’ who will be held accountable for £60 billion of spending money by ‘fiscal control and proprietary mechanisms’ of the yet to be established NHS board. And most of this should be up and running by 2012.

 Theoretically, it might work. The NHS is a clinical service and clinicians (not just doctors) should be in charge of it, rather than bleating about the management from the sidelines. GPs are generally good with budgets and can hire the cream of the redundant crop of NHS managers to help them spend it wisely, but they’ll also need to involve their hospital colleagues. Some GPs aren’t remotely interested in commissioning, so will need to be herded into consortia with some ‘can do’ enthusiasts, otherwise we’ll end up with the winners and losers of fund-holding.

 The Treasury is understandably twitchy about handing so much money over to one clinical specialty, and Lansley’s vision isn’t helped by  ‘no-can do’ NHS chief executive David Nicholson, who closed the Confederation conference by saying he doubted the Tory reforms would be ‘anywhere near ready for full implementation by  2012.’  Hardly the rousing call to arms Lansley was hoping for, but perhaps realistic given Nicholson’s failure to introduce GP commissioning under Labour. This was launched in 2005 with a target of ‘100% voluntary coverage’ by 2007, but there has only been sporadic interest.  Overall, Nicholson’s commissioning regime was rated ‘poor to mediocre’ by the common’s health select committee. Clearly something needs to be done and Nicholson possibly isn’t the man to do it.

 What the NHS needs more than ever was nailed in the Bristol Heart Inquiry 10 years ago: a change of culture. Lansley already has a public inquiry at Mid Staffs in his in-tray and private inquiries into the sacking of Cornish chief executive John Watkinson and Bristol’s dysfunctional pathology service. And there are strong calls for inquiries in East Midlands from allegations by Professor David Hands and Gary Walker, a former boss of United Lincolnshire Hospitals NHS trust. What appears to link all these allegations is a defensive, power-obsessed management culture that bullies whistleblowers into submission. Health care is complex and mistakes inevitably happen. But if we keep hiding them, we keep making them. Perhaps Lansley is right. Time to transfer the power to GPs. We may not have all the answers, but at least we won’t beat them out of you.