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“2020health is an important and thoughtful contributor to the health debate”

Dr Sarah Wollaston MP, Chairman, Health Select Committee

 
 

The Health Bill with Dr Sarah Wollaston MP

Mar 23. till Mar 23.

2020health Expert Roundtable on The Health Bill with Dr Sarah Wollaston MP

2020health roundtable discussion breakfast event on the Recent Health and Social Care Bill.

Date
March 23, 20112011-03-23T08:30:00 - March 23, 2011 2011-03-23T10:00:00
Time
8:30 AM 2011-03-23T08:30:00 - 10:00 AM 2011-03-23T10:00:00
Location
Portcullis House, Westminster, London

Attendance

1.       Dr Sarah Wollaston MP

2.       Priya Madina-Senior Government Relations & Policy Manager,GlaxoSmithKline UK

3.       Fiona Calnan- CEO, UKSH

4.       Ronan Collins- Communications and Public Affairs Manager,Janssen

5.       Ray Jordan- Solutions Director, Planned Care Solutions

6.       Nick Wensley- Benefits Management Practice Lead, Steria

7.       Dr Jonathan Shapiro-Consultant Director,2020health.org

8.       Lucy Cork- Group Public Affairs Manager,Alliance Boots

9.       Simon Edwards- Head of Policy, Royal College of Surgeons

10.    Jonathan Lisle- Partner, DLA Piper

11.    Katherine Murphy-Chief Executive, The Patients Association

12.    Julia Manning-Chief Executive, 2020health.org

13.    Dr Eleanor Winpenny-Researcher, 2020health.org

Support for the aim of the Health Bill

General support for the aims of the Health Bill to get GPs more involved in commissioning.
The vision is exciting, putting patients at the heart of healthcare practice.

Criticisms of health bill

Much could easily be changed without the massive structural reorganisation.
Scale and pace of change too great.
Previous pockets of good commissioning will be lost.
It may take 5 years for GPs to find their feet and start to develop good commissioning.
Fear that Monitor may develop into something the public is less comfortable with further down the line.
Fear that the Bill is creating huge numbers of possibilities for legal challenges
The problem of long-term care is much greater than the need to reorganise the NHS and the money used for restructuring could have been better spent on improving long-term care.

Difficulties with the process

For political reasons things need to be done quickly – need to make progress during the first year of a parliament.
Department of Health officials really felt that leadership would come from within and that structures would grow organically.
NHS managers have a culture of helplessness – they have not been as forthcoming in taking responsibility for devising new structures as was expected. But then these were described as bureaucracy at the start of the process.
There is a dilemma around instruction versus freedom – there was originally a willingness to allow consortia to develop their own structures and ways of working, however there is now a danger that this will begin to retrench with much stronger structures being mandated from the top.
More could have been done to convey the vision of the changes before they were implemented.

The role of GPs

GPs should be involved in the parts of commissioning which involve planning clinical pathways.
GPs’ lack of commercial experience is a concern.
Many emotional issues may be brought to discussions around forming partnerships and working together, as for many GPs their practice is a large part of their lives.
GPs are not very good at big number accountancy and transactions so will need strong support.
GPs currently deal with people and not populations.  It will need to be the consortia which considers commissioning for the population, not the jobbing GPs. We do not want GPs to be distracted from their day job of treating individuals.
GP consortia will need good input from public health medicine and qualified contracting and accounting support.

GP engagement

GPs are now responsible for the funding if the system goes wrong
They are much more likely to take an interest when they are implicated in the results
Financial risk for the GP consortia will be helpful in maintaining GP engagement

Transparency

Transparency is necessary around GP and consortia earnings of how money is being spent.
Suggestion that GP consortia board meetings should be held in public.
Transparency will ensure that bad practice does not occur and is necessary to protect the majority of GPs who are working properly.
Currently there is nothing in the Health Bill to prevent consortia moving their business offshore and this needs to be addressed.
Legislation is needed to protect information and information flow.
In Torbay there was overlap of purchasers, providers and commissioners and this was not a problem due to complete transparency in the system.

Integration

To deliver better care for those with long term conditions and the elderly, better integration is needed between health and social care.
Pooling health and social care budgets was possible before and without the reforms but competition concerns mean that in some places, e.g. Torbay, this model is now unravelling.
Integration to the point of sharing budgets is a slow process and relationships must be built first.  As with dating, the last thing that is done is generally setting up a joint account.

Choice

The intention is to expand patient choice but the money and capacity is not available to deliver this choice.
Choice will be at the expense of equity.  There are still issues around who will ensure equity of provision.
Do we need to define more clearly where you can have choice?
The need for choice conflicts with the development of strong commissioning pathways.  Can consortia expel GPs that do not follow pathways?
Difficulty of personal budgets – it has been known for un-caring carers to siphon off large parts of a personal budget; personal budgets are not a panacea.
Difficult to have the choice agenda, before the choices are available.
Some patients, used to the old system, see the offer of choice as the doctor not doing their job properly.
There is a need to manage patient expectations.  Currently we have mixed messages and conflicting policies.  A good patient experience will depend upon the service meeting the patient’s expectations. We need clarity on what choice can realistically be offered.

Competition

There is concern that the current bill precludes continuity of care, due to competition rules. Designing a care pathway must not be seen as anticompetitive.
Choice and competition need to be based around small enough sectors of provision, so that they can be allowed to fail. We do not want a situation as with the banks where services are so critical that failure is not permitted.
There are concerns among surgeons around the competition issue – consortia are not sure if they can speak to acute clinicians and whether the clinicians are speaking in a professional or a provider capacity.
There is a lack of confidence and understanding of how competition rules will work.

Commissioning

There is an assumption that the quality of NHS data is good and can be used for commissioning purposes, whereas in fact it is often fairly poor.
Commissioners should be commissioning for future requirements not current requirements

Conflicts of interest and sanctions

Can Monitor police conflicts of interest between GP consortia as commissioners and providers?
Can the consortia impose sanctions on a practice?
A robust structure is needed for each consortium, with financial penalties and the potential to remove GPs from the consortium who are not pulling their weight.
Non-performing GPs will need to be performance managed by the consortia.
In a study of GP Fundholding, The King’s Fund found conflicts of interest in more than half of practices investigated.
Some feel that conflict of interest is completely irrelevant – what we are concerned with is provision of a good service.  If some people make additional money from providing this service this is not a big problem.

IT and communication

GP commissioners will need different IT systems from PCTs.
A government fund for innovation and IT is needed for the GP consortia.
There is no such thing as bad communication, only people who don’t want to talk to each other.
Hospital records are currently a disgrace with errors and additional unnecessary information.
Would it be better for all records to be hosted on the cloud and owned by patients?
If patients held their own records they would know if they were correct and could ask for errors to be changed.
The source of the different data would need to be clear, especially if added by the patients themselves.
Dr Brian Fisher, Lewisham has been giving patients access to their records for many years, as part of Patient Access to Electronic Records System (PAERS).

Benefits of national versus local

The movement towards more local commissioning means that providers (including hospitals who have been providing the service for years) and having to fill in increasing numbers of forms before being contracted to provide a service.  These forms are generally different between different PCTs, and will be different for different consortia.
Losing the SHA level of commissioning will cause a huge increase in costs.
The changes are introducing a new definition of the public sector, with the ‘what’ decided nationally and the ‘how’ done locally.
There is a potential conflict between local ownership of services and the benefits of scale and standardisation.
GP consortia may choose to join up and commission services jointly at a larger scale.
How much variation should there be in the system?  The application of quality standards is needed to ensure consistency across different localities.
The general pharmacy contract will remain national but additional services and enhanced services will be local, split between consortia and the local authority.
Some public health services are being cut.

Acute to home care

The move from acute care to community or home care will mean large changes for the acute sector with potential loss of income.
Some hospitals are introducing bays rather than beds.  Patients are treated quickly and then sent home again.

Specialisation

Very specialised surgery will be commissioned by the Commissioning Board.
The Royal College of Surgeons is concerned about the surgery which will be commissioned locally but will need to be organised over a larger region than can be provided by the GP consortia. Something is needed to replace SHAs that can work at this level.
In general clinicians will always want to become more specialised, but at the moment this cannot be afforded by the NHS, with the current way of working.

Leadership and accountability

The bill doesn’t make clear who is accountable for what.
Leadership should be based on reputation.
Leadership needs to be in the form of more engagement, not enforcement.
David Nicholson may lend consistency of leadership.
Long-term leadership is needed, for example in the form of a board which is outside of government.

Summary

•    There is a dilemma around instruction versus freedom – there was originally a willingness to allow consortia to develop their own structures and ways of working, however there is now a danger that this will begin to retrench with much stronger structures being mandated from the top.
•    More could have been done to convey the vision of the changes before they were implemented.
•    GP consortia will need good input from public health medicine and qualified contracting and accounting support.
•    Transparency is necessary around GP and consortia earnings of how money is being spent.
•    Pooling health and social care budgets was possible before and without the reforms, but competition concerns mean that this model is now unravelling.
•    There is a need to manage patient expectations.  We need clarity on what choice can realistically be offered.
•    There is a lack of confidence and understanding of how competition rules will work.
•    A government fund for innovation and IT is needed for the GP consortia.
•    There is a potential conflict between local ownership of services and the benefits of scale and standardisation.
•    The bill doesn’t make clear who is accountable for what.
•    Leadership needs to be in the form of more engagement, not enforcement.