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Is the NHS in safe hands?

Published on 18/11/13 at 08:04am
Hunt image

A total of 16 months have passed since Jeremy Hunt took over as health secretary from Andrew Lansley, and in that time he has redirected the NHS to an entirely different set of priorities.

Yet another change of direction in health policy would have been undesirable, if it wasn’t for the fact that Lansley’s Health and Social Act 2012 was a botched job: a massive restructuring programme which had very little to do with the majority of health service’s most pressing issues.

Hunt is addressing some thorny, long-term problems which had been knocked down the agenda by the massive organisational restructuring in which PCTs were abolished in favour of CCGs. Lansley saw himself as a man with a vision for the NHS and imposed it on the health service, whether it needed it or not.

In contrast, Jeremy Hunt is much more the ‘manager’ type, and is trying to address a number of areas which are genuinely top priorities. Whether Hunt is actually making the right decisions on these questions is a different matter, of course, but his are much more sober policies than the idealistic campaigns of Lansley. 

Here’s a quick recap of some key areas Hunt has tackled so far:

• Patient safety: giving CQC statutory
independence

• Cost control: calling for an NHS pay freeze

• Reform of primary care: renegotiation of GP contract

• Tackling A&E crisis: £500 million funding

• IT/digital technology efficiency: ‘paperless NHS’ by 2018.

The two most urgent issues are almost certainly patient safety (in the wake of the Mid Staffs inquiry) and the control of NHS finances.

Lansley knew about both of these high priority areas - the gravity of the Mid Staffs scandal was already apparent when he took the helm in May 2011, and the health service’s QIPP target of £20 billion saving was also already in place - but rather than focussing on these existing problems, he chose to swamp the service with his massive reform programme.

Now that the general election in Britain is barely 20 months away, the Conservatives know that convincing voters the NHS is safe in their hands, is one of the key battlegrounds that would help them hold onto power. That’s why Lansley’s revolution has given way to Hunt’s more measured approach.

Mid Staffs - never again

One of the most important recent announcements concerns the future of NHS patient safety monitoring, in the wake of the Mid Staffs scandal. The question is not purely about how to prevent serious lapses in patient care - but also how to guarantee that there is no suspicion of a cover-up at the government or watchdog level if and when problems do occur. 

This is exactly what the Tories allege happened between the old CQC leadership and the DH during Labour’s term of office, accusing officials at both levels of silencing whistleblowers and deliberately downplaying warning signs.

Politically, it may prove to be a very effective strategy for the Conservatives, even if Labour - who are now threatening legal action against the claims - are able to refute the allegations.

Hunt has just announced that he and his successors will no longer have the power to intervene in the CQC’s operational decisions. For example, the watchdog will no longer need ministerial approval to launch an inquiry into an NHS trust or care home. 

The health secretary will also no longer be able to direct CQC on the content of its annual report. Professor Sir Mike Richards was appointed as chief inspector of hospitals in May, Andrea Sutcliffe was named chief inspector of adult social care in July, and Dr Steve Field became chief inspector of general practice in August.

These roles will also be made statutory positions, aimed at insulating them from political interference. As part of the CQC’s new tougher regime, 11 hospitals were put into special measures in July, an unprecedented move by an NHS regulator.

Hunt says Richards will be the ‘nation’s whistle-blower-in-chief’ and will ensure that there are answers to some simple questions: How good is my local hospital? Is it safe? Does it have enough staff? Does it put patients first?

Clearly, Hunt can’t take the credit for arriving at this solution; events and the prevailing demands for accountability have made any other course of action impossible. It can only be hoped that the new system will not be as flawed as all the other earlier safety regimes of recent years.

Integration transformation

There was absolutely no mention of the concept of ‘integrated care’ in Lansley’s original reforms, but the idea has now taken centre stage after front-line clinicians, healthcare think tanks and others demanded its inclusion.

Indeed, integrated care is now the one ‘big idea’ on which the Department of Health is hanging its hopes. They believe it to be the best hope of containing health and social care spending, which many warn will go through the roof as the population continues to age and develop a growing number of complex and costly long-term conditions.

For this reason, the government has set aside the hefty sum of £3.8 billion for its new Integration Transformation Fund (ITF). The ITF does not come into full effect until 2015/16, but CCGs and local authorities are to collaborate in the 2014/15 financial year, with an extra £200 million due to be transferred to local government from the NHS.

The government says two-year plans for 2014/15 and 2015/16, which must be in place by March 2014, are needed - meaning discussion about how the ITF will work began with immediate effect after its unveiling
in August.

GPs - heroes and villains

While Lansley foisted a whole new additional job on GPs - i.e., leading CCGs - Hunt has looked at the core function of general practice, and is looking at reforming this role. Moving from ‘good cop’ to ‘bad cop’ with regularity, Hunt has identified the current GP contract as ‘disastrous’, and a reason for many of the health service’s current problems - but he has also identified them as potential saviours.

Hunt says the GP contract, introduced in 2004, is a major reason for the rapid rise in A&E attendances seen in recent years (even if many argue that the reasons are more complex) and is now demanding GPs take ‘named doctor’ responsibility for out-of-hours care.

These clinicians will provide proactive care for older patients with complicated health needs, the idea being that this will stop chronic problems worsening, and ultimately prevent emergency admissions to A&E. This plan draws on models drawn up by the King’s Fund and Nuffield Trust, but is being opposed by the BMA.

At the same time, Hunt is trying to build bridges with GPs, hailing them as the group who must lead the modernisation of the NHS. The government wants GPs to lead the re-design of services and integration with social care, and give CCGs even more budgetary responsibility, by leading the ‘Integration Transformation’ initiative. 

NHS England versus CCGs?

Despite the growing workload of CCGs, many health service insiders say a flaw in the new structure will prove to be an obstacle: the dominance of NHS England and its power. Many feared that NHS England (formerly the ‘NHS Commissioning Board’) had grabbed too much power for itself, leaving CCGs unable to develop true autonomy and control over their local health economies.

The most notable example of this is in the commissioning of primary care, which is overseen by NHS England - as it was decided that CCGs would have a conflict of interest in determining their local services. Shailen Rao is managing director of Soar Beyond, a consultancy helping both NHS and industry. 

He says CCGs are generally coping well since they took over since April this year, but the presence of NHS England means they don’t have the influence of their predecessors. “It all adds up to a picture in which CCGs have less power than PCTs had,” Rao told Pharmafocus.

Asked if he felt some CCGs might buckle, he replied: “I don’t get a sense that CCGs are unstable, but the real question is whether they are being allowed to take charge.” The real problem is that the new system is muddied by too many organisations competing with each other for influence. “Overall we are seeing more layers of organisation, more bureaucracy, and less clarity,” Rao added.

Impact for pharma

So what do all these developments mean for pharma? Certainly, the blizzard of change has not eased, and the proliferation of organisations is making life harder for decision-makers. Rao says there is some evidence of the new NHS taking a more open attitude to medicines costs, but the main picture remains about cost containment.

Rao also says that many pharma companies are still approaching the medicines access question from the wrong perspective. “The main point to consider with pharma is that they are still trying to position the drug in terms of its chemical benefits. They ask: ‘Can you help us re-badge the drug?’ and ‘Which of these benefits is most important to the NHS’. But I tell them, these are the
wrong questions.”

And in areas where pharma companies are sure they have compelling data - such as in the novel oral anticoagulants (NoAc) market - the NHS and independent experts are less convinced.

Andrew McConaghie

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