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NHS reform: did the government get it right?

Published on 27/01/14 at 08:17am

Some nine months after the coalition government’s controversial health reforms came in, have they been a success? And how are they helping to solve the problems of a health service wrestling with restricted funding and a crisis in service quality following a series of shocking revelations and reports?

Everyone connected with healthcare in England wants to know - and we might reasonably have hoped to learn some of the answers from a recent London conference titled ‘The future of the NHS: progress on implementation and next steps’ organised by the Westminster Health Forum.

The government view

The under-secretary of state for health Lord Howe spoke first - and quickly declared that it’s too early to say whether particular aspects of health reform have been successful or not. This question will be answered when he presents the year-on-year report on the reforms required by the Health and Social Care Act (2012), Howe added.

He also revealed that the Department of Health (DH) is commissioning independent research looking at the impact of the reforms and the transition - including the impact on patient care. Nevertheless, NHS organisations and local government should be proud that the huge restructuring implemented on 1 April 2013 has been completed without major hitches.

“During this period of great flux, high levels of service and quality were maintained,” Howe argued. He went on to reassure his audience that the changes that came into effect in April last year were well-meaning and sensible, and that there were instances where they were being implemented effectively by some very good people. What is more, they were the only way of even beginning to address the looming health service funding gap.

In case delegates felt they had heard this quite a few times before and were falling asleep, Howe won a laugh by quoting an anecdote about Mao Tse-Tung who, when asked what in his opinion had been the effect of the French Revolution, replied that in his view it was ‘too soon to tell’. (At the end of the conference, his close colleague NHS England chairman Professor Malcolm Grant made the same point to the same audience, and underlined the point using the same quotation. It’s obviously been popular in the corridors of power lately.) 

Howe outlined some of the issues we most need to worry about, in particular the demographic changes coming our way. By 2030, the number of over-65s will increase by 50%, and the number of over-85s will double. Over 15 million people currently have a long-term condition, and in just five years 29% of over 60s will have two or more.

The minister said that this could only be addressed by better integration of care, and added that the health and social care integration fund shared between the NHS and local authorities would help to create a more sustainable NHS delivering services more efficiently for older people, and people with disabilities, and reduce pressure on A&E.

Howe went on to say that the government is also working on moves to deliver seven-day working across the health service and, following a consultation, it is also working on plans to improve the care of the frail and elderly.

These developments went along with health secretary Jeremy Hunt’s recent announcement that patients will be given a named GP responsible for their care and for ensuring they do not fall between the gaps in services, or suffer as a result of changes to out-of-hours and ambulance services.

Howe also lauded the new inspection approach of the CQC - which is to employ relevant experts and address more searching questions - and Hunt’s decision to relinquish some powers to intervene in the CQC’s inspection work.

With the health secretary no longer able to direct the CQC to carry out inspections, and with the CQC no longer needing Hunt’s permission to carry out an inspection, he claimed the organisation would gain much credibility. Perhaps more surprising to those accustomed to working with quality standards published by NICE, Howe revealed that the CQC is working with the DH to develop ‘fundamental’ standards of care.

These will be concept statements that outline standards that providers registered with the CQC should always meet, and which patients should expect. This autumn will see a refreshed mandate for NHS England, together with the government’s response to the consultation on the care of the frail and elderly, and an updated NHS outcomes framework. This, Howe said, would make clear the priorities for the rest of this parliamentary term. 

A dissenting view

But when UK Faculty of Public Health president and former director of public health for Cumbria Prof John Ashton spoke, he could hardly have been more scathing about the effects of the April 2013 reforms. To cheers from the hall, he said that he did not recognise most of what Lord Howe had said about the reforms.

“We’ve got to have a conversation about the health service based on reality, and not rhetoric and fantasy. It’s a misnomer to call them reforms,” he argued, adding: “They have caused chaos and people need to get out more if they think they haven’t.”

They have caused chaos in morale, he said as well as leading to three years of blight, and they have pushed aside the trajectory that many in the old system were on, such as the care closer to home agenda that he and colleagues had been implementing in Cumbria. 

The reforms, which were the ideological baby of former health secretary Andrew Lansley, had been ‘half-baked’ and there was now a real problem to address, said Ashton. “If you go out and about, you will hear the word fragmentation over and over again - it’s become unclear who is responsible for what.”

The professor cited the example of child and adolescent care, which is now divided between the NHS, Public Health England and local authorities, and is causing him considerable concern. 

“This is a group we need to address if we’re going to achieve the goal of economic competitiveness in the world. We produce babies which, by and large, are healthy but by the age of 18, between 10% and 15% of them are in serious trouble in one way or another, whether it’s alcohol, drugs, obesity or failure to achieve in the school system.”

From the standpoint of his experience in Cumbria, he also complained that much of what he’d seen of the reforms had been metropolitan-driven. “I’ve learned a lot about rural life and the rural agenda has not been considered,” he said. 

“Choice is an irrelevant concept in a rural area. What people need is good quality services where they are [...] The pursuit of excellence in all services is more important than choice.”

What is to be done about it? Ashton called for a renewal of the vision for the health service that takes account of the issues. “Integration is obviously critical, but you’re not going to get it when you’ve got fragmentation.” 

He went on: “We need to get a quart out of a pint pot, but how do you get a quart out of a pint pot when you are inviting in large measure the independent sector and will create inefficiency, surplus capacity and so on - and to boot take 10% off the top as profits? 

“And we need a much stronger partnership with the public. We have to accept that 98% of healthcare is lay-provided, and that we need seriously to invest in the lay healthcare system, in families and in community support, neighbours and so on.” 

Ashton said that some very big wins stand to be achieved in healthcare with the right approaches - for example, Cumbria currently has 6,000 to 7,000 people with dementia and in just five or six years that figure will be 10,000. 

“If each person who has a dementing illness can be enabled to be independent-living at home for an extra year, that will be 10,000 bed-years not spent in a hospital, care home or nursing home,” he said, adding: “That’s a phenomenal amount of resources.”

He went on to argue that this can be achieved with the right kind of housing and infrastructure, and re-engineering of neighbourhoods so that they’re safe for people in their frail years. However, instead of dealing with these issues, the political conversation is all about hospitals and beds, and bringing the private sector into the NHS, he concluded.

More reassurance

Winding up the conference, NHS England chairman Prof Malcolm Grant adopted much the same reassuring tone that Howe had employed. No doubt aware that GPs in particular resent what they see as NHS England’s dictatorial approach, he argued that diversity was something to be valued. 

He approved of the fact that CCGs across the country are going about their work in very diverse ways. For example, the CCGs now in existence range from a population of 900,000 to 70,000. “I happen to think that is excellent,” he said, “because we are about to find out what model works best, and what geography. 

“We will see how smaller CCGs are succeeding in capturing the enthusiasm and imagination of their members,” he said, “and we shall see how those which have the size and scale will be able to internalise their activity and to bring about what, through the reform, they want to achieve.

“Let me stress [...] our job is not to micro-manage the CCGs. Our job is to work with them and to join with them in visiting the new world of the operation of the NHS.”

He concluded: “It seems to me entirely appropriate that CCGs should decide that the priority in their area is the frail elderly, or the ill health due to poverty and deprivation that needs a different approach. It’s up to the CCGs to decide who they work with and what their priorities are.”

Gavin Atkin, health writer

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