The Health Bill plan B is dead, but plan C lives on
David Cameron has made passing the Health Bill a matter of confidence – making it close to impossible the legislation will fail. We now need to ask what kind of bill will be passed and what will happen afterwards.
Once again the prime minister felt the need to put his reputation on the line over the reforms because parliamentary opinion was in danger of swinging against his health secretary. Part of that change in opinion came with the realisation there was a Plan B for NHS reform which could achieve much of its original intention without much of the current cost and disruption.
The Department of Health denies outright that there is a Plan B. But HSJ understands senior civil servants have informally discussed what would happen if the Health Bill was pulled. Broadly, the solution would see the NHS Commissioning Board remain a special health authority and, as planned, take responsibility for commissioning development and oversight, and resource allocation. Primary care trust clusters would be maintained. Clinical commissioning groups would continue to go through the authorisation process and would operate as cluster subcommittees.
However, HSJ understands most of these civil servants now believe, with so much water under the bridge, that just getting on with the structural reforms as is would be the best outcome.
However, they have also discussed a Plan C which would see the bill passed, but with section 3 – which deals with the regulation of competition for NHS services – dropped or amended, perhaps severely.
Andrew Lansley makes it clear in his article for HSJ this week that he believes competition has a “critical” role in delivering better NHS services. However, despite this defiance, there is widespread cross-party belief that concessions are on their way.
The issue is fiercely complicated, but three broad scenarios are possible. The most likely is that amendments counterbalance requirements to compete with those to cooperate, weaken the impact of competition law, and prevent foundation trusts being abandoned to the market by maintaining Monitor’s existing regulatory role. Next in likelihood is some attempt to push the introduction of the new regulatory regime further into the future. The least likely outcome is the complete abandonment of the proposals – something which would force Mr Lansley’s resignation.
Almost exactly a year ago HSJ declared competition should not be the first choice for NHS services, as “it too often has unfortunate consequences and costs”, but that it “may sometimes be the best option”. We hope that peers – and just as importantly those same senior civil servants who are responsible for drafting the secondary legislation and guidance which will provide the substance of the new policy – will deliver something proportionate and workable. Certainly a longer timescale would help in that regard.
But those who take a harder line on increasing competition and a resulting larger role for the private sector – most notably the British Medical Association, but also the Royal College of GPs – may have some hard thinking to do.
If the bill is passed with the competition provisions more or less intact, what guidance will they give members? Readers can judge for themselves the impact of a statement from the BMA or RCGP declaring members should not be involved in decisions giving private providers a greater role in determining or delivering NHS services. But if that was deemed possible and desirable it might mean walking away from clinical commissioning, or at least fighting a guerilla war against the policy.
The passing of the Health Bill is only likely to mark the end of the beginning of the war these reforms have ignited within the service.
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Readers' comments (16)
John lee | 16-Feb-2012 10:56 am
In all the debate so far around the reform of the NHS, there appears to be an elephant in the room of whom nobody dares speak. It was alluded to recently in NHS Confederation Chief Executive Mike Farrar's call for an end to the "hospital-or-bust model of care”, with around 25% of hospital admissions capable of being avoided and patients cared for in their own homes or other community settings. He went on to suggest that this would involve "changing how health services are paid for –perverse incentives often mean it may not make financial sense to provide care out of hospital even though this may be best for patients". These perverse incentives are underwritten by the elephant in the room, Payment by Results.
Introduced by the last Labour Government in 2004 to support the policy of Patient Choice, and let the money follow the patient, it has led to an unsustainable pursuit by providers of hospital activity, out-patient as well as in-patient pathways, whilst deflecting management attention away from managing the cost base.
Furthermore, the Coalition’s focus on the growth in bureaucratic management structures in commissioning seems to miss the point that it has largely been symptomatic of the increasing complexity of the national tariff and HRG4, and that Clinical Commissioning Groups will require similar resources to those of the PCTs in order to performance manage under Payment by Results. Only a complete overhaul of current funding arrangements for hospitals will enable Mike Farrar’s exhortations to become reality, and ensure the continued premise of a health service free at he point of delivery.
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Anonymous | 16-Feb-2012 12:04 pm
Can somebody please explain to me why PCT's had to divest themselves of their provider arms as it was seen as a clear conflict of interest in that commissioning and providing by the same organisation was considered a no/no.? Yet GPs' provide services and can become GP Commissioners with an option to commission services effectively from themselves and yet this isn't anti-competitive, and is somehow different indeed it is being encouraged through the whole ethos of the Health Bill? This hypocrisy continues to baffle me...am I missing something??? Full credit to the Royal College of GPs' for opposing this bill as clearly they have much to gain by its implementation.
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Mike Jackson | 16-Feb-2012 12:26 pm
An excellent analysis. If Part 3 remains as it is Commissioning Support Organisations will be under a duty to 'stimulate the healthcare market' regardless of the views of GPs and CCGs. Look at the JD for the Managing Director of Oxford CSO that says precisdely that
http://www.jobs.nhs.uk/cgi-bin/vacdetails.cgi?selection=912816087
Rebalancing co-operation with competition is unlikely to work either. Look at the existing Co-operation and Competition Panel (CCP) web site. http://www.ccpanel.org.uk/ It has only ever dealt with choice and competition cases and its guidance is all about competition. The members and staff of the CCP, like Monitor, is populated by corporate lawyers and competition specialists who are there to ensure nothing impedes the market.
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Anonymous | 16-Feb-2012 6:19 pm
As a patient all this talk of competition makes no sense at all: I can't even choose to switch GP beyond a handful of equally duff practices near my home.
Given that 90% of patient interaction with the NHS is in primary care, that's where the first steps to delivering choice and competition should be taken.
How can anyone expect a competition free primary care sector to efficiently promote competition in secondary care?
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Anonymous | 16-Feb-2012 10:55 pm
re-do acute funding, and re-do acute structures at the same time. There are far too many separate trusts, particularly in London, to make the consolidation of acute services and a shift to primary / community care do-able.
Force a pile of mergers into super acute trusts with a slimmer management team that then have to get their own duplication of services across sites in order, instead of lots of separate trusts gaming against each other and commissioners.
It would have been a lot better if LaLa had tackled this in the Bill rather than purging experienced commissioners and hoping GPs will take on the challenge of acute reconfiguration. But obviously that would have meant attacking hospitals full of doctors and nurses, rather than PCTs full of management.
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Anonymous | 17-Feb-2012 9:45 am
"Another fine mess you've got me into" ought to be the headline for LaLa and Cameron's next meeting.
It is depressing beyond words that the obvious logical implications of the basic fact that the NHS is a CASH LIMITED BUDGET has been missed by ALL politicians as they try to convince voters they are REFORMING the NHS.
Choice assumes spare capacity, competition assumes winners and losers but politicians with no moral courage have failed to take on public expectations and challenge lifestyle consequences when the reality was it would have been simpler to ensure performance management of the worst out of the system and get the remainder to meet the STANDARDS of the best.
Now we have PlanB, PlanC and Plan Destruction!
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Lance Quin | 17-Feb-2012 4:36 pm
Comment above concerning lack of competition in Primary Care is surely not quite correct? GP Practices are private contactors providing services on behalf of the NHS. The implication is that the GP market is sufficuently saturated as to limit it's attractivenes to additional suppliers. If anything, it indicates that market forces alone cannot be relied upon to drive change. Standards, informed by the outcomes achieved by the best performers (whether in primary or secondary care services) must inevitably underline any commissioing framework. Has the discussion about the appropriateness of the structures become an unhelpful diversion - as so often is does?
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Anonymous | 17-Feb-2012 8:37 pm
I wonder how many Managing Directors of the new CSO's will really have the commercial and business acumen, deck chairs and moving perhaps. The job description link above makes interesting reading. Before we have even got started the words 'customer focus' are already overused and have lost meaning, the CSO's are surely more about a professional service, I would replace customer with client... If this is the road we are going down.
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Craig Gunton-Day | 17-Feb-2012 9:49 pm
I am coming closer to the conclusion that, regardless of political stance, reforms are needed for the benefit of the patient and the service.
If done correctly there is no doubt that CCG's could provide a better focus on clinical engagement and patient enagagement.
The problems with the Bill rests, in my opinion, with the lack of clarity in the players (CCGs, PCT Clusters, Monitor, SHA's etc) and their roles in the NHS.
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John lee | 18-Feb-2012 10:54 am
In all the debate so far around the reform of the NHS, there appears to be an elephant in the room of whom nobody dares speak. It was alluded to recently in NHS Confederation Chief Executive Mike Farrar's call for an end to the "hospital-or-bust model of care”, with around 25% of hospital admissions capable of being avoided and patients cared for in their own homes or other community settings. He went on to suggest that this would involve "changing how health services are paid for –perverse incentives often mean it may not make financial sense to provide care out of hospital even though this may be best for patients". These perverse incentives are underwritten by the elephant in the room, Payment by Results.
Introduced by the last Labour Government in 2004 to support the policy of Patient Choice, and let the money follow the patient, it has led to an unsustainable pursuit by providers of hospital activity, out-patient as well as in-patient pathways, whilst deflecting management attention away from managing the cost base.
Furthermore, the Coalition’s focus on the growth in bureaucratic management structures in commissioning seems to miss the point that it has largely been symptomatic of the increasing complexity of the national tariff and HRG4, and that Clinical Commissioning Groups will require similar resources to those of the PCTs in order to performance manage under Payment by Results. Only a complete overhaul of current funding arrangements for hospitals will enable Mike Farrar’s exhortations to become reality, and ensure the continued premise of a health service free at he point of delivery.
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Anonymous | 20-Feb-2012 12:25 pm
Mr Quinn above says "the GP market is sufficuently saturated as to limit it's attractivenes to additional supplier".
This is wrong as is the idea that just because GPs are private businesses there exists competiton between them. The two do not automatically go hand in hand (as anyone in the private sector knows!).
Fact is, there is virtually no compeition in primary care in the Uk. Patients are forbiden from choosing between practices in any meaningful sense. And this in turn makes it all but impossible for a group of young GPs to innovate by setting up a new practice of their own. It could be the best new practice in the world but patients would not be able to move freely to it. No customers=no business=no innovation=unhappy patients (who die early)
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Anonymous | 20-Feb-2012 6:19 pm
Anon 12:25 is wrong about choice of GP. Patients are free to move to any practice where they live within that practice's catchment area. There haven't been restrictions for more than 15 years. Whether there are sufficient practices to provide a good choice or whether the patient likes any of the available practices is another matter.
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Anonymous | 20-Feb-2012 11:21 pm
You cannot pretent there is a competitive market in primary care simply because some policy somewhere says patients are free to move to a new practice if they are in the catchment area. That's just bonkers.
The barriers to entry are massive;to the point of being totally restrictive. How could any "new business" really hope to set themselves up within the catchment area of an established practice, even one with poor patient experience feedback that might indicate some willingness of people to move.
As the system stands a GP practie has a virtual monopoly within it's patch and is all but guaranteed an income for life provided they bounce along the bottom of the quality standards. Not saying most do, but you could and keep your exclusive rights to an income.
The sooner GP boundaries are opened up the better from the point of view of choice and driving quality. But the other complications that come with it mean i suspect it will never happen.
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David Hooper | 21-Feb-2012 10:50 pm
When I was at school I was told "If you don't know the words just sing 'la-la, la-la'."
A lesson remembered for more than 60 years!
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David Hooper | 22-Feb-2012 6:39 am
When I was at school I was told "If you don't know the words just sing 'la-la, la-la'."
A lesson remembered for more than 60 years!
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Anonymous | 22-Feb-2012 7:16 pm
12:06.....If Part 3 remains as it is Commissioning Support Organisations will be under a duty to 'stimulate the healthcare market'
I dont think so. CSOs are under a duty to deliver whatever services their paying clients ask them to, within the limits of what they are able, competent and accredited to provide.
The fundamental difference of a CSO is it is impervious to 'duties' from the centre. It has no statutory mandate. It is one of the very few things in the new reforms that breaks the existing rule-set.
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