NHS reorganisation: don't leave the patients behind

“Nothing about me, without me” is the longstanding rallying cry of the charity sector. So to see patients at the heart of the white paper has been refreshing, after a cautious spell in health policy designed principally not to upset too many interests.

Patient groups have given the white paper a strong welcome. Praise has rung out for the renewed drive for greater choice and control, the promised information revolution, the focus on outcomes as well as quality and, of course, the return of the “any willing provider” policy. While the details remain unclear, patient groups are inherently pragmatic and most are looking to see how they can help.

Aside from liberating the NHS, the new commissioning framework will hopefully liberate and empower patients. Many people with chronic conditions feel trapped in a culture of dependency on healthcare professionals. Giving them more clout, within an agreed care plan, should unleash new and cheaper forms of care, many of them web based or run by alternative providers, such as pharmacies or even patients.

Underneath the enthusiasm there is also anxiety that the NHS’s recent achievements could begin to unravel under the twin pressures of change and cuts. Whether they were targets or entitlements, the speed with which you can see a GP or nurse and the time you spend waiting for specialist treatment will remain key aspects of the health service’s performance in the eyes of patients. Will abandoning performance management measures liberate professionals to make the best clinical decisions or allow queues to build up once again?

There is also some quiet scepticism about GP commissioning. On the one hand, there is a clear logic in organising commissioning at a local level in primary care and some GP groups demonstrate an excellent grasp of what is needed. On the other hand, GPs are not universally seen as the best patient representatives and variations in primary care outcomes are as striking as those in hospital performance, but without their transparency.

Few patient groups believe GPs are sufficiently interested or prepared to match the standards of commissioning achieved by the best performing PCTs, especially in areas that have the worst outcomes - and of course often the fewest number of GPs. One recent survey found only a quarter of GPs believed they had the skills to commission mental health services, for instance, and similar doubts have been expressed about maternity care.

In practice, commissioning will hopefully be driven by multidisciplinary groups that include nurses and other health professionals alongside GPs. The jury is still out over whether greater private sector involvement in commissioning will make it easier or harder for patient groups to be part of the solution. With so much at stake, their strong involvement in building GP consortium capacity in deprived communities would provide reassurance the lessons of the past will not be lost.

But, of course, language itself is not enough to seal the deal with the sector. The true test of the white paper will be how it translates into action on patient outcomes, emergency admissions, health inequalities and service integration. Patient group support for the white paper rests on two foundations. First, we are passionate about the big society and welcome a vision of the NHS with more room for community solutions, patient voice and social enterprise. Second, we expect active government when outcomes are poor and many will jibe at the retreat from performance management. 

There are good reasons for retreating from the active government of recent years. Indeed, New Labour was trying to decentralise and make policy smarter. But, equally, primary care trusts have demonstrated an active state can be effective at delivering targeted interventions where needed. Will a liberated NHS allow professionals to improve quality for the benefit of all patients or will the retreat from management yield widening local variation and continued pressure on costs?

Smart government and big society are closely linked in deprived communities. The fate of valuable but unconventional interventions now run by PCTs, such as those engaging diverse local communities in health provision, will show whether the optimists or pessimists were right about the new commissioning model.