With admirable speed Mark Baker and Radcliffe have published this commentary on The New NHS: modern, dependable. But does it provide more than a close reading of the white paper itself would do? On the whole, yes.
To begin with the layout is clear with lots of summary boxes and separately titled paragraphs. You can chose which bits you want to read. Baker's style is lively and occasionally sardonic - and he is alert to every confusion in the government's thinking.
In part one he draws out some of the paradoxes. First, the tensions between vertical integration, which is more about performance (proving it to superiors up the line) or horizontal integration (working well with peers and with other local agencies). Second, this government, even more than its predecessor, is ambiguous in its espousal of the local determination of priorities while at the same time having very clear national strategies.
The required style of leadership is yet another paradox - obedient or entrepreneurial? Finally, which does the government want more: integrated commissioning of services or integrated care of patients?
In part two, Baker takes each chapter of the white paper apart to look at its implications. Like others, he seems to find the primary care groups the most interesting. He believes they are more like mini health authorities than expanded fundholders. Later on he expresses some concerns about what he calls 'the marriage of collectivism and the achievement of improvements at practice level' and the tension that will develop between GPs and nurses.
The continuing independence of GPs is believed by many to be part of a not-so-hidden agenda. Baker feels that while salaried GPs might provide a better service to deprived areas, it is not likely to make GPs more manageable, any more than it has their salaried consultant colleagues.
Will the new arrangements lead to higher standards? While accepting that doctors always have ways of subverting any system, Baker feels that there is a trend to greater accountability for clinical practice, and that even given the dubiousness of some of the comparative data progress will be made in standardising practice and improving clinical performance. The trick, as he says, 'is to ensure that the professional focus on development satisfies the political and managerial need for control'.
As the government's proposals are somewhat vague in places, action- mad managers will, as they did last time round in 1991, outstrip the NHS Executive's guidance and get on with the restructuring at speed. But where will it all lead?
Part three examines some of the themes for the future. The present structure certainly cannot be seen as set in stone. As PCGs work towards the fourth level, so existing trusts will be reconfigured and the role of HAs will diminish.
Baker also feels that despite the re-emergence of strategic planning, more importance will be attached in future to ensuring smoother and more efficient care for patients.
Ultimately, the question of devolution in England will have to be faced. First, because HAs will, in time, merge and the role of the regional offices will change. But second, the ever present conundrum of how to mix the oil of health with the water of social services cannot be solved under the present political arrangements. Only a reconfiguration of public services based on more local communities can do that. But it may be wise to wait for the results in Scotland, Wales and Northern Ireland before introducing devolution to England.
What remains clear is that getting the best organisation to serve the needs of the population will remain challenging to governments and NHS staff alike.
Visiting senior fellow, health services management centre, Birmingham University.
No comments yet