The Conservatives want it. Gordon Brown might do it. But what would an independent NHS look like? HSJ brought together key healthcare figures to debate the possibilities

Simon Stevens
is president of UnitedHealth Europe
Chris Ham is professor of health policy and management at Birmingham’s Health Services Management Centre
Niall Dickson is chief executive of the King’s Fund
Dr Gill Morgan is chief executive of the NHS Confederation
Mark Britnell is chief executive of South Central SHA and a former foundation trust chief executive
Robert Naylor is chief executive of University London College Hospitals foundation trust
Andrew Lansley is Conservative health spokesman

Simon Stevens Let’s start with some ground clearing. To talk about the benefits of NHS independence doesn’t mean you have to claim you can take all politics out of the NHS; instead it is to note that other countries manage to avoid such politicisation. And we don’t hold the education secretary accountable for a child’s exam results, but we expect them to be accountable for schools in the round. Sometimes it is claimed that the best or only way to grant more independence is to take everything the DoH does and hand it over to an arm’s-length board that is either immune from political or electoral pressure or from bottom-up pressure from patients. That would be a producer monopoly worse than British Leyland in the 1970s - even then you could choose to buy another car!

Instead we should think of a continuum of independence; the question is then how we can make the NHS more - rather than completely -independent. And rather than thinking of the NHS as a lumpen institution becoming more independent we should think about how some of the key oversight functions - regulatory, commissioning, governance etc - can be made more independent. We have made a start with the National Institute for Health and Clinical Excellence around rationing, the Healthcare Commission on quality inspection and Monitor on corporate governance of foundation trusts. How do we finish the job?

Niall Dickson We have to be clear what we mean by ‘independence of the NHS’. Is it possible, as some say, to disentangle managerial and technical decisions from those decisions requiring value judgements? It sounds simple but in reality separating strategic policy matters from operational issues is anything but. Many of us remember the row between the last Conservative government and Prison Service chief Derek Lewis over whether ministerial
policy led to the failings of the prison service or because he couldn’t run the prisons properly.

However, if we believe that national politicians are not good at the operational side of commissioning or provision it makes sense to move to something more devolved.

Ministers have divested themselves of some authority already. It is possible there is a missing next step here, which is to still have the DoH ultimately controlling the NHS through the commissioning function while asking if there is a case for making it more offshore. For example, if ministers were left with only deciding overall funding, who would decide the basis on which allocations were made to different parts of the country? We may argue that it is a technical matter but behind it lies a set of value judgements. The trick is making the process transparent and if it is a value judgement, it should be in the hands of politicians.

If we are serious about full independence, we would have to be talking about a commission or board that reports directly to Parliament and I am not sure if they have the ability to scrutinise effectively. We have to explore exactly what we want to take out of the DoH and I believe we should operate on the principle of subsidiarity - we should devolve decisions as far as possible to the most appropriate level in the system .

Democratic input

Andrew Lansley It seems that the starting proposition is not that we take politics out of the NHS, but that we take politicians out of day-to-day management. Clearly people working in the NHS feel strongly that the manner in which politicians are interfering is detrimental to effectiveness.

It isn’t that they shouldn’t be accountable because when you talk to the public, they actually want it to be more accountable. There is an argument for a greater democratically elected input from local authorities into service planning and scrutiny than we have at the moment but less from national politicians. People ask for this independence for very sensible reasons. People right across the service have learned how to manage performance more effectively but they are not now being allowed to do it because the central targets are part of a structure that interferes with that.

Independent sector advisers like Simon [Stevens] are not going to invest if the whole system is riddled with political risk and the tariff manipulation earlier this year suggests it is. The secretary of state should be responsible not only for resources but for leading on public health and determining the boundaries of the NHS.

I don’t think an NHS board should be allowed to decide what constitutes comprehensive healthcare, that is a political decision. With value-driven judgements such as resource allocation, the whole point is you don’t say to the NHS ‘do it independently and have your own values’. You put it in statute. This is not unusual. The government manages other public services by putting into statute what it wants.

Dr Gill Morgan As a taxpayer I don’t want politics out of the NHS because every year a political decision has to be taken about how much we as a civilised society are prepared to invest. That has to be political. What the service doesn’t want is political interference in day-to-day management. The closer you get to the clinical domain the less they believe there is a ‘central’ view.

What is really important is that we don’t throw babies out with bathwaters. If we begin to define a thing called the new NHS and we start talking about provision we run the risk of creating a board that begins to pull some of the provision issues up to the centre again. The history of devolution is that whatever level you devolve to becomes the new centralists.

We do have a model for provision which I think is very strong - autonomous boards held to account through both the contractual and regulatory process. An independent NHS board that compromises that would be a bad thing.

At the heart of what needs resolving is to what extent the NHS is a centrally branded set of defined provisions wherever you live, and how much is it a local service shaped by circumstances. The answer is a bit of both and getting that balance right is critical. We have to move to something that truly devolves some commissioning authority and gives a very clear local remit. But if we are going to try to develop specialist services, like those for cancer, we also need a strategic overview. Doing nothing but localism is equally bad.

Professor Chris Ham I started by being quite sceptical about this issue of independence. Perhaps a more useful way of framing the question is to ask how we locate accountability for performance at the most appropriate level in a way that frees up clinical teams for what they are trained to do but also recognises that politicians and those who control budgets ought properly to be held accountable for what they can be.

Is there a way to bring in more local accountability with a bigger role for elected people? If we do that and have a more limited notion of what the national politician should be held accountable for, how do we avoid building in new kinds of tensions between people with legitimacy derived from local democratic process with those at national level? I think if we just go for more local democratic accountability without looking at ways of shifting the raising of resources then we are going to build in some irreconcilable tensions. I hope that we can look further afield at other systems.

Mark Britnell We should recognise the major impact politicians have had on health, and the NHS in 1948 and the NHS plan of 2000 are great examples. Over the last 20 years, political influence has had a profound effect - but so has demography, pharmacology, clinical competence technology and so on. The irony is that these changes are so substantial that they are the reasons politicians can no longer micro-manage the NHS for the next 20 years.

I think 2008 could be a seminal moment. Politicians should be saying that the changes are likely to be so profound that we must find a different way of letting the service respond.

The NHS should be given more deep-seated legal freedoms. Looking at foundation trusts, this government was brave in severing its right arm legally to make sure it couldn’t take powers back. The debate now is whether we give the FT movement more power and not less. For me the role of the secretary of state is to set policy and raise money and then hand responsibility to legal institutions that transcend political cycles - because the solutions to many of our problems certainly transcend those cycles.

I think legally you should create institutions that can withstand and rebuff micro-management and political control.

GM Are you saying that on the commissioning side we should have the same autonomous separation of a commissioning organisation at a local level from the day-to-day strategic frameworks set by politicians?

MB I would completely separate the running of health services from the fiscal policy debate over allocations through the creation of separate structures. That isn’t taking politics out of the NHS, just putting it in its proper place.

Robert Naylor I remember leading a King’s Fund debate in the 1970s on taking politicians out of the NHS. Having argued for less political interference, I was taken aside by one of my elders and told not to be so naive. Well here we are 30-odd years later having the same debate and I expect we will still be here in another 30 years. I cannot see how you can possibly take politics and politicians out of the NHS when it is 100 per cent tax funded.

What we can learn is that there is a spectrum; the FT movement has been extremely successful - the first wave has learned a lot about being more commercial, more patient-focused with greater public involvement. Our accountability to the patients and members grows more and more while the politicians interfere less and less. Members and the board of governors exercise a lot more leverage over what we do. They make me accountable for what matters to them.

What impresses me, and I didn’t believe it would happen, is that politicians have largely kept out of much of what FTs do. I don’t agree we need much greater powers - we only need some changes at the margins. Providing what we want to do is supported by governors and members and we don’t breach our licence with Monitor, we are pretty free to do what we want.

Improving commissioning will be the prime purpose of the DoH in future, turning itself into the commissioning arm of government to maximise the health benefits of taxation. The role of the politician is to develop policy and determine the GDP spent on health. I would advocate an independent board to allocate funds across the regions, to many fewer PCTs (and 150 is still too many; 60 or 70 would be better).

Foundation future

SS What I have heard so far is that firstly there is acceptance that the right way to make providers operationally independent is not through the recreation of something called the NHS Executive. It is to turn all NHS trusts into FTs and then have a level playing field.

But if you are going to do that it is no good dispensing with the catalytic impact that political process has had on performance without replacing it with something equally powerful - consumer choice and new commissioning models. If all operational independence means is that you have a lot of very powerful providers immune from any form of pressure from above or sideways then you end up with something worse.

We must find a way of ensuring that you have the proper rules of the game established in a transparent way to allow for the combination of choice and contestability to work across a level playing field of provision. Where that takes you is the debate we are getting into, the accountability and configuration of the commissioning process, assuming that market regulation, quality and some rationing are offshore.

You then have this question as to whether the DoH is the commissioner and I think this would be a folie de grandeur. At best the DoH can ensure the integrity of the commissioning system but commissioning is going to have to be done by other entities.

I am personally a bit sceptical about the idea that accountability should be to local authorities or elected boards if they don’t also have responsibility for raising NHS revenues.

GM The nationalism/localism debate is very important because there are some components of what commissioners do that you could very well be decided at a local level. For example, things jointly provided with social care - but when you get on to a burns unit you might have to think fundamentally differently about where the commissioning accountability lies.

RN What I wanted to go on to say was I would clearly put the GPs on the provider side and not at all on the commissioning side. I think practice-based commissioning will become just as big a nightmare as fundholding was. The majority of GPs won’t play the game and there are far too many small practices to make it viable. The average London practice has 2.5 GPs and you can’t possibly give them PBC, you need groups of 20 or more.

I would go for professional commissioners as in insurance companies whose job is solely to worry about how much blood they can sweat out of the taxpayer’s pound. GPs are going to have to group together and get much more involved in the district general hospitals which are going to be squeezed like a tube of toothpaste - all the complex patients will come to the tertiary centres while all the routine patients go to community hospitals.

CH You do need some of that professional technical side to commissioning but how do we fit that on the side of what you were describing, Rob, because it is quite powerful the relationship you have with FT members and stakeholders?

You can claim greater legitimacy in your relationship with the community while PCTs remain unreconstructed. And yet increasingly as the money gets tighter they are going to be taking controversial resource allocation rationing decisions without any similar basis of accountability.

ND There is a difference between a local authority running services, commissioning services and the quite different function of holding services to account. Overview and scrutiny committees have been quite successful. What they are doing is a different form of accountability and a legitimate one for a body that neither raises nor spends NHS resources. They should be asking if their population gets value for money and if they can hold to account those who run the local health economy.

At the national level I am still not clear about the implications of the emerging model whereby there is something more ‘independent’ in relation to commissioning - what does that mean for ministers? What should they hold on to? What do they divest themselves of that could be decided by a national body overseeing commissioning?

MB The NHS board may be the logical conclusion of giving legal independence to commissioning. The point I was making was that we shouldn’t fall into the trap of saying independence equals the board. Independence should be about proper legal powers that politicians cannot claw back.

AL I think there is a relationship between a board in this context - responsible nationally for the commissioning side - and NICE. It is all very well NICE having commissioning guidelines; there is no point in doing so in the absence of the board taking responsibility.

The NICE side of politics

GM NICE is not independent of this process. In Oregon where there was an attempt to assess and rank procedures on cost per quality-adjusted life year, the state government was shocked to see how little you could afford when you drew a line of affordability. More money got put into the system because politicians could not deal with the political impact.

Whatever cost per QALY is used by NICE should, I think, sit with government; it’s a political decision. NICE has to work in a political environment. The first political bit is the cost per QALY. Then there is the technical job that goes on within NICE which looks at things in detail and makes value judgement. The decision is then passed to the local level which is where PCTs run into problems. This is partly because of the lack of acknowledgment that something about the overall amount we want to invest in new services has to have a political dimension to it locally as well as nationally. Nobody is actually charged with the accountability at any one level of saying this is what we deliver as a civilised society. It is not as simple as saying that once you pass a decision into a technocratic process it stops being political.

CH I believe NICE has done a really good job on the whole but it is not being strongly connected down to local commissioners and the constraints they confront. I think now is an opportune time to look at governance of NICE and to reconnect that with what PCTs experience day-to-day to make sure when they make technical and value judgements they are much more strongly informed by the local commissioners.

MB We should have similar legal freedoms applied to PCTs. This is how I would develop the legal form and function of this independence, extending beyond the day-to-day realms of politics. I am less concerned about a uniformity of approach through commissioning but there should be standardised regulation.

ND It would be if the patient had a clue what any of this was about. But they have absolutely no relationship with local decision-making or understand why there are any variations anyway.

AL How do you have a national service paid for through taxes, with their expectations, that is so inconsistent? From their point of view there is no such thing as variability. They are well or they are not and what they observe is variation in access that they regard as unjustified.

We also need to distinguish between what OSCs do and the role of the democratically elected local authority. You can’t say to an LA that the OSC is the only way you express your mandate - they have an executive and it is their job to impact on local services. So let us imagine more of the PCTs being care trusts doing health and social care and using local authority budgets.

ND There is another point about how in a devolved system you manage the market. You will have to have a degree of planning in the process, it can’t be a free-for-all. Even supermarket sites are planned to avoid huge overprovision.

MB If I was in government and thinking about giving a proportion of GDP to a legally separate entity I would expect five major things over a five-year period - an increase in life expectancy between one and two years, health inequalities reduced by at least 20 per cent, independent clinical assurance and excellent clinical services, levels of public/patient satisfaction at 75-80 per cent at least and surpluses being generated for reinvestment at 3-6 per cent. A constitution or charter should not go into much more detail with the independent authority but some form of statute might be helpful.

Policy-making is different to strategy. Politicians should control policy at a national level which is then developed strategically by those competent to do so at a managerial and clinical level.

CH The public now have a chronic sense of not knowing what their money is buying and they need assurance. If you have created a more independent board responsible for commissioning you must have a set of outcome-based parameters that they can control.

AL My problem with the five-year targets is the mix of public health and NHS service outcomes - life expectancy, for instance, is the government’s responsibility while the NHS board can control things like patient satisfaction.

CH But of course performance measurement requires targets and it requires targets at each level of commissioning function.

GM There are some things provided for NHS patients that could easily be commissioned locally within an NHS setting, the kind of thing that is provided by your district nurse at home. Why does that need to be commissioned in anything other than a locally democratic service? That’s very different from the tertiary service or bigger hospital where you cannot have multiple standards.

CH As always, the devil is in the detail. It does make sense to have a more independent commissioning board but do you stick with the current appointed PCTs? Do you go for legal independence? Do you give local authorities a much bigger role for commissioning healthcare?

ND I would argue for leaving things evolve at this point. I do not think the level of clamour for independence is strong enough to justify disruption.

RN I don’t think commissioning can be floated offshore - it’s an integral part of a spectrum from politicians, through the DoH and down to PCTs. The current capability of commissioning needs to improve, particularly in a city like London. Greater efforts have to go into getting a better dialogue between commissioners and providers. There are too many fragmented discussions.

SS I agree that we need to act in the name of commissioning, not in the name of independence. The next steps on independence would be clarity around market regulation - who is doing that and what’s the role of the SHAs and on how to get some capacity building and competitive challenge into the commissioning process itself.

MB We need to concentrate on developing commissioning but the end point should be they have a prize which is legal independence. Hospitals have been going for a couple of hundred years at least and have had plenty of time to think about how they operate. Purchasing has been around since 1991 and commissioning has just been introduced.

My model is that the SHA at least in the short term starts to develop commissioning through a process similar to foundations, so you go at the pace of the quickest. By 2008 you start to get incentives for commissioning to be better because they are getting legal freedoms. The irony is if we do not make commissioning stronger and legally independent I am not sure you can have an independent NHS.