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The NHS, it's a matter of trust

"It is vital that the focus now turns to ensuring that this essential reform programme is implemented with the proper investment and regulatory support GPs need."


Andy Mullins and Dominic Frankis
Guardian Public
8 November 2010

GPs need real freedoms as well as support if they are to improve local health and social care services

The coalition government's proposed reforms to the NHS, detailed in the Equity and Excellence; Liberating the NHS white paper are the biggest in the NHS's history.

But the public appears to have little confidence in the government's vision. A recent YouGov survey commissioned by PA Consulting of more than 2,000 members of the public showed that four-fifths of people felt that making local GPs responsible for planning and buying NHS services would not improve services. Nearly half of those polled said they did not trust their local NHS to engage effectively on proposed changes or closures of NHS services within their area.

However, there is some public support for service changes to be led by GPs and clinicians. Two fifths of the public have shown they would be supportive of change where there is a clinical and economic case for closing local NHS services - but 46% said they were more likely to support proposed changes if they were backed by local GPs and hospital doctors.

If clinicians and GPs are to be given the chance to do this effectively there are four key barriers that need to be removed.

First, they must be given the requisite powers, free from political intervention, to deliver new and innovative care pathways where they lead to better health outcomes. Despite support from GPs and an independent review panel, local political pressure can derail proposals. Ultimately, it will be the willingness of the government and of local authorities to fully devolve responsibility to the front line that will determine whether real innovation and improvements can be made.

Second, designing changes to local clinical services and undertaking consultation exercises with the public and the service providers needs to be done properly. Any failure may lead to legal challenge by way of judicial review. Despite the ten years of experience and skills Primary Care Trusts have in managing consultations, campaigners have enjoyed some success through this mechanism. Clinicians and local GPs will require strong support to develop their capabilities in this area.

Third, the white paper proposes a 45% reduction in management costs, while proposing the most radical shake up of the system and responsibilities since it was established. This is accompanied by tough challenges for GP consortia to improve the value of their local health and social care services and the patient outcomes they deliver.

Given these pressures, the NHS target for management costs of 0.6% to 0.8% of the £70bn GP commissioner budget seems over ambitious. Some insight into more realistic numbers can be gained from American charities, required by law to report their management costs. Typical highly rated US charities spend 4%-8% on management and some respected medical charities spend more than 10%. The American Red Cross spends 4.5% and the Mayo Clinic (one of the pioneers of the sort of integrated care the NHS will have to copy to get a grip on hospital costs) spends more than 12%.

If central targets for management costs are imposed there is a risk that commissioners will be set up to fail before they start. The best way to avoid this is for GP consortia to be given the freedom to spend whatever they need on management, but be held account for outcomes.

Fourth, empowering GPs and clinicians to deliver service improvements locally will require more regulation to develop a competitive market for NHS services. Providers will need to be freed from central control and allowed to innovate and GPs must also be free to change the way health and social care services are delivered locally. GP commissioners are likely to have a preference for existing suppliers, partly because it is what they know and also because they will struggle to challenge the traditional power bases of secondary care providers.

Creating a culture of competition, so that the benefits of a commissioning-based system can be realised, will need close and proactive regulatory control in the early years. In the telecommunications sector it took over 20 years for the regulator to arrive at a point where it felt the market was sufficiently competitive to operate effectively without the need for direct regulatory control.

The aims of Andrew Lansley's reforms – putting patients at the centre of the NHS, improving the outcomes of the treatment we all receive and putting GPs and clinicians in charge - are right. However, it is vital that the focus now turns to ensuring that this essential reform programme is implemented with the proper investment and regulatory support GPs need.

Andy Mullins is head of health at PA Consulting Group and Dominic Frankis is a health expert at PA Consulting Group  

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