Friday, March 18, 2011

NHS 2011: Conspiracy or Cockup?


Dawn Yellowstone Park©Am Ang Zhang 1986

Is it really that difficult to grasp!

Most people in well paid jobs have health insurance including those at the GMC. GPs have traditionally been gatekeepers and asked for specialist help when needed. If we are honest about private insurance it is not about Primary Care, that most of us have quick access to; it is about Specialist Care, from IVF to Caesarian Section ( and there are no Nurse Specialists doing that yet), from Appendectomy to Colonic Cancer treatment ( and Bare Foot doctors in the Mao era cannot do those either), from keyhole knee work for Cricketers to full hip-replacements, from Stents to Heart Transplants, from Anorexia Nervosa to Schizophrenia, from Trigeminal Neuralgia to Multifocal Glioma, from prostate cancer to kidney transplant and I could go on and on. China realised in 1986 you need well trained Specialists to do those. We do not seem to learn from the mistakes of others.

When there are not enough specialists to go round in any country money is used to ration care.

So we are going to but in a peculiar manner as the NHS used to be state run. Reform!!!

Some very clever people indeed are working for the government. 

Is it Conspiracy or Cockup? You decide.

The AWPs are already there and many specialists are working for them. Foudation Hospitals if they fail will be bought up by the likes of Circle.

Private patients will now have priority and the notion that one should “let them eat cake” does not apply here.

More like: “ Let them not see a Consultant!”
Uncorrected evidence: Health Committee
Dr Hobday: I believe the devil is in the detail. When the White Paper on the Bill was first published, a lot of GPs were in favour of it because there was a simple statement that GPs were going to be put in the driving seat of commissioning. As soon as the detail was looked at, now there are polls that say the vast majority of GPs are against it because of the conflicts of interest, et cetera. It purely depends on the mechanics and nuts and bolts of how it is going to be put into operation. If it is put into operation properly, I believe reconfigurations and commissioning will be easier.
To add a further point, yes, referrals to consultants are the sort of things that must be written into contracts. We now have a situation, and have done for some years, where, as I said earlier, we seem to be referring to buildings rather than people. If we try to refer to named consultants we find our patients in front of a nurse specialist. That sort of thing, in my opinion, is one of the first things that will be stamped on if we ever get the reins of commissioning.
Chair: Mr Boyle was shaking his head.
Seán Boyle: On that simple point, it doesn’t have to be stamped on. Why should it be stamped on?
Dr Hobday: For choice-I am sorry.
Seán Boyle: There are things which nurse specialists can do which they do very well.
Dr Hobday: But not without our saying so.
Seán Boyle: What we are looking at here is a situation where we can deliver the same quality of care more cheaply through using different types of people. I think there will be no argument from the specialists, from doctors, that they should be doing what they are specialised in doing and that other professionals should be doing things which they can do. That is why I was shaking my head, because a lot of people are quite pleased to go to a nurse specialist rather than to a consultant. That was my point.
Q365 Chair: Dr Hobday’s point, as I heard it, was that if you are referred to see a consultant then it should be the original decision by the GP rather than by the institution they are referred to.
More uncorrected evidence Health Committee

Professor Corrigan: No. You said the reverse, that this is not a hidden agenda. This is, in fact, the agenda of a culture. The interesting thing is that if the NHS Commissioning Board is staffed by people from the history of the NHS with that culture, then they are likely to construct an authorisation process which is pretty topdown.
If you look at what was constructed by Monitor, it was constructed from outside of the National Health Service. It was constructed by an organisation that had a very different ethos. What they have now is an authorisation process, "Are you good enough to be?" You are in that and you now have a compliance process which is, all the time, saying, "You have a plan for next year." "It is your plan"-the FTs have said-"and you have said you are going to have a 3% growth. We are half-way through the year and it is only a 1% growth. Let’s have a conversation." That seems to me to be a different sort of performance management than has traditionally existed in the National Health Service.
If the NHS Commissioning Board is peopled by that old culture, we are likely to see something really top-down. Then the real problem starts. What happens if GPs walk away from that? This is a voluntary group of people. PCT Chief Executives, if they don’t work for the NHS, have to get a job outside the NHS. GPs have jobs. They can go on being GPs. They don’t have to do this. There is no conscription that can make them do it. You can pass a law saying they have to, but if they don’t there is a real problem. If they start to experience this, as some of them are, as something which they didn’t sign up for, then you have a much bigger problem than the one you are posing, which is people walking away from it.
Q85 Chair: You say there is some evidence of this already. Crikey. We have barely started.
Professor Corrigan: There is a piece in last week’s HSJ from Charles Alessi talking about his experience of the cluster in southwest London. If you are a Pathfinder, you have signed up to do a number of things. You want to crack on with it and, suddenly, there is someone saying, "You’ve got to do this, you’ve got to do that and you’ve got to do the other thing." I think there is a beginning of that experience.
Professor Paton: I agree, boringly, that there probably isn’t a hidden agenda, but I almost wish there was. It is almost worrying that there isn’t a hidden agenda. The most worrying thing of all is that Ministers actually believe in this, if I may put it that way.
There is another reason beyond pure culture as to why there are forces-not conspiratorial forces-towards taking it back. That is the abolition of what we academics pompously like to call the mesotiers, the strategic health authorities, the PCTs, whatever they might be. They happened to be that recently but it could have been the health authorities before 2001 or it could have been other things. My concern, still answering the question about "Is it centralism or devolution?", about the Bill is that the abolition of that whole raft of middle tiers, if you like, will lead to the inappropriate decentralisation-not devolution, but decentralisation-of some things and the inappropriate centralisation of others. That will not be because of a conspiracy. There may be those who are glad to take advantage of a chance to do that, but it is not a conspiracy, in my view, by those who wrote the Bill or had the aspiration for the policy last summer in the White Paper. It relates to the somewhat hackneyed thing now about, "Is it revolutionary or evolutionary?"
It is not evolutionary in terms of building on existing structures. It is chaotic in that sense, and I am using that word perhaps non-prescriptively. It is chaotic as a description. But, also, I don’t think it is going to be revolutionary, perhaps for cultural reasons but for other reasons too: the agenda, in terms of delivering quality, cost improvement and everything else together, and the need to do that on the hoof-mending the boat while sailing in it-and-not a personal comment at all-the need to do that using the regime of Sir David Nicholson and his staff. That is a very centralist phrase, isn’t it, "Sir David and his staff"? With Sir David and other NHS managers at the centre, it is going to happen that there will be a lot of centralisation of things which could be at what you would call a regional level, and so on and so forth. It is all about performance management. Who is going to do the performance management of the interim as well as the long term?
Another very contingent but nevertheless important thing is this: it is eccentric, is it not, that those institutions which are being abolished, which might, in a cynical frame of mind, be carrying out a scorched earth policy, are the ones that are going to have to oversee the creation of the new future? That strikes me as extremely odd. But, again, there is no alternative. It is not a conspiracy. It is just that there is a policy, an aspiration and a vision with almost no regard, I would argue, for effective implementation.
My final point, and then I really will be quiet, is this. I don’t want to be rude about Alan Milburn and Paul in 2001 but the 2001 reform created a lot of turbulence and, in my view, inappropriately messed about with the middle tiers to such an extent that we saw a reaction against that later. I would predict-maybe because I am cynical as I get older, but maybe not-that you will see something similar having to emerge. That is my answer to the second question. It will be a process because it has to be. It is not so much a policy as a vision. A policy needs to be implemented. A vision needs policy and implementation, and that is going to have to come on the hoof.
Q86 Andrew George: If it is not a conspiracy, then is it worth us exploring whether a cockup is likely to happen? What is liberating about a proposed structure which has the current proposals for the commissioning of primary care-GPs themselves, dentistry, opticians, training and of a whole set of primary care services-which, clearly, cannot be commissioned locally? That is hardly liberating, is it? Are we not, if you like, leaping from the fear of conspiracy into a cockup? 

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