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NHS Reforms

As part of NHS reforms, doctors will be holding the purse strings from 1 April 2013. Dr Mark Porter reports on what GP commissioning will mean in practice.

As part of NHS reforms doctors will be holding the purse strings from April 1st. In a special edition of the programme Dr Mark Porter finds out what the changes actually mean in practice. He meets GPs who have already been piloting some of the ways in which health services are commissioned to find out what they will mean for services on the ground. He also hears from GPs and hospital doctors about their concerns. One doctor says implementing GP commissioning is like flying a plane while it's being built. Why are GPs concerned and what could the changes mean for the future of our health services?

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28 minutes

Programme transcript - Inside Health

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THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

INSIDE HEALTH

 

TX:  26.03.13  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  PAM RUTHERFORD

 

 

PORTER

Hello and welcome to an Inside Health special on the NHS reforms. Next Tuesday will see the biggest shake up of the NHS in England since the service was formed 65 years ago as GPs take over the role of commissioning services on your behalf - everything from looking after a new baby, to getting a new hip. But what will that mean for you and your family? I will be putting your questions to our panel of experts later.

 

Before then BBC Health Correspondent Branwen Jefferys will be joining me to help explain the reforms, along with a number of GPs involved in implementing them.

 

Richards

Commissioning is a word that doesn't mean very much to very many people but to me it could easily translate into one word - buying.  Think GPs, think nurses - they are having more control of the family budget.  What food does the family need?  You think about it, you go out and buy it.  With the family we'll decide whether we can afford it from Waitrose or from Lidle - that's clinical commissioning.

 

Porter

And, as well as trying to demystify the reforms, we will be getting insiders' views on the likely impact - their hopes and their fears.

 

Jenkins

This is a massive organisation to suddenly change, the comparison that we all use is that you're trying to fly the aeroplane whilst it's being built and that is very difficult.

 

Freeman

The pieces of the NHS have been thrown up in the air and are landing and many of them have landed because this change is so big.  I think one of those penny drop moments was at a members' event of all of our practices recently when we were talking about the things we had to deliver and one of them was that we have to ensure that there are no hospital acquired infections and one of the GPs said - but how can we do anything about that, that's a hospital issue?  And the answer was - you commission those services now, you're responsible for those services and the quality of those services.

 

Porter

But first let's start with some basics - what do the changes involve? BBC Health Correspondent Branwen Jefferys is here to provide some clarity. Branwen, give me a simple overview of what happens next week.

 

Jefferys

Well Mark these are the largest and most politically contentious changes within the NHS since it was created and to many patients they're completely baffling because if they go into their local GP's surgery or their local hospital next week nothing will change.  This is all about who makes the decisions about money - big changes about who holds the budgets - and also a new legal framework for how those decisions are made and when the private sector or charities should be brought in to compete against the NHS.  All GP practices in England have to join new organisations called clinical commissioning groups and they'll be taking over a large slice of the budgets for the NHS in England, buying a lot of your routine care, whether that's operations and medicines or paying for the A&E department or the ambulance service in your local community.

 

Porter

So effectively the money's going with the patient but the people holding the purse strings are going to be these CCGs.  What's happening to the people who were doing this before because presumably it was going on before?

 

Jefferys

Well there's always been a budget for your local NHS, an amount allocated to your area.  Before that was managed by local NHS managers in organisations called primary care trusts, those are being dissolved, they're losing the legal responsibilities and so many of the managers are going with that and there's a fear of loss of memory, loss of knowledge.  Some of them, however, will be sitting on these new clinical commissioning groups alongside some of the local doctors.

 

Porter

Now when we talk about the money going to GPs, it's actually going to the clinical commissioning groups upon which the GPs - I mean they're on the board - but it's not just GPs is it?

 

Jefferys

That's right, it's going - the money goes to new organisations in which GPs are being given a big say alongside some of the former NHS managers who will be advising them and helping them make the decisions, hospital doctors, maybe a nurse and also crucially some people from the local community as well.

 

Porter

Why has it proved so controversial?

 

Jefferys

This is meant to be all about putting doctors closer to decision making.  The real test will be whether or not they have the freedom to shape it.  The controversy is around how much they will be constrained by the need to bring in competition for NHS services from the private sector, will they be able to do that when they think it benefits patients or will they be forced by new legal frameworks to open up the NHS to far more competition than it's experienced before.

 

Porter

Branwen, we'll come back to you in a moment. 

 

Although CCGs officially take over next week, in some parts of England they have already been sharing the reins of power as part of a pilot programme for the reforms. Oxfordshire, which includes David Cameron's constituency of Witney, is one such area. The Oxfordshire CCG is one of the largest groups, responsible for 650,000 people and with a budget of £65 million. I went to meet its Chief Clinical Officer, GP Dr Stephen Richards, at his practice in leafy Woodcote.

 

Morning, yeah my name's Mark Porter from the BBC, come to see Dr Richards.

 

Richards

I'm very excited indeed about the approach of April 2nd.  This gives GPs and other clinicians the opportunity to work with their population in a completely different way with large amounts of taxpayers' money to improve services for patients.  I see our GPs as being the expert shopper our population has always wanted.  The GP you have known for many years is your expert shopper for the NHS and putting GPs in a position of influence and authority about how we buy services to me is where we should have been going in the NHS for many years and now it's coming.

 

Porter

What do you think the people of Oxfordshire are going to notice - what's going to be different about the system under your care?

 

Richards

Well I think first things first Mark.  The world is not going to stop going round on April 2nd, the health services are not going to stop being delivered as they are now. What we are looking to do is dramatically change those services over the coming few years.

 

Porter

Change them in what way - presumably for the better but can you give me some examples?

 

Richards

In the NHS we've spoken for many years about getting care closer to people's homes and we've got a number of examples already up and running in this county.  So in Whitney we deliver investigations of bowels that would normally have been done up at the big hospital in Oxford, in Bicester we investigate bladders, similarly that would have been done elsewhere.  And we're delivering care for the frail elderly in Abingdon in a very different way, with a full multidisciplinary team nearer to the patients' home.  There patients we might be concerned about as GPs can be seen same day very quickly, they can have specialist opinion, they can have the tests that can be done simply like chest x-rays, ECGs and blood tests done there and then and are more likely to get home with a clear diagnosis so that the GP can then continue to look after them.

 

Porter

One of the biggest changes of course is that the care that you'll be commissioning won't necessarily be coming from the NHS, it might be coming from outside providers - private companies.  What's happened in Oxford so far?

 

Richards

So we have already some experience of working with the private sector and one of the areas we have commissioned differently is for audiology - for hearing aid services.  We have set up contract after due process with Specsavers to deliver some of this for our population.  We are still working with that provider to improve the level of service that they're providing through this new scheme.

 

Porter

What have you learnt from that relationship that's been on-going?

 

Richards

We've learnt that there are inevitably teething troubles.  Because of the popularity of the advertising for Specsavers more and more of the people going through their doors are coming back to their GPs asking to be referred.  This has been a challenge and is a challenge for GPs because this is new demand that was not in the system previously.  By going to the private sector it has opened the doors and more people will be getting more hearing aids.

 

Porter

Which is costing you more money.

 

Richards

Which will ultimately cost the taxpayer more money.

 

Porter

What do patients think of the audiology scheme at the moment - those who go to Specsavers and get their new hearing aid do they like it?

 

Richards

They like the convenience of it and they like the fact that it's not a hospital.  That's the feedback I've had even from someone this morning.  So it is something that they like, whether it is going to be delivering the quality and value for money long term remains to be seen.  I personally do not see a major shift towards the private sector coming.  I believe we must work more closely with our public sector colleagues to markedly improve the service delivery that the NHS can give its population.  We are absolutely against cherry picking, we need the whole patient to be considered and not just the easy bits that colleagues in the private sector might be looking at.

 

Porter

Because it is a matter of patient confidence isn't it, I mean they want to know that you don't have a vested interest but also wanting to know that financial decisions aren't affecting their care, that their care isn't being withheld because it's going to cost money.

 

Richards

I think there are two things you've got there:  one is the conflict of interest of the GPs who could have an interest in the provision and I think that needs to be done hugely transparently so that we can build that trust for our population; I think there is a separate issue around the cost of those services provided.  We will need to be making some hard decisions with our population in this next coming period, there is no new money, we will have to be looking at what services we can seriously consider for change.

 

Porter

Stephen Richards talking to me at his surgery in Oxfordshire.  Branwen Jefferys, Stephen mentioned there the importance of keeping people out of hospital and it's not just about patient welfare though is it - money?

 

Jefferys

In the end the NHS has to live within a fixed budget and something that many patients don't realise is that wherever I go as an NHS patient, whether it's into a local hospital or into another service that the NHS is paying for, the money follows me.  So if I go into a hospital it could cost £2-3,000 for each hospital admission to my local NHS budget, that's money that can't be spent elsewhere.  If I was a patient who needs a hearing aid, choose to go for the option of having it done by the private sector then that money is being spent in the private sector and taken out of my local NHS budget.

 

Porter

Well the example we heard there was the money going to Specsavers, the money's going to Specsavers it's not going to whatever audiology department that work is replacing, so does that audiology department and other services within the hospital are they likely to whither on the vine?

 

Jefferys

It could mean a shrinking of NHS services, the more money that goes elsewhere.  But how much that will happen, as we heard, will be down to these local commissioning groups.

 

Porter

Thank you Branwen.

 

Oxfordshire CCG may be champing at the bit to take over commissioning care for its population, but not everyone is quite so confident. GP Gill Jenkins sits on the board of the Bristol CCG and while just as keen to make the changes work, she has some reservations.

 

Jenkins

A year ago I sat in front of Andrew Lansley who said - do it how you like, just make it up as you go along - which was slightly gobsmacking to be told that.  There have been increasingly more rules and definition of the role but I would say the government's rushed it completely, they've left it very late and it hasn't been easy through the transition.

 

Porter

This is part of the underlying theme of the reform isn't it, that actually local people will get together and sort out what's needed locally and it may be very different here in Bristol compared to Nottingham, Cambridge, London or wherever?

 

Jenkins

Yes, so in Bristol we have certain factors about our society, we have an ageing population, we have a large black minority ethnic immigrant population, we have a very large growing proportion of children, some of whom have very complex problems, so we know what problems we've got to deal with and I mean this is a massive organisation to suddenly change.  The comparison that we all use is that you're trying to fly the aeroplane whilst it's being built and that is very difficult.

 

Porter

Money's a recurring feature in all of this...

 

Jenkins

Unfortunately.

 

Porter

... is it the primary driver to provide the same service cheaper?

 

Jenkins

No, and I think that's very important that we do have to consider money and Sir David Nicholson has set us this challenge to reduce our budgets annually to get down the spending but our prime purpose is quality of care and we're very aware that if that means the hospital, that means the hospital.  But most patients would rather be managed at home if possible.

 

Porter

Do you think priorities might change under this, what I would call, regime change if you like, that perhaps now, for instance, you can have your cataracts done pretty well when you want them if you fulfil certain criteria, that we might be raising the bar so that it's more difficult for people to get treatment - at the moment they've taken for granted?

 

Jenkins

Yes that's - no and that's already happened, that's been in progress for quite a while.  So, for example, locally if you need your varicose veins done actually they're not life threatening and unless you have certain severe criteria symptoms you won't get them done as you might have expected.  And I think unfortunately we'll see more of that because when the budgets are totally stretched and we have to focus on acute emergent care the chronic problems that won't affect longevity but may affect quality of life are the ones that will get - I don't like to say dropped...

 

Porter

They might feel the pinch.

 

Jenkins

They'll feel the pinch, yes.

 

Porter

What about the involvement of private companies - people from outside of the NHS?

 

Jenkins

This is where there are huge concerns because I think most of us really feel that we don't want privatisation of the NHS.  And so recently part of the Health and Social Act was this section 75 where it was going to be open to any new service or change in service was going to be open to anybody who fancied bidding for it and you could argue that some of the major, major companies could afford to almost do it as a loss leader to get in there and we're very aware that this would be a conflict to our basic feeling about how the NHS should be run.  It's difficult when the Department of Health or the government are going to allow this, although now there's a question of change of the section 75, but it's going to be very hard to avoid and I know in some areas of the country they've taken over by stealth - my sister's a care of the elderly specialist and they've had their community health completely taken over by a private provider with none of them being advised about it.

 

Porter

Do you have fears about this going wrong and if so how might that impact on the people of Bristol?

 

Jenkins

I think there is a fear that we're going to have problems delivering the service, we're going to have problems with the providers we have - the hospital trusts, the community health etc. etc. - providing the service that we want.  It's not easy - it's a massive change in a massive system.  People have questioned whether this is the end of the NHS, is it disintegrating - I think there are real concerns this is so, not because of the change in managerial style and bringing in some GPs and other doctors for clinical input but simply because the budget cutting every year has to reach the point where we can't provide the service, I mean that's sort of a given - if you keep reducing the money there's a point where we can't do things and that I think is the worrying factor.  There's definitely a conspiracy theory that the government knows this already and has given the task to GPs because they know we'll fail and then they can say you failed, it's your fault we'll give it all to private.

 

Porter

Gill Jenkins.

 

A 120 miles east of Bristol, Howard Freeman - Chair of the Merton CCG and the London Clinical Commissioning Council - is cautiously optimistic.

 

Freeman

I wouldn't be the chairman of a CCG if I wasn't optimistic.  I believe in the basic philosophy behind the changes, I think the changes have been done as well as possible, I think there's some areas where further changes will have to be made because I just don't think they will work exactly as they are at present but I do think that this is the direction of travel we have to go in, it's not the end point, this is part of an evolution and if you ask me where we'll be in five years the answer is we won't be here.

 

Porter

Howard Freeman. Well to discuss some of the points raised and answer your questions we are now joined by

 

Health Minister Dr Dan Poulter on the line from Millbank

 

David Wrigley who is a GP in Lancashire and spokesman for the Keep Our NHS Public.

 

And, rather confusingly, another Dr Mark Porter - this one being the Chair of the British Medical Association.

 

Welcome to you all. Let's start by finding out what's been bothering our listeners:

 

Scott Samuel

My name is Alex Scott Samuel, I'm a diabetic and I receive my healthcare at the moment from five different providers and the fact is that privatisation and integration of care are diametrically opposed to each other, it just won't be allowed for these private companies to share information in the way that my current NHS providers do.

 

Porter

Health minister Dan Poulter - this is a concern that's raised quite often, that of integration and different sections of the new NHS talking to each other, how can we guarantee that private companies will be able to communicate with each other and share information about patients like this?

 

Poulter

One of the problems, as you just heard from the patient who very eloquently put it himself, is that even within the NHS as it is at the moment there isn't enough joined up working, there isn't enough integration, the gentleman describes five different health service providers looking after his care.  There is too much silo working and there's not enough focus about looking after people with long term conditions like diabetes or asthma in their own homes in their own communities.

 

Porter

But if that might involve a private company is it going to communicate freely with another private company in the same way that specialists at a hospital might share a set of notes?

 

Poulter

Unfortunately at the moment - and I know as a doctor - specialists don't share notes as effectively as they should do and there is a very fragmented care particularly between what happens in primary and secondary care.  So what this is about is about saying who can deliver the best care but in a way that is focused much more in a joined up way, an integrated way, on the patient or on the person receiving the services and putting the money, the budget, into the hands of clinical commissioning groups and GPs in the community is a much more effective way of looking after people with long term conditions and that will put much more focus on the quality of community based care rather than more sort of fragmented reactionary care that we have at the moment which is sort of picking up the pieces when things have gone wrong for people with long term conditions.

 

Porter

David Wrigley, as a GP lots of your patients will have more than one long term illness and currently being seeing a number of different specialists, won't bringing more care into the community - private or otherwise - improve matters for them?

 

Wrigley

I don't think so.  The increased use of the private sector will lead to many more providers in the NHS and it leads to fragmentation of care, multiple providers providing care behind the NHS logo.  And, for example, earlier when you talked about audiology, currently in the hospital it's provided to a very high standard if those staff come across a problem they would call over an ENT doctor to help out and look at it, whereas your high street audiology service they can't do that and it leads to fragmentation and there's no - I can't see any integration there in the example I've used.

 

Porter

Inside Health listener Dave Nicholl is a consultant neurologist in the West Midlands:

 

Nicholl

Obviously I'm speaking in a personal capacity.  I struggle at the moment to know who I'm meant to be liaising with at the CCT level to actually organise services.  That's because people are being appointed in one place to another but at the moment I can't give you the name of the person I need to be speaking to and that is frustrating to put it mildly.  What's the specific evidence that actually competition and privatisation actually helps in healthcare because there isn't any?

 

Porter

Minister, two questions there, first of all, are we ready for this next week if consultants don't even know the names of people who are going to be commissioning their services?

 

Poulter

Well I'm not sure that many consultants necessarily know - and I certainly don't - didn't as a hospital doctor - know who the commissioners were in PCTs.  And what we now will have is a much more of an opportunity to have a face to face relationship in the future between hospital clinicians and those people who are working in the community.  And let's remember it's actually going to be doctors and nurses who are going to be in charge of services and delivering care and that's already shown in many part of the country, in my own part of the world, in East Anglia, to have massively benefited patients.  And we've seen that the movement to the new arrangement with the clinical commissioning groups has led to a 15% decrease in the number of elderly care admissions at Ipswich Hospital in my own part of the world.

 

Porter

What about this thorny issue of evidence?  Is there any evidence that you can show that competition improves outcomes for the patient?

 

Poulter

Interestingly we know that competition effectively was brought into the NHS by the previous labour government and when, for example, there was an issue with the waiting times for cardiac surgery the previous government introduced other providers to deliver that care, brought down waiting times and improved the quality of care for many of those patients.  But what matters is that we deliver care in a way that is tailored around the needs of patients and far too often in the NHS and social care there's too much silo working - primary care works in its own silo, secondary care works in its own silo, social care works in its own silo.  And so giving the money in the budget to local GP commissioners to focus on the needs of the individual, that community focus on keeping the well in their own homes, is a much better way of focusing on tailoring the care to individuals.

 

Wrigley

I'm afraid the minister's got his facts wrong - that competition actually worsens outcomes, we just need to look across to the USA, they're the biggest marketised healthcare system in the world, they have a shorter life expectancy than we do and they have worse infant mortality rates.  And we actually spend half amount per person on healthcare than the USA.  So competition, which they have in America in spades, actually worsens outcomes.

 

Poulter

Well I don't think that's true at all, I mean if we look at infant, children's health we have some of the worst health outcomes for children in Europe and that's something that I launched, a multi-agency pledge, it's exactly we're talking about here which is different parts of the system gearing up and working better together to deliver more care in the community.  And the children's and young people's health outcomes forum which did a report on this last year said that we need to do better on things like children's health, which is the issue you just mentioned, and the system at the moment in the current NHS is too fragmented and there's not enough focus on community based care and preventative care in the community.

 

Porter

Mark Porter let me bring you in, Chair of the BMA, you represent both GPs and doctors working in hospitals - what do consultants think - we've done a lot of talking about GPs - what do the consultants and secondary care think of these reforms?

 

Mark Porter

Well we were talking just now about evidence and I think there is some evidence from the studies of how health systems work that competition can indeed increase the quality of outcomes, it make things better but you lose something in that, what you lose is a comprehensive service, a universal service - David mentioned just now the outcomes in the United States, nobody would ever want to replicate what happens over there elsewhere and that's a service built on competition.  But the real message here is not so much about looking for bits and pieces of evidence to support this or support that contention, it's that what do hospital doctors think when they introduce a new technique or a new treatment or a new development, it's where's the evidence on this and let's see that evidence before we do it.  And of course what we have here is a great untried experiment, what we have here is something that's been pressed ahead for political reasons that can sound good when presented well but which at the end of the day have never been tried out before, a conversion of a service on this scale while reducing its resources has never been tried out anywhere in the world and I think hospital doctors, along with GPs and patients, are very concerned about the possibility of that.

 

Porter

Listener Jonathan Phillips doesn't think healthcare services - he's e-mailed in - to say should be run for profit because their priority will always be the bottom line and not the welfare of the people that they look after. As a 69 year old the reforms terrify me.

 

David Wrigley, do you think customers - as in people seeing private providers - get poorer care than patients?

 

Wrigley

I don't like the term customers being used for healthcare because the profits that these companies that the coalition are introducing into the NHS make money from NHS contracts and that money is not reinvested back into the NHS, it goes to the shareholders.  So, for example, today we've seen RAF search and rescue sold off, the East Coast Railway line is sold off, the profits they are making should go back to the Treasury to improve care for the NHS, well that's not happening.  When companies are involved they're driven by profit and it skews their priorities.

 

Porter

But David, one could argue that GPs are already private contractors and have been for some time offering services back into the NHS - what's the difference?

 

Wrigley

GPs have been self-employed since 1948 and contract themselves to the NHS and yes I do draw an income from the NHS but GPs are very different to your large multinationals, we're in a community for a duration of our career, we invest in the community, we invest in the NHS, it's in our bloodstream - the NHS - and these companies they come and go, they cherry pick the most profitable contracts and when the money's not there or the profit's not there they move on.  GPs don't do that.

 

Porter

Mark Porter what do you like about the reforms?

 

Mark Porter

I think the original vision was something that's quite valuable - clinicians back in the driving seat, making decisions with patients - the way it was sold was quite seductive and I think a lot of people were sucked into that at the start.

 

Porter

David, do you have anything you like about these changes?

 

Wrigley

One of - one positive thing about the change is that doctors and patients and nurses are more involved on the frontline decision making process.

 

Porter

What about your nightmare scenario Mark?

 

Mark Porter

I think there's a growing realisation that doing this at the same time as cutting resources into the NHS, because of the squeeze on the public sector, rushing to execution against a deadline of the 1st April, whether or not the service is ready and of course we're seeing what's happening at the moment with NHS one on one falling over, the nightmare scenario there is that the bits of the service will perform well, bits won't but the key thing about it is that this is an untested set of reforms that may produce problems in a number of areas and we'll lose the ability of patients to be able to rely on the NHS in the way that they can at the moment.

 

Porter

David, your nightmare scenario?

 

Wrigley

It would be a US style insurance based healthcare system - hugely inequitable and it would take us back to a pre-1948 NHS when patients actually feared being unwell.

 

Porter

Minister Dan Poulter, Mark Porter and David Wrigley thank you all very much.

 

One thing I think we can all agree on - these are uncharted waters and no one knows for sure how the reforms will eventually pan out, only time will tell whether the Health and Social Care Bill is the making - or the breaking - of a NHS fit for the 21st Century.  Either way, we will be watching.

 

 

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