NHS White Paper

The NHS White Paper is now available on the Department of Health website. In the next few posts I will go through these plans and put them into perspective. There are five main sections so I will devote a post to each one. These sections are:

Liberating the NHS

The Conservatives have always hated the NHS, the reason is that they really do not understand the reason for it. They see healthcare as yet another profit making business opportunity and yet the NHS is based on the principle of treating people without making a profit - what, they say, is the point of that? The very phrase "liberating the NHS" is highly offensive because it implies enslavement, and yet it is the principles of the NHS themselves that are liberating, liberating people from the constraints and enslavement that comes about from ill health.

Putting patients and public first

This should be a given with any healthcare system. My concerns here, as always, is that private health by law has to put the shareholder first (company law says that a company is run for the benefit of the shareholder, not the customer). I would say that the best way of putting patients first is through advocacy where a trusted professional representing only your best interests helps you to get the best care possible. However, the government says that in their view you have to do this. They say that this will be achieved "through an information revolution and greater choice and control". The choice and control will be yours, but how will you know what the choices mean?

Here is the key point:

Patients will have choice of any provider, choice of consultant-led team, choice of GP practice and choice of treatment. We will extend choice in maternity through new maternity networks.


The "any provider" will mean private hospitals. Since private providers cannot provide treatment at the rates of the NHS we have to wonder how the government will enable this. The previous government's ISTC programme was an attempt to privatise services, but it failed because ISTCs could not match the NHS on price or efficiency. As a consequence the New Labour government had to apply hidden subsidies to make it appear that these providers were efficient. It is very important that we scrutinise the government's plans for any hidden subsidy to the private sector.

The pledge for "consultant-led team" is vital. The result of the last Tory experiment ion GP fundholding resulted in 7% fewer patients being referred for specialist care, in other words GPs had a financial incentive to perform treatments that should have been performed by consultants and consequently patients did not get the best care. If these plans are implemented then it is vital that patients always demand a consultant-led clinic.

For example, when you compare hospital diabetic clinics with GP diabetic clinics, the hospital diabetic clinics are always consultant-led, whereas GP diabetic clinics are always practice nurse led. The monitoring that GP diabetic clinics provide are vital when it comes to diabetic control, but they should be in addition to, rather than a replacement for, hospital diabetic clinics. We will have to monitor the situation very carefully and make sure that the government's plans are not simply a case of cost-cutting and intended to downgrade the role of hospitals in  healthcare.

The "choice of treatment" is an interesting one. At the moment NICE approves treatments on their clinical effectiveness. Sometimes - but not always - cost comes into it, but the decision is mainly made on clinical effectiveness. It will be interesting to see if the government allows non-NICE approved treatments, or whether they will allow patients to have quack treatments like homeopathy or chiropracy.

Improving health outcomes

No government wants bad health outcomes, it is how you achieve them that is important. New Labour believed that performance targets were the answer (interestingly, the current government have not abolished the targets, they have simply stopped performance testing based on hospitals achieving the targets). Every healthcare professional will tell you that there have been huge improvements in outcomes over the last decade, the political issue is whether targets are the most effective way to achieve better outcomes.

The focus of the Department of Health appears to be to treat health providers like roofers. If you need a tile replacing you contract a roofer and after they have replaced the tile you check. If they have not replaced the tile, or they dropped the old tile on your conservatory roof cracking a window, then you do not pay the roofer for the work. Simple? Well we will see. The problem is that patients will have to know what the expected outcome will be and how to complain. This is fine for the pushy middle classes, but it is unclear now the non-pushy patients will benefit.

"Providers will be paid according to their performance. Payment should reflect outcomes, not just activity, and provide an incentive for better quality."

This seems like nonsense. The fact is that activity (the treatment) can be very expensive. Imagine the cost of major organ transplant, like a liver. Imagine the follow up treatment involved, the anti-rejection drugs that suppress the immune system which result in patients suffering greatly from what would be trivial infections for a healthy person. How do you determine the outcome here? How do you determine what proportion of the outcome is due to poor treatment or due to the patient? How do you determine what proportion of the payment is withheld due to a less favourable outcome?

Why should we wait for outcomes to be determined before we find out that a treatment is not being performed correctly, surely constant monitoring of procedure (oh dear, there is that process-led target phrase again) would reduce the chance of there every being a bad outcome?

Finally, all treatments have a chance of failure, but some treatments are very risky. Innovation means trying out new procedures and there is always a risk that the new procedure will fail. If a hospital will not be paid for this activity if their is a bas outcome then surely this policy will restrain innovation, perhaps even remove it altogether.

Autonomy, accountability and democratic legitimacy

This is the worrying part. This is where the p-word comes in: privatisation. Interestingly, the executive summary for this section includes a lot of policies on the autonomy point, a weak sop to the democratic legitimacy point and nothing on accountability. The Conservatives like to talk a lot about accountability, but they never implement plans where they are made accountable. (For example, moving to five year parliaments makes the Conservative less accountable because as voters we now have just one chance every five years to hold Conservative MPs accountable. Allowing dissolution during this five year period means that they would be far more accountable because at any one point during that period a Conservative MP could lose their job.)

This section seems to have some inconsistencies. For example, this phrase:

"local authorities will promote the joining up of local NHS services, social care and health improvement."

This means vertical integration and is what I think the NHS should be doing: one organisation responsible for end-to-end care. But this conflicts with the fragmentation of the health service that is promised in the "any willing provider" policy.

"We will establish an independent and accountable NHS Commissioning Board."

This is another area where the policy is inconsistent and we will have to scrutinise the proposals. On the one hand the government says that they will "devolve power and responsibility for commissioning services to the healthcare professionals closest to patients: GPs and their practice teams working in consortia" which means that the decisions are made at the local level. But at the same time the government will create the super-quango the NHS Commissioning Board. In earlier Conservative policy documents they say that this board will produce commissioning guidelines, so will this mean that the NHS Commissioning Board will determine services or GPs? Further, Conservative policy documents say in many places that they want to create a healthcare market of private providers paid with NHS funds. The question here is whether the sole responsibility of this new NHS Commissioning Board is to force GPs to commission private providers.

Cutting bureaucracy and improving efficiency

Bureaucracy is an interesting concept. No one likes it, everyone thinks that bureaucrats are there to do non-jobs that get in the way of us doing our work. Governments always say they want to cut bureaucracy because it is popular. the problem is that if you allow people to do whatever they like, they start to do things that you do not like, so then you have to bring in regulation and monitoring and bureaucrats.

For example, in the section above we are told that the government wants to pay providers based on outcomes. Where do we get these figures of outcomes? Who decides the proportion of payment according to the outcome? Who enforces this outcome based payment system> The answer is administrators and hence this will result in greater bureaucracy.

"The NHS will release up to £20 billion of efficiency savings by 2014, which will be reinvested to support improvements in quality and outcomes."

This is a pledge from the previous government and few NHS providers know how they will achieve it (it is a saving of 20%). In fact, the "efficiency savings" being made at the moment have resulted in the loss of 10,000 nurses jobs (source: RCN). New Labour made this wild claim, and the Conservatives are making it too. Making claims in absolute terms like this is very risky. What happens if, in September 2013 there have only been £11bn savings, will there be a sudden rush over 6 months (to the end of the financial year April 2014) to cut £9bn from somewhere, anywhere?

"The Government will reduce NHS management costs by more than 45% over the next four years, freeing up further resources for front-line care." 

Again an arbitrary absolute figure. Where does 45% come from? (See my later blog post on this.) The fact is that managers should be there to free-up clinical staff from any managerial responsibilities, but this government wants to push more managerial responsibility on clinicians, which means that they will be doing less clinical work. By all means make management more efficient, but do not make clinicians treat fewer patients.