An Elevator Pitch (or Lift Pitch) on NHS Reforms

 

 

 

The Health and Social Care (HSC) Act was passed in March 2012 and came into effect on April 1^st 2013. GP led CCGs (Clinical Commissioning Groups) became responsible for the NHS budget and are now compelled to use competition as a means of improving NHS services. To most of us this seems like a good thing at first glance. Many of us are unaware of what this really means. To help public awareness, here is my ‘Elevator Pitch’ on NHS reforms. An Elevator Pitch is a summary of a concept or argument, short enough to be delivered between floors in an elevator. In the UK, we might call this a Lift Pitch.

The NHS is one of the most efficient healthcare systems in the world. It provides universal, comprehensive healthcare to EVERYONE. Healthcare is free at the point of delivery. We do not run the risk of personal bankruptcy when we fall ill. NHS hospitals are run on a non-profit basis where savings are reinvested in healthcare. Clinical outcomes are excellent. The US spends 2.4 times more on health per person than the UK, yet Britons live longer than Americans. Despite these achievements, the NHS has come under significant attack in the media. Budget cuts at a time when the NHS is at its most efficient have led to staffing shortages and ultimately problems outlined in the Francis Report.

The HSC Act 2012 removes the Secretary of State’s legal obligation to provide or secure healthcare for everyone. The NHS is also now subject to EU Competition law. Section 75 (being debated in the House of Lords today) compels CCGs to invite bids for all health services from ALL willing providers. This leads to a free market based system where expensive tendering processes will consume much of the CCG budgets and time. In the US, administration costs account for 20% of healthcare expenses, three times higher than in the UK.

Healthcare providers will compete against each other for the contracts. This may improve some services. However, barriers between primary care and hospitals will move us away from integration and data sharing. There is a risk that profit making organisations will cherry pick lucrative contracts, leaving difficult and expensive services to non-profit organisations. The irony is that a last minute amendment to the HSC Act makes this even more likely. The amendment declares that the only services NOT subject to competition law are those which can ONLY be provided by a current provider (most likely to be complex, expensive services).

As NHS budgets become tighter and healthcare becomes more expensive (largely as a result of spiraling administrative costs), the NHS is likely to change from a mostly single payer (government funded) system to a US style multiple payer healthcare system, what Don Berwick refers to as a ‘zoo of payment streams’. We only have to look to the US to see how our healthcare system might look in a few years.

Vinod Achan

For my blog on Don Berwick, see here.

Nostalgia and the NHS



On BBC Radio 3 last night, Samira Ahmed hosted a debate on whether nostalgia was obscuring clear debate about changes in the NHS? GP and blogger Dr Jonathan Tomlinson argued on  behalf of the NHS. Journalist Ian Birrell argued against.

Ian Birrell painted a view of the NHS that many of us within it would not recognise. One of elderly patients dying in squalid conditions, doctors stifling change, doctors encouraging long waiting lists and disapproving of patient choice. Of course there are isolated examples of these, many of which are put under the microscope by the media. But these descriptions are not typical of the NHS.

Many of us within the NHS would love to and do engage in discussions about how service delivery can be improved. The NHS is constantly evolving and improving. Waiting lists have been driven down considerably. Care is becoming increasingly patient centred. We put the patient at the centre of everything that we do. Or we try to. And we deliver results. Cardiovascular mortality is falling faster than in any other OECD country, for example.

Compassionate care for patients with complex needs, especially the elderly and disabled, is precisely what the NHS strives for as it delivers universal comprehensive healthcare. Hospitals talk to each other and to GPs as a national network of organisations, mostly working together. We believe that healthcare is a basic human right. There are occasions when we fail, but those are the exceptions. As Don Berwick said, we leave no one out.

Healthy debate is essential to progress. What is hampering good debate and progress is the continuous cycle of redisorganisation costing billions of pounds. Teams of excellent administrators within PCTs, responsible for many of the recent service improvements, have been disbanded with a huge drain of talent. Instability leads to poor morale which, in combination with staff shortages, leads to poor care. The current reforms will lead to increasing competition and fragmentation amongst healthcare providers and spiralling administration costs. How we reverse some of these changes, and avoid a US style healthcare system driven by market forces and profit, will be the next big challenge that faces the NHS.

I invite both Samira and Ian to spend a day with me at the NHS frontline to see how things are being done well in the NHS.

Jonathan Tomlinson's response to this debate can be read here.

We Leave No One Out: Professor Donald Berwick



Professor Donald Berwick is a Professor of Paediatrics at the Harvard Medical School, Professor of Health Policy and Management at the Harvard School of Public Health, and CEO of the Institute for Healthcare Improvement. In July 2010, Professor Berwick was appointed by President Obama as head of Medicare and Medicaid but resigned at the height of the Obama healthcare reforms debate when it became clear that Republicans would block his appointment. Last week David Cameron appointed him to turn the NHS into the safest healthcare system in the world (in the wake of the Francis report). In his first interview as Cameron’s ‘Health Tsar’ with a newspaper, the Telegraph ran the title: “My Cure for the Sick NHS” (1).

Many of us will therefore be relieved to know that Professor Berwick is in fact a great supporter of the NHS. In the US, he has been denigrated by the Republican press for praising the NHS and wanting to move the US away from its traditional fee-for-service medicine. In a keynote lecture at the NHS Live Conference (July 2008) celebrating the 60^th birthday of the NHS, the following were just a few examples of his praise (2):

1.     “The NHS is one of the most astounding human endeavours of modern times” 

2.     “The UK promises to make healthcare a human right. The US does not promise healthcare as a human right and people ask, “How can healthcare be a human right? We can’t afford it.” As a result, almost 50 million Americans, one in seven, do not have health insurance. Here (in the UK), we make it harder for ourselves, because we don’t make that excuse. We cap our healthcare budget, and we make the political and eco­nomic choices we need to make to keep affordability within reach. And, we leave no one out.” 

3.     “In the US, we can hold no one accountable for our problems. Here, in England, account­ability for the NHS is clear.” 

4.     “In the US, we fund healthcare through hundreds of insur­ance companies, a zoo of pay­ment streams. Administrative costs approach 20% of US total healthcare bill, at least three times as much as in England.” 

 

For a video excerpt, see here.

Professor Donald Berwick is a friend of the NHS. By appointing him, David Cameron may in fact help steer the NHS out of the choppy waters we find ourselves in. Professor Berwick, we welcome you to the UK and look forward to your support and guidance in making the NHS even safer.

How Marketisation leads to Privatisation

The 2012 Health and Social Care Act changes the NHS in ways which we are only just beginning to understand. These will have an impact on how healthcare is delivered and paid for in the future. Some have described it as a privatisation of the NHS by stealth. The changes to the NHS over the years are summarised here in three key stages.

1) Once upon a time: The Department of Health (DoH) funded all general practitioner (GP) and hospital services via Strategic Health Authorities (SHAs). Hospitals did not compete and healthcare was not motivated by profit. But the NHS was not efficient.

2) Creation of an Internal Market: The concept of relatively independent NHS Foundation Trusts (FT) was introduced in 2002. FTs were hospitals relatively free of DoH control and able to reinvest their own profits to improve local healthcare delivery. Local people could become FT members and have a say in how their local health services should be provided. Competition between FTs improved healthcare efficiency but would lead to the closure of less successful hospitals (and sadly some successful ones). Primary Care Trusts (PCTs) would commission (purchase) a variety of services from local hospitals.

3) 2012 Health and Social Care Act: Things are about to change. At the cost of £1.5 billion, PCTs have been disbanded and 211 Clinical Commissioning Groups (CCGs) created. These were supposed to be GP-led but in practice will be managed by support services outside the NHS. From April 1st 2013, CCGs will be responsible for a £65 billion NHS budget in England, commission (purchase) services from a wider variety of providers, and 'have flexibility to use competition as a means of improving NHS services'. Under Section 75 of the Act, CCGs/GPs will be forced to open up every part of the local health service to private companies via time-consuming tendering processes. These processes are almost alien to the NHS but familiar to private providers waiting in the wings. Private providers will compete with FTs. Some may collaborate with FTs but their ultimate objective will be to siphon off profits for shareholders.

PS. Since this blog was posted, the NHS Commissioning Board has been renamed NHS England.

The NHS: Connecting the Dots

 

 

 

Aneurin Bevan (1897-1960)

 

Since its creation in 1948, the National Health Service (NHS) has provided universal free healthcare in the UK via a comprehensive primary care programme (general practitioners), a network of secondary and tertiary care hospitals, a superb ambulance service and public healthcare programmes. The three core principles of the NHS at its inception were:

1. The NHS would be universal. Everyone would receive medical treatment when needed.

2. The NHS would be comprehensive. It would cover all aspects of healthcare from mental health to cancer, dentistry to cardiac surgery

3. The NHS would be ‘free at the point of delivery’. No patient would be ever be billed for their treatment, no matter how complex or frequent that treatment or care might be.

Aneurin Bevan, the post-war architect of the NHS, wanted healthcare to be free from profit-making motives and for patients to not worry about how they might afford medical bills.

65 years later, the NHS is under some attack from sections of the media and government, not least because of the Francis Inquiry report which has highlighted failings in care at one NHS hospital. The culture of the NHS has been blamed. For most of us within the NHS, this brings into sharp focus the fact that staffing shortages, financial pressures imposed by government, increasing workloads and chasing of targets can lead to loss of morale and ultimately failure of healthcare. These are issues that can afflict all NHS trusts.

The Health Secretary Jeremy Hunt has described the NHS as 'mediocre' and 'coasting'. He has described the NHS as 'hitting targets but missing the point'. Roger Taylor has written much in support of the NHS but argued recently that ‘the Francis Inquiry report shows that those within the NHS cannot tell the difference between good healthcare and bad, and that we love the NHS too much to make it better (1)’. Enemies of the NHS will make the most of this opportunity to denigrate the NHS. 

I argue here that despite its failings, the NHS is admired by many both in the UK and across the world (2). Those within and loyal to the NHS are in the strongest position to drive improvements in national healthcare delivery, continue to build on an NHS of which we have every right to be very proud, and take it into the future without compromising its core principles. At a time when the NHS is coming under much criticism, it is worth noting that in the US where a very different healthcare system operates, 62% of all personal bankruptcies are related to medical costs. Of these personal bankruptcies, 75% had previous medical insurance (3). Life expectancy in the UK has improved by 4.2 years between 1990 and 2010 (4). The UK had the largest fall in heart attack related death rates compared to any other European country between 1980 and 2006 (5). The US spends 2.4 times more on health per person than the UK, yet Britons live slightly longer than Americans. By laying the emphasis on universal and uniform healthcare delivery across the country, the NHS can and will connect all the dots in a way that many other healthcare systems cannot.