Editor’s blog 13th January 2009: A right, righteous bollocking

Stop whatever you are doing now (yes, even reading something I write);
go here (http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/53/53i.pdf);
and download the House of Commons Health Select Committee’s NHS Next Stage Review report.

It is one of the best reviews of policy since the Committee’s work on MTAS / MMC.

You may remember that we were not wholly uncritical of The Good Lord’s proposals (www.healthpolicyinsight.com/?q=node/94 and www.healthpolicyinsight.com/?q=node/80) when they launched. The Select Committee report pulls no punches about the variable (and generally low) quality of commissioning expertise in PCTs, branding it “striking and depressing”. As the Committee notes, it has reported into the poor quality of commissioning in a series of previous inquiries.

The lack of suitable analytical and planning skills in PCTs is repeatedly cited as a barrier to the progress of commissioning. What is unfortunate is the extent to which commissioning has become the fulcrum for most proposed reforms, and for the devolution of power.

DH director-general of commissioning Mark Britnell will not be pleased to read that the report states that the committee “are not convinced that this (the World-Class Commissioning’ programme) will make the necessary changes”.

One of my criticisms of the NSR was that it looked suspiciously like replacing DH centralism with SHA centralism in the name of devolution. The report suggests that “SHAs will have an important role in managing the performance of PCTs, but there are also doubts about their ability to do this”. If such doubts exist, then what are SHAs there to do?

Paying attention to PBC?
In the attention to commissioning, practice-based commissioning (PBC) gets some welcome attention: “Professor Steve Field, Chief Executive of the Royal College of GPs, argued that GPs had not often chosen to take part in PBC because they “do not understand what it is…and PCTs think they are losing their influence if they hand over commissioning to groups of healthcare professionals”.

The report says that according to Kings Fund chief executive Niall Dickson, “PCTs are either not really encouraging them to do it or are not interested in doing it and are not promoting it. On the other side, some PCTs are saying that a lot of GPs are really much more interested in the provision side than the commissioning side”.

The report continues, “the BMA thought that it was important for the Department to provide a clearer explanation of what practice based commissioning is and what it is expected to achieve. The organisation considered that clarifying the goals of PBC was more important than the Department’s proposals to employ business consultants to help GPs and PCTs “work better together on commissioning”.”

At paragraph 55, the report concludes, “There is much to commend in the Review, in particular the emphasis on quality and leadership. However, we are concerned about its implementation. This will largely be done by PCTs, but we doubt that most PCTs are currently capable of doing this task successfully. We have noted on numerous occasions, and the Government has accepted, that PCT commissioning is poor. In particular, PCTs lack analytical and planning skills and the quality of their management is very variable. This reflects on the whole of the NHS: as one witness told us, “the NHS does not afford PCT commissioning sufficient status”. We consider this to be striking and depressing”.

At 57, it adds, “We are not convinced that the Next Stage Review will succeed in reinvigorating the scheme (practice-baseed commissioning). Moreover, the role of practice based commissioning in relation to the planned World Class Commissioning by PCTs remains opaque and needs greater clarification.`”

The price of a tethered GOAT
Darzi’s arrival as a minister was a part of neophyte PM Gordon Brown’s aim to form a Government of all the talents (GOAT). Referring to this, Heath Secretary Alan Johnson quipped to a weekend paper of Lord Darzi, “our GOAT is tethered”.

The report emphasises that not only are the analytical skills required to see commissioning succeed (let along become ‘world-class’), so too will be the administration of patient-reported outcome measures (PROMs). Due to start in April 2009, the report wryly notes that at the time of its signing off for print, the contract to support the administration of PROMs remained un-signed.

It emphasises that overall, information about the costs of the reforms is not available or has not been provided, noting that “not enough detail about cost is given … the Committee is concerned that neither Strategic Health Authorities (SHAs) nor the Department have been clear on where and how much money will be saved”; and recommends that “figures on implementation costs for individual SHAs and PCTs should be published as soon as possible.”

The flight to quality?
Quality payments under the NSR's Commissioning for Quality and Innovation (CQUIN) initiative are also discussed. “While the focus in the NSR on improving quality of care is welcome, variations in quality have been known about for a long time and have continued despite increased funding. The Committee does not accept that it was necessary or sensible to improve access before improving quality”.

'the report concludes, “the emphasis of policy for the last decade has been on access rather than improving the quality of care. We do not accept that this emphasis was sensible or that it was necessary to improve access before improving quality”.'

At 85, the report concludes, “the emphasis of policy for the last decade has been on access rather than improving the quality of care. We do not accept that this emphasis was sensible or that it was necessary to improve access before improving quality”.

It also warns against a dogmatic flight to incentives alone: “The Department should not rely solely on the use of incentives to achieve improvements in quality; they should be part of a wider package of measures.

“There is a danger that by focusing incentives on a narrow range of clinical services, performance elsewhere might decline.

“The incentive scheme on which Advancing Quality is based is used in the United States, a very different health system to the NHS. Its effectiveness may not be replicable in the NHS and should be demonstrated by rigorous evaluation.

There is a lack of information about how extensive the PROMs incentive scheme will be; how much it will cost to implement; when it will be fully implemented; and whether it will provide value for money.

The timetable for implementing the initial set of PROMs by April 2009 is
challenging. There is a lack of detail about how the PROMs results will be used by PCTs and SHAs to provide incentives to improve patient care. Furthermore the implications for the governance of clinicians need careful clarification.”

Polyclinics – one size fits all?
The Committee is not convinced by the Department's argument that all PCTs should have a GP-led health centre and recommends that their creation should be decided locally on a case-by-case basis. It also emphasises the need for research and evaluation of “whether it leads to better evidence-based medical interventions for patients and whether it reduces disparities in health care access and utilisation between different social classes”.

Sagely, and echoing a point former DH policy advisor and head of health at Trribal Matthew Swindells has been repeatedly making, the report also notes that “It should be recognised that the investment in primary care might increase demand for hospital care as deprived people get better access to care and referrals increase with more diagnostic tests”.

It concludes, “We were disappointed that neither the Government nor witnesses representing doctors could tell us what criteria should be used to decide whether a PCT needed a GP-led health centre. While polyclinics and GP-led health centres can bring benefits, we are disappointed that the Department is introducing them without prior pilots and adequate evaluation”.

Quotes and responses – what the papers and press releases said
Chair of the Committee, Kevin Barron MP, said, "we were pleased by the extent of consultation with clinicians and patients which went into the NSR, and the emphasis in the report on quality and leadership must be welcomed.

"However, we remain very concerned that PCTs are not yet up to the task of putting these reforms into practice. We heard a lot of evidence about weaknesses in PCT commissioning, which our Committee has highlighted in previous reports, and the ability of PCTs and SHAs to manage effectively these changes is a genuine worry.

"Lord Darzi's reforms must not just be the latest in a series of failures to make real change; the blueprint for effective reform is there, but the Department must listen and respond to the concerns and challenges highlighted in our report."

Health Minister Lord Darzi acknowelded the validity of concerns, telling the FT(www.ft.com/cms/s/0/ec99fc74-e110-11dd-b0e8-000077b07658.html), "I accept that there is more work to be done to strengthen PCT commissioning. That is why were are introducing a new accountability process that means from this year PCTs will face a rigorous assessment against their commissioning skills.

"We are also taking steps to nurture the next generation of NHS leaders by introducing leadership and management training throughout the career paths of all healthcare professionals. Improving the quality of services will undoubtedly lead to efficiencies, not only in financial savings but also in a more efficient patient journey through the NHS."

Dr Hamish Meldrum, Chairman of Council at the BMA, said, 
 Many doctors are frustratingly aware of the poor level of support available in many PCTs particularly in commissioning new services. The BMA has always supported the concept of Practice Based Commissioning as it can offer great benefits to patients, but this potential is too often squandered by the absence of adequate support or creative input from PCTs. Clearly the variable management quality in PCTs, highlighted in the report, must be addressed if patients are to benefit.

“The report supports the BMA’s view that the government directive - that a GP-led health centre be introduced in every Primary Care Trust regardless of local need - was short-sighted. It also reiterates our concerns that GP-led health centres have been introduced without proper pilots or evaluation.”