Editor's blog 29th March 2009: Bosanquet's six steps to reform

In contrast to Saturday's Gerry Robinson-fest, the Telegraph today managed to do quite a lot better by getting Professor Nick Bosanquet of Imperial and Reform, to give a much more reasoned critique.

Nick suggests six reforms, which are:
1. clarify NHS spending much better - ensure all NHS organisations, and particularly commissioning bodies (which as of 2010 will be all PCTs will remain)
2. a "strong drive" towards a mixed economy of care
3. abandon NHS Connecting For Health, replacing it with interoperability standards
4. more localism, with deregulation of central targets
5. extending patient choice and personal budgets
6. an end to national pay bargaining and allowing FTs to set their own pay rates

All are interesting ideas. The first is virtually impossible to argue against - as reform has driven greater financial openness through much of the system, the same must apply to the commissioning bodies. The second is Government policy - albeit one that has had hotly debated consequences with the Independent Sector Treatment Centre programme which bust the orthopaedic / anaesthetists' cartel. As the end of the ISTCs' first contract period hoves into view, as Health Investor discusses, we will see more about whether and how much the current DH top team want and will subsidise competition and contestability in the NHS.

The fate of NHS Connecting For Health has been the subject of increasingly heavy hints from NHS CE David Nicholson, as well as criticism from the NAO. There is a great deal of money in the CFH budget as yet unspent. The current media agenda offers many a potential "very good day .. to get out anything we want to bury", in Jo Moore's delightful phrase.

The fourth and fifth suggestions offer some pause for thought. We are headed towards greater localism under the auspices of world-class commissioning and PBC: albeit not very fast. However, the direction of travel appears very clear and unlikely to be reversed by a future administration of any conceivable political stripe.

However, the desire for deregulation of central targets is no way to avoid another Mid-Staffs. The entire problem was that the central targets were the wrong ones (or creating perverse incentives to save money at the cost of providing unsafe care), and not being properly of frequently checked at a lot of levels.

A 'bonfire of the targets' has evident superficial attractions - it is harder, but probably better, to seek smarter and more appropriate targets, and to set them with some degree of local ownership.

The extension of patient choice and personal budgets is an interesting area. Nick well knows that pilots will be starting soon for individual budgets for people with long-term conditions. As a respected academic, Nick may be allowing his enthusiasm to see the NHS delivering better care (and his faith that choice and individual budgets will deliver this) to outrun his patience in waiting to see how the pilots fare.

There are evident practical problems for personal budgets - even though the basic concept, of making services more responsive to individual patients' needs, looks very sound. The first is an equity-based one. Now the principle of NHS top-ups has been breached, there is evident risk of the NHS turning into a residualist service for the worse-off who cannot afford top-ups - albeit the current recession may start to shift hundreds of thousands of marginal seat voters into that grouping.

The second is also pragmatic - most NHS spending incurred by an individual's treatment happens in a person's last year of life. How do you know when that year will be? What do you - and the providers of your care - do if you run out of money before you run out of healthcare need?

The core business of the NHS is the management of long-term conditions, which are at their most complex with comorbidities among older people There are also obvious points about mental health.

The final point is an interesting one - Nick is aware that FTs are already able to set their own staff incentives as to vary pay upwards to reflect performance, although none yet do. Imperial (the University-cum-FT where he is Professor of Health Policy) have been talking about doing it. So doing would, he suggests, "put an end to the disproportionately high salaries that some doctors enjoy and make it easier to employ the rising number of junior doctors". It is certainly an intriguing thought, though it is not likely to do much for clinical engagement.