Editor’s blog Monday 12 July 2010: The NHS White Paper - some more questions in search of answers

Good morning. I think there may be some new people visiting today with the publication of what is clearly in no way one of those "top-down reorganisations of the NHS that have got in the way of patient care". (unless the evidence suggests otherwise, of course.

Welcome to Health Policy Insight if you’re a new or infrequent reader. I hope you find the site useful.

In late May, we published a list of what we see as 26 key questions relating to NHS reform policy.

Most remain significant, but the agenda appears to have moved pretty fast since then, with Monitor floating / leaking proposals for FTs’ assets to go off-balance sheet; the Health Secretary’s revelation that the independent NHS commissioning board will negotiate all contracts for primary care; and the NHS chief executive’s statement that the NHS will have to get involved in social care.

With that in mind, here is a list of some more key questions

Power and responsibility
1. What is the question to which denationalising the taxpayer-funded / backed assets of NHS foundation trusts (taking them ‘off the books’) is the answer?
2. Doesn’t enforced participation in commissioning effectively end the independent contractor status of GPs?
3. How can the 50 ‘accounting officers’ of the newly-made-up health authorities be accountable for clinical spending decisions they can’t control – or will they be able to veto GPs’ plans?
4. Who will appoint and dismiss the CE and or chair of the independent NHS board?
5. What frequency of political interference will indicate that the independent board is not really independent?
6. What mechanisms for redress (other than choice of another GP) will exist for patients who are unhappy with their local commissioning consortium?

Financial matters
1. Will local GP commissioning consortia be able to offer enhanced services to patients who want to ‘top up’ the NHS package?
2. Who will own the goodwill and intellectual property in GP commissioning consortia, and will there be an asset lock on these?
3. Who will manage the conflict of interest between GP commissioning and GP provision?
4. Will providers be allowed to compete for business on price?
5. Why will the three Cs of proposed policy – choice, competition and commissioning - work here, when insurance-based healthcare systems which use them are generally ineffective in constraining cost inflation?

The real basics
1. Will choice of commissioner (via choice of GP) have any geographical constraints?
2. Oversupply of acute provision (such as in London) was not successfully addressed by central diktat, managerial or political planning. Why will GP commissioning succeed where these failed?
3. Commissioning has to date generally failed to reduce unacceptable variation in clinical activity and outcomes in most health systems (Dartmouth Atlas et al). Why and how will GP commissioning succeed in this?
4. Reducing unacceptable variation in activity and outcomes will mean less clinical autonomy. Given the criticisms of “tick-box medicine” under the Quality And Outcomes Framework, how will this go down in primary care and secondary care?
5. Will private sector companies supporting GP commissioning consortia be allowed to refer to their own (or arms’ length) providers?

Clinical commissioning is the right idea. The detail will be everything.
It would genuinely be good to get clear and sensible answers to these and previous questions. The policy direction of travel – of getting clinicians genuinely and integrally involved in spending and service decisions – is correct.

The details, and in particular the incentives about money and reducing unacceptable variation, are crucial.