Editor’s blog Thursday 20 May 2010: The government’s Coalition Agreement on NHS and health policy reviewed

The Coalition Agreement starts with three words, in 56-point type – Freedom, Fairness, Responsibility.

Let’s judge what it specifically says about health policy (and related issues) as such.

And policy people, you now have your three key words for the next period of government. Think FFR at all times.

”In the NHS, take Conservative thinking on markets, choice and competition and add to it the Liberal Democrat belief in advancing democracy at a much more local level, and you have a united vision for the NHS that is truly radical: GPs with authority over commissioning; patients with much more control; elections for your local NHS health board. Together, our ideas will bring an emphatic end to the bureaucracy, top-down control and centralisation that has so diminished our NHS”

Foreword
Cameron and Clegg start (unsurprisingly) with a definition of their philosophical concordance: “We share a conviction that the days of big government are over; that centralisation and top-down control have proved a failure. We believe that the time has come to disperse power more widely in Britain today; to recognise that we will only make progress if we help people to come together to make life better.

“In short, it is our ambition to distribute power and opportunity to people rather than hoarding authority within government. That way, we can build the free, fair and responsible society we want to see”.

Ooh, they’ve invented the internet!
The Janus C&C coalition also spot the importance of IT: “technological innovation has – with astonishing speed – developed the opportunity to spread information and decentralise power in a way we have never seen before. So we will extend transparency to every area of public life”.

This is not going to come very naturally to the NHS, and its traditional management approach.

The ’Nudge’ theories of Thaler and Sunnstein get an airing in the pledge, “Our government will be a much smarter one, shunning the bureaucratic levers of the past and finding intelligent ways to encourage, support and enable people to make better choices for themselves”.

It sounds good, but it is unclear what it means in practice. It is also unclear that this approach will be trialled, to show it works.

The foreword’s last substantial point is on the NHS: “Liberal Democrat and Conservative ideas are stronger combined ... in the NHS, take Conservative thinking on markets, choice and competition and add to it the Liberal Democrat belief in advancing democracy at a much more local level, and you have a united vision for the NHS that is truly radical: GPs with authority over commissioning; patients with much more control; elections for your local NHS health board. Together, our ideas will bring an emphatic end to the bureaucracy, top-down control and centralisation that has so diminished our NHS”.

Crime and policing
“We will make hospitals share non-confidential information with the police so they know where gun and knife crime is happening and can target stop-and-search in gun and knife crime hot spots”.
A good idea up to a point. But a low score for freedom, no? Realistically, hospitals probably don’t have this kind of data much – ambulance services might.

“We will ban the sale of alcohol below cost price. We will review alcohol taxation and pricing to ensure it tackles binge drinking without unfairly penalising responsible drinkers, pubs and important local industries”.

Phew. Good intentions galore here (though once again, banning things isn’t really a freedom gig). But how do you do it? Immediately after this, it also states, “We will overhaul the Licensing Act to give local authorities and the police much stronger powers to remove licences from, or refuse to grant licences to, any premises that are causing problems”.

But this already exists: people simply don’t enforce it. Years ago, I worked in a pub during my student era: the landlord was careful to impress on staff that he could lose his licence and thus livelihood if I served people who were obviously drunk. So we didn’t do it. The law has not changed. This looks like another unnecessary new law, when enforcing existing legslation would work. Not a good omen.

It’s also not responsibility on the government’s part to waste Parliamentary time bringing in ‘tough new legislation on drinking’ – looks Mail-pleasing, and like Blairite eye-catching.

"We will reduce the number and cost of quangos"

Deficit reduction
”We will significantly accelerate the reduction of the structural deficit over the course of a Parliament, with the main burden of deficit reduction borne by reduced spending rather than increased taxes.

“We will introduce arrangements that will protect those on low incomes from the effect of public sector pay constraint and other spending constraint”

Little comment needed, other than  to observe that if inflation keeps rising, BoE interest rates start rising and all bets will be off. The Euro’s woes won’t give us covering fire forever.

The low pay issue will be significant for the NHS as an employer. Let’s hope it will be uncomplicated to administer.

"We will reduce the number and cost of quangos".
Thought you might. Which ones?

Equalities
”We will undertake a fair pay review in the public sector to implement our proposed ‘20 times’ pay multiple”

High score for fairness and responsibility; low score for freedom.

“We will …  in particular, work to limit the application of the Working Time Directive in the United Kingdom”

Europe
A massive NHS management issue here: “We will …  in particular, work to limit the application of the Working Time Directive in the United Kingdom”

This will make a very real difference to the careers of junior doctors and the clinical viability of smaller acute providers. What might it cost in overtime payments?

Families and children
“We will refocus funding from Sure Start peripatetic outreach services, and from the Department of Health budget, to pay for 4,200 extra Sure Start health visitors”.

The meaning of this is a bit beyond me – I’m not good on children’s services policy. In the abstract principle, cutting outreach work leads to less discovery of unmet needs. Is that very fair?

Government transparency
“We will require public bodies to publish online the job titles of every member of staff and the salaries and expenses of senior officials paid more than the lowest salary permissible in Pay Band 1 of the Senior Civil Service pay scale, and organograms that include all positions in those bodies.

“We will require anyone paid more than the Prime Minister in the centrally funded public sector to have their salary signed off by the Treasury.

“We will introduce new protections for whistleblowers in the public sector.

“We will take steps to open up government procurement and reduce costs; and we will publish government ICT contracts online.

“We will require full, online disclosure of all central government spending and contracts over £25,000”.
There is a lot of good, principled stuff here: high levels of freedom, fairness and responsibility.

You will note that they are not banning high salaries; merely requiring the information to be published. This may create easy journalistic targets, but embraces realism that if you are going to make meaningful – i.e. difficult – reforms of the public sector, it could be necessary to get very good people in to do them.

The section on whistleblower protection is particularly to be welcomed in the NHS.

Justice
“We will explore alternative forms of secure, treatment-based accommodation for mentally ill and drugs offenders”.
Pfoomf. The NHS is responsible for healthcare in prisons. It looks as if there is going to be a new organisational form (s?) to deal with in this regard. Which said, could be a big virtue. Prisons are proven to be not really very good at rehabilitating addicts, and they are very bad for your mental health.

UPDATE: Andy Bell of the Sainsburys Centre for Mental Health points out that "the NHS already spends almost £1bn a year on 4,000 medium and high secure beds so this is not a new thing but hopefully finding a way of speeding up a badly blocked system (currently 8,000 people in prison with severe mental illness, but most on short sentences and need diverting out of custody altogether)".

NHS
Quite a bit to discuss. Real-terms funding increases guaranteed; 1/3 cut in management costs confirmed; independent NHS board idea endures; direct local elections for some PCT board positions; renegotiating the GP contract; free choice of GP registration regardless of geographical list base.

I think we need to quote the whole thing here. So I have.

I’ve underlined all the bits that are obviously existing policy:
The Government believes that the NHS is an important expression of our national values. We are committed to an NHS that is free at the point of use and available to everyone based on  need, not the ability to pay. We want to free NHS staff from political micromanagement, increase democratic participation in the NHS and make the NHS more accountable to the patients that it serves. That way we will drive up standards, support professional responsibility, deliver better value for money and create a healthier nation.
• We will guarantee that health spending increases in real terms in each year of the Parliament, while recognising the impact this decision will have on other departments.
• We will stop the top-down reorganisations of the NHS that have got in the way of patient care. We are committed to reducing duplication and the resources spent on administration, and diverting these resources back to front-line care.
• We will significantly cut the number of health quangos.
• We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line.
• We will stop the centrally dictated closure of A&E and maternity wards, so that people have better access to local services.
• We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf.
• We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT). The remainder of the PCT’s board will be appointed by the relevant local authority or authorities, and the Chief Executive and principal officers will be appointed by the Secretary of State on the advice of the new independent NHS board. This will ensure the right balance between locally accountable individuals and technical expertise.
• The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs. It will also take responsibility for improving public health for people in their area, working closely with the local authority and other local organisations.
• If a local authority has concerns about a significant proposed closure of local services, for example an A&E department, it will have the right to challenge health organisations, and refer the case to the Independent Reconfiguration Panel. The Panel would then provide advice to the Secretary of State for Health.
• We will give every patient the right to choose to register with the GP they want, without being restricted by where they live.
• We will develop a 24/7 urgent care service in every area of England, including GP out-of-hours services, and ensure every patient can access a local GP. We will make care more accessible by introducing a single number for every kind of urgent care and by using technology to help people communicate with their doctors.
• We will renegotiate the GP contract and incentivise ways of improving access to primary care in disadvantaged areas.
• We will make the NHS work better by extending best practice on improving discharge from hospital, maximising the number of day care operations, reducing delays prior to operations, and where possible enabling community access to care and treatments.
• We will help elderly people live at home for longer through solutions such as home adaptations and community support programmes.
• We will prioritise dementia research within the health research and development budget.
• We will seek to stop foreign healthcare professionals working in the NHS unless they have passed robust language and competence tests.
• Doctors and nurses need to be able to use their professional judgement about what is right for patients and we will support this by giving front-line staff more control of their working environment.
• We will strengthen the role of the Care Quality Commission so it becomes an effective quality inspectorate. We will develop Monitor into an economic regulator that will oversee aspects of access, competition and price-setting in the NHS.
• We will establish an independent NHS board to allocate resources and provide commissioning guidelines.
• We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong.
• We will measure our success on the health results that really matter – such as improving cancer and stroke survival rates or reducing hospital infections.
• We will publish detailed data about the performance of healthcare providers online, so everyone will know who is providing a good service and who is falling behind.
• We will put patients in charge of making decisions about their care, including control of their health records.
• We will create a Cancer Drugs Fund to enable patients to access the cancer drugs their doctors think will help them, paid for using money saved by the NHS through our pledge to stop the rise in Employer National Insurance contributions from April 2011.
• We will reform NICE and move to a system of value-based pricing, so that all patients can access the drugs and treatments their doctors think they need.
• We will introduce a new dentistry contract that will focus on achieving good dental health and increasing access to NHS dentistry, with an additional focus on the oral health of schoolchildren.
• We will provide £10 million a year beyond 2011 from within the budget of the Department of Health to support children’s hospices in their vital work. And so that proper support for the most sick children and adults can continue in the setting of their choice, we will introduce a new per-patient funding system for all hospices and providers
of palliative care.
• We will encourage NHS organisations to work better with their local police forces to clamp down on anyone who is aggressive and abusive to staff.
• We are committed to the continuous improvement of the quality of services to patients, and to achieving this through much greater involvement of independent and
voluntary providers.
• We will give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices. This includes independent, voluntary and community sector providers.

Blimey. Where to start?

Well, the underlinings above point out that much of this stuff is not new. I underlined the penultimate point about plurality of provision because ex-Health Secretary Boy Wonder Burnhoid’s “preferred provider” nonsense was really only an untenable aberration, which never appeared in a White Paper.

Nothing about the Conservatives’ Department of Public Health concept, though the independent NHS board does get a mention – public health is staying with PCTs.

Nothing about making every NHS provider into a foundation trust.

Nothing about NHS IT.

There is an interesting ambiguity in the language where it promises to, "stop the top-down reorganisations of the NHS that have got in the way of patient care". Does this mean that top-down reorganisations that won;t get in the way of patient care will be fine? Either way, there is nothing about doing away with (or reducing in number) SHAs - though this was a Lib Dem manifesto idea, and would save some management costs. Maybe SHAs could abolish themselves? Or PCTs - or PBC consortia - could do it?

Monitor becomes the NHS economic regulator and, obviously, tariff setter – but it’s not clear whether and how the lines of accountability to any independent NHS board would work. The NHS Co-operation and Competition Panel will obviously get eaten up by this Monitor on steroids.

Warm words for GP commissioning, but nothing said about hard budgets. Is this a “corpse” (copyright David Colin Thome) I see before me?

There are three mentions of quality, but none of productivity. There is absolutely nothing about variations in clinical performance, workrate or outcomes. There is no mention of cost-effectiveness.

The Lib Dem manifesto guarantee of a right to go private if defined entitlement timescale is not met does not make it. The Conservative promisre to abolish all targets likewise.

The independent board is not going to be very independent or indeed influential if the SoS still appoints CEs. You’d have to be concerned about the politicisation of appointments.

The aim to “reform NICE and move to a system of value-based pricing, so that all patients can access the drugs and treatments their doctors think they need” is weird if not sinister: NICE is a system of value-based pricing. What reforms are they taking about, other than the new National Cancer Drugs fund over-ruling NICE HTA when it comes to cancer drugs, which are obviously going to be good value whatever their price?

Freedom-wise, much of this is impossible to judge, in the absence of some proper detail. There is a lot of talk about decentralisation, but the SoS will retain final say on CE appointment.

New quango the independent board’s appointment scheme, constitution and degree of liberty is unclear; the same goes for New Economic Monitor On Steroids.

The wording on reconfiguration is interesting: no “centrally dictated closure of A&E and maternity wards” and “top-down reorganisations”.

Fairness-wise, there is remarkably little. The cancer drugs fund is arguably unfair to patients with less politically popular illnesses.

There is virtually nothing here about responsibility (a Lib Dem manifesto theme).

Political reform
“We will give residents the power to instigate local referendums on any local issue”.
OK. That’s all service closures out the window, then.

“We will make the running of government more efficient by introducing enhanced Departmental Boards which will form collective operational leadership of government departments.”
They’ve been reading up on the Cabinet Office’s capacity and capability reviews. You know the ones: in which the DH usually performs very near the bottom.

Public health
Again, in full, in italics, already-happening stuff underlined:
“The Government believes that we need action to promote public health, and encourage behaviour change to help people live healthier lives. We need an ambitious strategy to prevent ill-health which harnesses innovative techniques to help people take responsibility for their own health.
• We will give local communities greater control over public health budgets with payment by the outcomes they achieve in improving the health of local residents.
• We will give GPs greater incentives to tackle public health problems.
• We will investigate ways of improving access to preventative healthcare for those in disadvantaged areas to help tackle health inequalities.
• We will ensure greater access to talking therapies to reduce long-term costs for the NHS
Nothing about how public health pooled budgets with local government will be incentivised if public health responsibility still sits with PCTs. A mention of outcomes at last, but what metrics? Are we going to see stupid things like the 2-week quitter smokers triggering rewards? What has been learned form the incentives in the GP contract QOF?

Also, a mention of responsibility – taken by people for their own health. That’s fine. It’s also the right thing. But how?

Social action
“• We will support the creation and expansion of mutuals, co-operatives, charities and social enterprises, and enable these groups to have much greater involvement in the running of public services.
• We will give public sector workers a new right to form employee-owned co-operatives and bid to take over the services they deliver. This will empower millions of public sector workers to become their own boss and help them to deliver better services”.
This already happens, with very low uptake so far. Which is largely due to the NHS pension. Only obvious change is that the ‘right to request’ seems likely to become a right.

Social care and disability
“• We will establish a commission on long-term care, to report within a year. The commission will consider a range of ideas, including both a voluntary insurance scheme to protect the
assets of those who go into residential care, and a partnership scheme as proposed by Derek Wanless.
• We will break down barriers between health and social care funding to incentivise preventative action.
• We will extend the greater roll-out of personal budgets to give people and their carers more control and purchasing power.
• We will use direct payments to carers and better community-based provision to improve access to respite care”.
Oh brilliant. A commission on social care.

How could that possibly fail?