Guest editorial Friday 30 July 2010: One step beyond ...

Irwin Brown of the Socialist Health Association looks ahead to a post-restructuring future

Come with me into the future of Andrew Lansley’s imagination.

It’s OK, you can hold my hand.

Imagine for now that the changes in the DH structural reform plan actually happen as planned.

The remaining acute and mental health trusts somehow overcome the obstacles they have faced for the last six years and become FTs. Those few PCT provider arms which are not absorbed by the nearest acute or mental health trust also become FTs.

Over 500 GP consortia overcome major governance and risk issues, and all GPs agree to new contractual arrangements binding them into consortia. A DH-appointed Independent Commissioning Board finds a way to performance-manage the system architecture. The SHAs and PCTs go quietly, and the NHS still makes its £20bn savings.

Who’s who in the new NHS
Providers are mostly large FTs offering a wide range of care services, sometimes through their strategic (private sector) partners, and through outsourcing; they make good use of the end of restrictions on their income.

A few small fledgling community and staff FTs are gobbled up after they are seen by the GPs as irrelevant.  FTs are providing most services, as GP Consortia turn out to be even more conservative than their PCT predecessors, opting for the preferred provider approach.  

Competition?
Rather than competing, the FTs focus initially on building strong clinical relationships with the GPs and on hoovering up all the income they can from patients in their own locality.  Only a few trying predatory excursions outside their patch. They reach an accommodation with private providers by outsourcing work to them and overt competition is avoided.

Direct use private healthcare actually declines, thanks to successful marketing by the FTs.

There is informed choice for the patient of any willing provider and payment by volume, plus a quality adjustment, covers most services and pathways.   Some patients have their own budgets to buy what they want, with full set of regulated and competing independent providers available; but most patients (especially those living in areas of deprivation) show no interest.  

Two-tier terms
Many FTs and consortia find ways to have a two-tier workforce, as new employees are barred from entry into the NHS pension fund.  The change programme leads to tens of thousands of staff movements under TUPE and redundancies.

All change but no change
But little progress will have been made in integration with social care or even along patient pathways. The shift from acute to primary care will be a trickle; not a rush. Emergency admissions will continue to rise, and inequality will have persisted.  Almost all patients choose their nearest provider.

Targets have re emerged within the numerous contracts, and outcome measures were favourably received only until the Independent Commissioning Board sets up an outcomes monitoring and performance management framework, with league tables produced by Dr Foster.

The costs of managing the highly complex network of contractual relationships are going up, taking resources away from front-line care.  Many GPs resent having been drawn into the bureaucracy of commissioning, and hate the political exposure as numerous postcode lottery issues arise.

Health and Wellbeing Boards are fractious, complicated and ineffective talking shops, with councillors and GPs poles apart on who should be making the decisions; and both avoiding any unpopular reconfigurations.

The private sector lobbyists will still be as frustrated as ever.

Outcomes will have continued to improve - but not faster than the established trend.  

”Never let a good crisis go to waste”
At the next available financial crisis point, the GP commissioners will be branded as failures (like all commissioners before them). Then the next step will be taken, to further develop the market!

Contracts will be offered to private sector providers to run groups of consortia, with some risk sharing involved. A few FTs are privatised, to show the way to the others who are not sufficiently entrepreneurial and to stimulate proper competition.

'One more heave'.

And throughout, The Empire that is the DH continues to adapt and survive.  

And then ...