The dust has settled…
… people have moved on.
The, what-was-a-ten-year-plan, finally got published… late, and now there is a scramble in the DH+…
… to figure out how to turn pie-in-the-sky into meat-and-two-veg for the NHS, in about eight and a half years and…
… try and enthuse people working in the debris of redundancy and reorganisation, with no money and even less capital, to do some of it.
A theme that runs through the Plan is choice. It’s not new. Somehow, plan writers are always mesmerised by the thought of the NHS as Tesco’s.
Twenty-five years ago, the NHS underwent a significant policy shift towards market-style reforms, under the Blair and Brown Labour governments.
Much of the choice and competition agenda was developed and implemented under Alan Milburn, Secretary of State from October 1999 to June 2003.
His tenure laid much of the foundation for what followed.
The mantra of the period was ‘choice and competition’, underpinned by the belief that introducing market mechanisms into healthcare would drive up quality and improve efficiency. Alas…
… the evidence that has emerged since paints a very different picture.
The reforms largely failed to deliver their promises, and by 2011, the policy had begun to quietly recede.
A closer read of the new 8.5 Year Plan looks to me like Milburn, who has popped up on the DH+ board, is back in the driving seat.
The market reform agenda was fired up by the 2002 Wanless Report, which called for greater responsiveness and efficiency…
… paving the way for the introduction of patient choice of hospital, Payment by Results, foundation trusts, and increased commissioning competition through independent sector treatment centres and private providers.
The policy was borrowed from economics theory; competition between providers for patients would lead to better quality, shorter waiting times, and improved efficiency.
In 2006, patients were given the right to choose from at least four hospitals when referred for elective treatment.
Three years before, Primary Care Trusts had been encouraged to commission services from ‘any willing provider’. A policy known as World Class Commissioning was launched to professionalise and commercialise the commissioning function.
Monitor was established as a regulator to promote competition among NHS providers and new market entrants.
Despite extensive structural changes, actual patient uptake of choice was a dud. Research by the King’s Fund and Nuffield Trust found that while patients supported the idea of choice in principle, very few actively used it.
Patients do what patients do… opt for the nearest hospital because: it’s convenient, travel is simpler, we know people who have been looked after there, relatives can help, and inpatients can be visited by friends and family, and…
… surprisingly in the world of supermarkets, which health planners find so beguiling, locality and convenience are the key determinant of where we shop.
The evidence for improved quality as a result of competition was weak. Later work by Propper suggested benefits may have been overstated and were not sustained over time.
More worryingly, there was no consistent evidence that competition reduced costs. In fact, transaction costs rocketed. The NAO reported:
‘… the administrative burden of commissioning and managing competition was high, while the health outcomes failed to justify the expense.’
The introduction of private providers into the system also raised problems with cherry-picking and destabilisation of Trust finances.
By 2011, the failings of the choice-and-competition model were becoming obvious.
The NHS Future Forum review (2011), led by Professor Steve Field, called for a recalibration away from competition towards collaboration and integration.
From that point onward, the rhetoric shifted. Simon Stevens’ Five Year Forward View (2014) effectively buried the agenda, replacing it with a vision of integrated care and system-level planning through partnerships and integration…
… a place where the NHS is most comfortable and at its best… collegiate and sharing best practice.
When the evidence is clear, why would any organisation have another go at it, largely on the say-so of the person who encouraged it in the first place and saw it discredited…
… why do it again?
Perhaps making all of our local hospitals well run, efficient and safe is just too much to ask? Beyond DH+ to plan, create and see through.
The coterie of Labour luvvies running the NHS today must stop looking backwards for policies, they must look forward with evidence, not nostalgia…
… and build a service that works for today, not reheat the failures of yesterday.
News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.
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