SECOND OPINION
That is the lowest rate since the 1950s. This is also before an allowance is made to ring- fence and transfer around £1bn a year to local authorities for their new public health responsibilities and the removal of “end year fl exibilities” to cover overspends. If these are included in the calculation then the NHS faces an unprecedented period of sustained budget cuts.
Additionally the NHS is also expected to off- set some of the lack of funding by achieving a dramatic £20bn of effi ciency savings over the current spending review period to 2014.
There is no escaping the fact that provid- ing choice is expensive, and it is no surprise therefore that PCTs have, in practice, been doing their utmost to limit patient choice. The Interim Report of the Department of Health’s Co-operation and Competition Panel (CCP) has highlighted some of the strategies being pursued by PCTs in order to balance their books as the fi nancial crunch begins to take effect.
It found that almost half of all PCTs were taking steps to frustrate policy on competi- tion and patient choice using: “directions to GPs, activity caps, waiting list requirements, and triage and referral management sys- tems which direct patients to particular pro- viders; and seeking to insert provisions into contracts with providers that restrict patient choice including, for example, activity caps and reductions in the types of procedures that providers can offer.”
The CCP report also highlights the potential savings from such restrictions on competi- tion and choice, alongside other steps in- cluding “uniform minimum waiting periods before patients can be treated”. It is bizarre that at a time of great fi nancial pressure in
the NHS, the Government remains deter- mined to impose the ‘any willing provider’ model on the English health service, and continue to promote and enforce a wider range of patient choices when they know that the new consortia will have to deliver unprecedented levels of NHS effi ciency.
Choice in routine elective care is question- able, given that few clinicians would recog- nise that much elective care is in any way routine. Just as patients vary, their care varies too. Whilst the NHS Tariff gives the impression of common prices across the NHS, the ‘market forces factor’ applied to it location by location ensures signifi cant vari- ation in the prices that commissioners must pay to providers.
Excessive Intervention
Patients and many clinicians may fi nd it diffi cult to accept established thresholds for intervention. A treatment that is benefi cial for one patient can be harmful for another, and enforced patient choice can provide a strong drive for excessive medical intervention. The quality of information available to patients and clinicians must be very high in order to manage the pressure to reduce intervention thresholds, particularly in such a time of fi nancial constraint. Furthermore, robust incentives need to be in place to reward those who adhere to best referral practice.
In recent decades a huge amount of care has become possible and available in a com- munity setting. Routine elective care cannot be regarded as separate to this, and care has to be integrated across the spectrum of hospital and community settings. As Mar- tin McShane, a doctor and PCT strategic director, has written: “The elderly patient
with ischaemic heart disease, diabetes, and chronic pulmonary disease who requires a hip replacement needs close and integrated working between the hospital and out-of- hospital services”.
They do not need to be organisationally in- tegrated. In fact McShane argues that they should not, but should be able to work in an integrated fashion. Thus limiting choice to ensure good communication, threshold and protocol adherence will deliver the best outcomes.
To some patients choice will be helpful, Mc- Shane suggests, for a fi t young man with a hernia. The only basis for differentiating between patients is the one-to-one relation- ship between the doctor and the patient, or nurse and patient. All this points to commis- sioners being able to restrict choice along a care pathway when they are confi dent and can demonstrate that this will deliver better outcomes and effi ciency.
The changing nature of medicine, with shortening hospital stays and the rise of community-based care, raises new threats of disintegration in care. Sharing patient information between both settings can be benefi cial to the quality of care.
Having strong relationships between com- missioners and providers is crucial, and the volume of interaction required for some types of care is simply not possible within a fragmented and uncoordinated environ- ment of ‘any willing provider’.
FOR MORE INFORMATION This is an extract from a longer essay by Lord Owen, ‘Fatally Flawed’. For full references, see:
www.lorddavidowen.co.uk
national health executive May/Jun 11 | 19
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