LEADERSHIP & MANAGEMENT
Thomas Cawston, senior researcher at the Reform think tank, which favours free market solutions to delivering public services, discusses accountability and the fl awed leadership that has resulted in poor NHS reforms.
T
he proposals in the NHS White Paper aimed to put “patients at the heart of
everything the NHS does” and ensure there is “no decision about me without me”.
According to Nick Clegg, “the right kind of reform starts from the patients’ point of view. Not bureaucrats, not unions, not ministers, not political parties – patients”.
And Ed Miliband has argued that “change in the NHS works best where it strengthens accountability and makes the NHS answer- able to patients”.
All agree that a lack of accountability to patients is the root cause of poor perfor- mance in the NHS. Despite reforms to cre- ate greater freedoms for individual organi- sations, the NHS continues to be centrally led through big central authorities and the use of top-down targets. Too often staff in the NHS do what is in their own interests, not those of their patients. So the real test of reforms is whether they actually convert rhetoric into reality. The current reforms are the latest in a long line of failures.
The reforms to the commissioning struc- tures were intended to localise power, yet the Government’s reforms make the NHS accountable to many different and new or- ganisations. Accountability will be divided between clinical commissioning groups, clinical senates, health and wellbeing boards, HealthWatch, regulators and the Department of Health. In practice, this will make it next to impossible for the patient to work out who actually is responsible for delivering better healthcare.
In the unnavigable bureaucratic spaghetti of these new structures patients will get totally lost – and their voices will be un- heard. As Lord Crisp, the former Chief Executive of the NHS, has recently ar- gued, the Government’s reforms are tak- ing the NHS back to a “medical model”: rather than a system that is responsive to the needs of patients, the new NHS will be dominated by the interests of doctors. In this respect, it will reinforce one of the long-term problems with the NHS; namely that it is a monopsony in which the health- care professionals too often have power without accountability.
30 | national health executive Sep/Oct 11
The result of these confl icting accountabili- ties will be that the Secretary of State will be asked to intervene. Moreover, the new National Commissioning Board will exer- cise draconian powers over the new local commissioning groups. Sitting before the Health Select Committee, Sir David Ni- cholson stated that “we’ll have to centralise more power in the very short term to de- liver benefi ts”. The Government’s reforms will actually lead to a top-down approach, exactly the opposite of its intention.
While greater patient choice was a key theme of the original White Paper, Govern- ment ministers are sending mixed signals on opening up the NHS to competition and giving patients real choice. Meanwhile the Co-operation and Competition Panel has found that nearly half of primary care trusts are blocking choice.
The NHS has created caps on the number of people private providers can treat, prom- ised NHS hospitals set numbers of patients and even introduced minimum waiting times to restrict the fl ow of patients.
The NHS Future Forum called for a revised role for Monitor and the Government’s re- sponse proposed for the Commissioning Board to develop a “choice mandate” to establish the terms of patient choice. But choice is meaningless without alternatives to choose between.
But even while some doubt patients’ capac- ity to choose treatments, patients are now more engaged in their healthcare than ever before. There is now much greater access
to information of the quality of NHS ser- vices. Through the developed world, the practice of medicine is changing from pa- ternalism to partnership with patients. In our consumer age expectations are rising and the NHS must respond.
To transform the delivery of healthcare, health services need to be held accountable to patients. Medical Homes and Account- able Care Organisations in the USA offer a powerful vision of how clinical commis- sioning groups could be developed into in- tegrated, patient-centred and team-based providers, competing to attract patients on quality and cost.
In Valencia in Spain, a public-private part- nership now delivers comprehensive and integrated care at reduced cost and better outcomes. In Holland patient choice of insurer has led to more effective commis- sioning and greater effi ciency among hos- pital providers.
Even in some of the poorest regions of India patients are choosing healthcare on quality, not cost, where hospitals are com- mitted to improving customer satisfaction. Real patient choice, not accountability to the Secretary of State, will put the patient at the heart of a health service that delivers quality, affordable healthcare.
Thomas Cawston
FOR MORE INFORMATION Visit
www.reform.co.uk
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