Death by 1,000 cuts?

Linda Duberley asks: is there light at the end of the tunnel, or is it a train coming towards us?

In May the new coalition government outlined its reorganisation of the NHS. Everyone knows the NHS needs to cut back on waste but more re-organisation is not necessarily what the doctor ordered. According to Health Secretary Andrew  Lansley, the party has begun its drive towards better patient outcome by publishing a revised Operating Framework.

We took a further step, putting in place a zero tolerance approach to infections; setting out how we can move from process targets to evidence based quality; developing payments for performance, geared to results; and moving towards a service which empowers clinicians and makes them more accountable for achieving the best outcomes for their patients.

“Five years ago, I told the NHS Confederation that the NHS did not need half-baked, inconsistent reform or a direction of travel with no idea of the destination. I believed then, as I believe now, that the NHS needs coherent, consistent reform, and a clear understanding of where we are much reorganisation.

At first this seemed likely but far less so now. A new system, comprising what could be the biggest change in the history of the NHS, is now likely just as the hardest cutbacks are about to begin. Partly this is the inevitable result of the coalition’s dual aims and partly of the inevitable distaste politicians have for practical solutions. Central to the reforms is the restructuring of the Strategic Health  Authorities (SHAs) whose responsibility it is to plan health services and training for healthcare professionals.

The Lib Dem manifesto described them as the least effective part of the health service and promised to abolish them. The coalition government has now confirmed an independent board for the NHS which will set priorities. Concern comes from two quarters. Staff at the SHAs are wondering where this leaves their jobs and ultimately patients, and prospective patients are wondering  if this improves the care they are likely to receive. Insiders at the SHAs say that although some new organisations are likely to be created the actual work will remain the same and will continue to be valued and carried out… somewhere in the pipeline.

This will mean expenses but not necessarily root and branch change. Reassuring for the staff but maybe not the patients. A spokesman for the Department of Health commented: “Process of change will begin with the SHAs. There will be a clearer split between their commissioner and provider responsibilities. The remit of the SHAs will change. The independent board will combine functions through the regional offices that will report directly to the chief executive.”

But there are few fears that the system will change overnight. As the authoritative system for making decisions in the NHS they will continue to exist all the way through to April 2012. In fact, as the gatekeeper to the system it is likely that the SHAs will have more work to do holding everything together during this period. Clear gains through effective streamlining need to be realised for the amount of reorganisation involved being worthwhile. At the moment, that is a difficult calculation to estimate. One senior manager at one of the UK’s biggest SHAs said: “You do  need a regional tier to keep control of the system. There is some speculation that because of these management cost savings organisations will be axed, but in my view SHAs are very efficient and will be able to make the savings.” Despite the current climate many managers are still reassuring staff, confirming that there is plenty of work to do during a  period of transition and that, even once reorganisation has taken place, well paid and challenging work will still emerge.

An NHS insider told us: “A lot of people in the NHS have been through this all before and they know people might be doing the same job, but perhaps in a slightly different organisational format. We should be very confident that this will happen again in this case.”

But this is not necessarily an ideal scenario. As Polly Toynbee pointed out in last month’s (August) Guardian, distracted staff can spend a year reapplying for their old jobs under new nameplates and settling into different hierarchies instead of focusing on what matters most: good, clean and cost-effective care. She wrote of one public health director in the  South West who had reapplied for his job seven times under a Labour government. So, according to insiders and keen observers, it is a finely balanced risk calculation as far as the SHAs are concerned. But many share one concern.

Andrew Lansley’s white paper hands over almost the entire £80bn NHS budget to GP control. Thirty-five thousand GPs will be organised into groups of 500 to 600 to commission all local services. This is where much of the doubt and speculations lies. The outgoing Primary Care Trusts (PCTs) were created by the Labour government, and their relatively  short history has already been reorganised. In 2006 the number of PCTs was halved to 152, a process which doctors criticised at the time for leading to a period of upheaval and indecisiveness. This new dramatic reshaping of the NHS will depend critically on persuading family doctors to accept contracts, which effectively turn them into business managers. Many don’t want to do it and some are not competent enough to undertake this dual role.

Sir David Nicholson, the chief executive of the NHS, has explained that there is huge determination to get this core part of the reform off the ground as soon as possible, but that there is an inbuilt brake factor, not least the complicated set of negotiations with the British Medical Association.

Deals will need to be done on how much GPs are paid for taking on a commissioning role that is currently undertaken by the PCTs. In addition, the contracts for the whole of primary care, also with the PCTs, will be held in the future by the independent board, including those for all 8,000 GP practices in England.

According to Sir David, even with all the goodwill in the world – and that is a wishful scenario – it is unlikely that this new system will be up and running within the next couple of years. Some GPs are already involved in practice-based commissioning but there is a long way to go before all GPs acquire anything like the number of skills they need. He gave most GPs a score of just three or four out of 10 for their commercial abilities. In addition, all the research shows a massive variation in the quality of prescriptions and the hospitals referrals made. Sir Richard Sykes, newly resigned head of NHS London, broke his silence on the BBC recently to express his concern over the plans to push family doctors into the world of commerce. 

GPs are not entrepreneurs, he said. The new GPs will also have to carry the burden of the cuts in local care services for the disabled and the elderly. Homecare will have to come out of their budgets, which are likely to shrink. It is hard to imagine how the deaneries will survive in their current form. Although unused to public attention, each deanery commissions postgraduate medical and dental education to standards set by the General Medical and Dental Councils  and Postgraduate Medical Education and Training Board. Although they have been criticised in the past for not  providing accurate and detailed information to applicants, it is hard to see how they would be scrapped in their entirety.

It has been speculated that they could be aligned with regional divisions or they could become attached to the new consortia. Senior managers seem to agree that whatever the future holds, no one believes there will be less medical education and less dental education, so the repercussions for staff may not be as severe as suggested in some quarters.

We can only hope that the GPs are up to the task and that sufficient numbers of them will be interested in managing  NHS budgets effi ciently and equitably. If not then we might all be heading for trouble.