Thursday, 16 September 2010

Welcome to the NHS reform merry-go-round.

When I first began to work in healthcare in England, I got caught up in the so-called ‘Griffiths reforms’ of the mid-eighties which moved responsibility for managing hospitals away from geographical organisations known as Health Authorities and to the hospitals themselves.

Within a couple of years, the transformation was complete. Acute (short-stay) hospitals were more or less responsible for their own destiny, with other services run by just under 200 District Health Authorities, each responsible for about 250,000 patients.

Although this measure had been brought in by the administration of Mrs Thatcher, the government (which meant her) decided a while later that reform hadn’t gone far enough. So it introduced the concept of GP (General Practitioner) fundholding, which meant that GPs – or at any rate GP practices – or at least some of them – would hold the funds that paid for hospital care and purchase services from them.

This led to a reversal of the ‘Christmas Card test’. Up to that time, generalists would send hospital doctors a Christmas card each year in the hope that they would remember the gesture when it came to choosing which GP’s patients to treat first. After the introduction of GP fundholding, the traffic was reversed, with hospital doctors sending GPs Christmas Cards in the hope that they would remember them when it came to referring patients for acute care.

One of the benefits of the system was that GPs could provide some of the services themselves, such as minor surgery, so they could divert some of the funds they were receiving to pay for such care, into their own practices.

I’m sorry, I mean of course that it gave them an opportunity to provide services more efficiently on behalf of their patients.

When Labour got into power in 1997, they moved to put an end to this system. It was costing too much and favouring certain patients over others: those who had a fundholding GP could expect preferential treatment, and certain GP practices simply didn’t have the means to set themselves up as fundholders. So instead we got Primary Care Trusts (PCTs; originally they were Boards but soon they became Trusts – that’s how exciting the blistering pace of reform became.) There were about 300 of them, covering over 150,000 patients each.

To compensate GPs for the loss of earnings from fundholding – sorry, to make up for the loss of a means to help improve healthcare delivery – the government put in place nice new contracts that guaranteed them a fair remuneration, of about five times the earnings of ordinary mortals. Nothing to worry a banker, who makes us much in a year as a normal man in 50, or 100, or sometimes even 200, but nonetheless nothing to be sneezed at.

Then the government decided that there were too many PCTs, so in 2006 they brought the number down to 150 covering some 300,000 patients each.

Now of course we have an exciting new government that wants to do things differently. It wants to get back to GPs calling the shots in acute hospital care. I’ve heard it said that this may not be unrelated to the fact that the wife of the present Minister is a GP herself, but you can imagine how shocked I am that anyone should utter a thought so cynical.

The beauty of putting the GPs back in the driving seat is that it’ll make decisions much more local, much closer to the people affected. Obviously, you can’t get right down to the most local level of all – a single GP. I mean, how do you manage things like major organ transplants at the level of the individual generalist? In some years, he or she might not order a single one. To be honest, even one practice may be a bit too small. It looks like we’re going to have to work at the level of consortia of practices.

In fact, the government thinks we could probably work with about 500 Consortia covering 100,000 patients each, although the British Medical Association has announced that to get the proper coverage, we’re going to need about 100 Consortia, each handling about 500,000 patients. Obviously, in the BMA’s approach it’s hard to see just how the much-vaunted localism will be achieved.

We’ll probably end up compromising on about 200, rather like the number of District Health Authorities and somewhere between the first number of PCTs and the final number.

It’s great how these things keep going round and round. It gives the old hands like me a sense of familiarity, a sense that we recognise the landscape. Again.

The thing to admire in all this coming and going is the consistency. Through all these reforms, there have run some unvarying golden threads:
  • Each is designed to do away with the obscene inefficiency of the previous system, and to deliver better care at lower cost
  • Each of them costs a fortune to implement
  • Each of them has been deemed a complete waste of money by the next lot, even when the next lot is just the same lot following a change of mind.
  • The next initiative is designed to usher in a golden age of better care for less money.
A couple of other constants is that no managerial staff ever get the chance to see any initiative fully-implemented, and most of them turn up in the next embodiment of the NHS in much the same role or perhaps with a small promotion.

The doctors, of course, always end up with a smile on their faces. And aren't smiley faces just what we expect in a fairground?

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