Saturday, 4 February 2012

Healthcare reform and its victims

From the moment the present British government was formed in May 2010, the Health Secretary Andrew Lansley has been dead set on reforming the National Health Service.

Lansley: minister for caring
In particular, the organisations that control around 80% of the Service’s budgets, Primary Care Trusts (PCTs) are due to go by April 2013. That means that bodies employing some 200,000 people are into a process of closure that will, by the time it’s over, have lasted practically three years.

Many are jumping ship as quickly as opportunities open, conscious that it may be dangerous to cling on to the end: most will probably be reassigned to positions in the new hierarchy, but some will certainly be made redundant. As people leave, few are being replaced, so the remaining staff are facing increasing stress dealing with an undiminished workload. 

And that’s going to go on for another fifteen months: the certainty of growing pressure coupled with nagging uncertainty over the future.

The process is likely to cost around £1.2 billion at a time of pressure to reduce expenditure. 

I’ve been working with the health service for over quarter of a century and I’ve seen repeated reforms of its organisational structure; I have yet to see any that were clearly better than any other. 

I’ve only seen one that was significantly and radically different: the Thatcherite initiative to introduce ‘GP fundholding’. This meant that General Practitioners held the budget to pay for hospital care directly themselves. Many of the reform initiatives, including Lansley’s, have had the proclaimed goal of involving GPs in decisions about hospital care, but fundholding was the only one which got them actively engaged with the process, because it gave them real clout. 

It was, however, fundamentally flawed: as well as ‘commissioning’ (i.e. paying for) care, GPs were also providers of care, meaning that they could buy services from themselves. That made the system open to abuse that came close, on occasions, to outright corruption.

In fact, the only time that I’ve seen real improvement in the service was under the last government, and not because of any of its tinkering with management structures, but because it invested more money. Spend a bit more and the NHS gets a bit better.

Will Lansley’s brave new system be an improvement? The clue is perhaps provided by the recent revelation that it will involve five levels of management in most areas, and more in some. It will pay lip service to the principle of GP involvement but in reality it will be administered, as usual, by professional managers — the ‘bureaucrats’ the media love to hate but which cost only 3% of the NHS budget and mean that clinicians spend as little time as possible on administration.

So the reform will be painfully disruptive and expensive while leading to little or no gain. Since everyone is against it — the vast majority of health service professionals themselves as well as their organisations — there is some optimism around that it may be possible to block the changes. That’s not an optimism I share: a British government with a majority in the House of Commons can ultimately force any measure through that it has set its heart on. This will go through. The government will do it simply because it can.

So spare a thought for the people working in the PCTs. Most of them take pride in jobs they believe make a real difference. In general, they work hard and do their best to deliver a good service to others.

And they will in the end have spent three years watching their organisations slowly dying, colleagues leaving, their workload piling up and their futures being increasingly clouded with uncertainty. 

British Prime Minister David Cameron used to like to claim that he was building a Big Society in which we would all find our place. Imagine what it would be like if he set out to build a small one.

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