4 Feb, 13 | by BMJ Group
With little media attention, shadow health secretary Andy Burnham has proposed scrapping clinical commissioning as part of a new round of NHS upheaval if Labour is returned to office.
In a speech at the King’s Fund recently, Burnham tried to portray his ideas as a mere reshuffling of the structures that will be in place this April.
Just like Andrew Lansley in opposition, Burnham said “our fragile NHS has no capacity for further top-down reorganisation… I know that any changes must be delivered through the organisations and structures we inherit.”
But he goes on to propose profound changes in the way the NHS is structured. He is developing a plan which will require change at least as great as that needed for the coalition government’s own reform plans.
The slogan is simple—One Nation Labour will deliver “whole personal care.” The vision is laudable—full integration of physical, mental, and social care services. And the analysis of the weaknesses of existing services is one every health and social care professional would recognise—disjointed services too focused on hospitals and care homes rather than providing preventative care to help people live as independently as possible for as long as possible in their own homes.
But his prescription is to take the £60bn budget about to be placed in the hands of clinical commissioning groups (CCGs) and hand it to councils’ health and wellbeing boards.
The sleight of hand is to say that CCGs would remain as clinical advisors—so no top-down reorganisation. This does not stand up to scrutiny. Taking £60bn from GPs and giving it to local government is, by any measure, a massive change to NHS structures, let alone culture. In particular, if CCGs are going from leading their local NHS and buying tens of billions of pounds of services, to not leading their local NHS and buying nothing, it is difficult to sustain the argument that they haven’t, in all but name, been abolished.
It is not that Burnham’s ideas are wrong—the aim of a fully integrated service is surely one that most people would embrace—it is that he is in grave danger of repeating Lansley’s error of seriously misjudging the amount of structural change required to put them into practice.
If Labour forms the next government these reforms would be coming in roughly five years after the beginning of GP led commissioning. Most CCGs will only just be starting to become truly effective, after the long haul of building relationships, determining need, consulting the public, making difficult decisions about strategy, and working with clinical and managerial partners throughout the system to put it into practice. Burnham is planning to ditch all that painful progress and start again with a new system. He needs to provide convincing evidence that yet another round of organisational disruption will benefit patients.
Labour is also proposing to reinvent the role of the district general hospital (DGH). The idea that seems to be emerging is to make the DGH the hub of whole personal care, including social care. This would greatly reduce the need to close A&E departments, Burnham says.
You can see why this model would appeal to a politician. At a stroke all those difficult arguments about reconfiguring services and moving away from the 1950s model of local hospitals are gone. But it is at best optimistic to suggest that the way to pump more money into preventative and community services is to channel it through the very institutions that are currently soaking up the cash in providing precisely the opposite.
The financial sums for all this need careful analysis. Burnham appears to believe that the NHS could drastically scale back the current wave of service reconfigurations, avoid hospital closures, maintain a far larger number of A&E services than is currently envisaged, pay for the set-up costs of his reforms, and still provide integrated, preventative care in the community.
Integrated care would certainly be more efficient, but that is not the same as being cheaper. Indeed, establishing such a system would require substantial investment, and it is far from clear that the lifetime costs for each of us would be significantly reduced, even though quality of life in our later years may well be improved.
While the broad aim is welcome, there are serious financial, organisational, and practical flaws in what Labour is proposing.
Richard Vize is a journalist and communications consultant specialising in health and local government. He was the editor of the HSJ 2007-2010.