Richard Smith: Will the Big Society help with NHS efficiency savings?

Richard SmithWill the Big Society, GP commissioning, and a major reorganisation help or hinder the NHS in making 4% efficiency savings compound over four years? This was the question that kept running through my mind as I listened to a discussion at the King’s Fund on whether the current health reforms amount to “patient power or professional capture.”

Stephen Dorrell, chair of the Health Committee and former secretary of state for health, said that making the efficiency savings was the “key issue.” No health system anywhere has, he said, ever succeeded in making such efficiency savings.

Sounding sceptical about the ability of the NHS to succeed, he said that the idea of the Big Society (I’ll continue to capitalise the phrase for the rest of this article, thinking it “respectful”) was simple not difficult. He thought it best caught in the phrase “There is such a thing as society, but it is not the same thing as the state.”

In other words, each of us has a responsibility to others. We can’t abdicate all such responsibilities to the state. Some might see “professionalism” (absolutely one of the words of the moment) as antithetical to the Big Society in that it’s about the power of professionals not people, but for Dorrell professionalism is an “application of Big Society.” As part of their contract with society professionals have freedom but also responsibility. That responsibility means that doctors – and particularly their leaders and institutions – must rise to the challenge of improving quality and efficiency in the NHS.

Clare Gerada, the new chair of the Royal College of General Practitioners, accepted this challenge. In particular Dorrell wanted the colleges to address practice variation, but Gerada, adapting quickly to her political role, said that GPs shouldn’t be blamed for practise variation, Rather it was important for people to understand the deeper context that led to such variations.

A senior manager from the audience made the observation that in 12 years of hearing advice from royal colleges he couldn’t think of one piece that didn’t amount to more doctors and more resources, but Gerada interrupted him and said what about shared care.

Then we descended into the inevitable debate around choice, which, as Dorrell said, does mean competition but not necessarily commercial competition. Rather it might be professional competition. Secretaries of state for health – with the exception of Frank Dobson – had for 20 years favoured choice recognising it as one of the incentives for raising quality and improving efficiency. Gerada pursued the usual doctor line that when it came to providers patients wanted quality not choice, but she fully supported choice of treatment and shared decision making.

Gerada accepted that there was “an inherent conflict of interest in GP commissioning,” and many of those in the audience, some of them managers facing redundancy, were more worried than those on the platform about this conflict of interest. Will GPs reform primary care as well as secondary care? Will patients lose trust in GPs if they think that decisions about them are driven by cost rather than their best interests?

Speaking for patients, Angela Coulter, observed that it would never be possible to involve patients at a political level in designing the NHS if they weren’t involved in their own care. Three things are necessary for true shared decision making – good evidence based information, support for decision making from professionals, and clinicians who are willing to act on patients’ choices. All three are deficient in the NHS, she said. “A system as paternalistic as the NHS has been,” she concluded, “can never hope to get people involved in difficult decisions.”

Wasn’t all this a bit airy fairy and theoretical, asked Polly Toynbee, the Guardian columnist. Isn’t it getting brutal out there in the real world? Yes it is, answered Robert Creighton, chief executive of Ealing PCT and two other PCTs. He asked whether the meeting was on the record, was told it was, and then said “This could be a bloody awful train crash.” He could see “collapse of the system” and thought that the NHS was looking inwards just when it needed to be concentrating on getting more for less. The previous day he’d spent 13 hours interviewing staff and hadn’t had any time to think about quality or cost. What, he wondered kept him going when he was heading towards redundancy and politicians tell him that what he’s been doing for the past eight years has all been a waste of time?

This outburst led to spontaneous applause, and, as one of the audience observed, “If that’s what he says on the record what would he say off the record.”

My provisional answer to my initial question is that the Big Society and GP commissioning could potentially help with making the dramatic savings that the NHS needs, although whatever benefits they bring may be years away, but the major reorganisation will surely get in the way.

Richard Smith was the editor of the BMJ until 2004.