It is all over now. The Health and Social Care Bill has been passed. The politicians have moved on, content to leave professionals and managers to pick up the pieces. Whichever side of this exhausting, divisive, and passionate argument you favoured, we are in a different place now. It is no longer a question of should we or shouldn’t we? Instead it is: how do we make this radically different NHS work for our patients? And how do we avoid reasonable fears about the bill from becoming a reality?
That will depend, at least in part, in just how different the landscape turns out to be. So it is right now, while decisions on interpretation and implementation are still to be finalised, that doctors must seize the initiative. The devil, we are told, is always in the detail. It is up to us to make sure the detail is right. Whether or not you support the reforms, there is work to do and room for optimism.
The long debate over the bill was made all the more difficult because there were two diverging strands. One was about clinical commissioning and the establishment of Clinical Commissioning Groups (CCGs), while the other focused on greater competition and increasing NHS marketisation. Things were easy if you were against or in favour of both, but problematic if you favoured some parts and not others.
Yet despite the complexity and the fervour, the debate revealed a surprising level of agreement between both sides about what we did—and did not—want to see. Few, for instance, wanted an NHS dominated by corporate providers or where commissioning decisions were made by private companies through “commissioning support.” Few on both sides wanted to see competition treated almost as a religion, irrespective of the good of local people and patients. And we are absolutely united in the view that too much (and too over-weening) bureaucracy would be nothing but destructive.
Both those for and against the Bill spoke from a strong ethical base, with a common commitment to fairness and creating a more cost effective NHS. Indeed, in many ways, the yes/no view amounted to how optimistic or pessimistic you were. The optimists thought that clinical commissioning would put clinicians in the driving seat, able to decide how much competition was needed to improve local services for their patients. The pessimists thought it was a convenient fiction to camouflage the privatisation of the health service—the end of the NHS as we know it—with doctors set to take the blame.
Yet clinicians, and especially GPs, have proved themselves to be endlessly pragmatic, adaptable, and powerful. Witness the speed with which the GP Quality Framework was put into action. For all clinicians, the Outcomes Framework makes more sense than the endless previous targets that were demoralising and were eventually gamed by clinicians and managers in both primary and secondary care. Provided the new outcomes are translated into a minimal number that genuinely demonstrate patient benefit, then things should be better.
The development of clinical commissioning itself has been an inevitable evolution from Fundholding/Locality Commissioning through Primary Care Groups to Practice Based Commissioning. As one GP recently put it: “In other industries workers at a similar level of seniority to GPs would be expected to be accountable for the simultaneous flows of activity and money” (1). Like it or not, the role of the GP, traditionally advocate of the individual patient, now extends to the health of all patients in his or her CCG locality and the cost effective use of NHS resources. In short, GPs and other clinicians are now responsible not only for individual patients but also for the sustainability of the wider NHS. That is quite a responsibility but primary and secondary care doctors together can lead the change. We can use our abilities and power to ensure that the NHS, patients, and the public all get the best possible health service.
A recent article on the Bill in the BMJ said: “The single greatest fear is the potential for more private medicine.” Clinician views will differ as to whether a little bit less or a little bit more private medicine, or a little bit more or a little bit less competition, is desirable. All would agree, however, that a complete takeover by corporate industry would be undesirable for both provision and commissioning. The new system gives clinicians two bites of the cherry to prevent this from happening.
As commissioners: GPs working with specialists and other clinicians will be in a position to commission the services that they and their local patients deem to be the best and, if the current government promises are to be honoured, to decide the means by which such services will be commissioned. Furthermore, we will have a second bite because many patients coming into GP surgeries will be deciding alongside their GPs, which of the various services on offer they wish to choose. Add to that the relatively low profit margins in general practice and community care, and even the greatest pessimists should recognise that we, as clinicians, have a sporting chance of getting this right. Meanwhile, the whole debate on whether we need more or less competition is becoming altogether more pragmatic and less ideological (2) with the recognition that competition can be an answer to some questions but is not a panacea.
If we want to avoid our worst fears, then all clinicians need to recognise that our choice now is whether to run with the solution decided, continue to “dig in” – or walk away. To do the latter would be a great pity because there is a real chance that, in strength, we can create an NHS that works, that squares the circle of competition vs integration, and that avoids the nightmares of the pessimists. That is so especially if we can combine the energy, enthusiasm, and ethics of those who argued most passionately on both sides of the Bill. We should and must all be on the same side now otherwise we will all be equally culpable of the consequences that follow. And bad consequences would be inevitable if clinicians turn their backs on these reforms.
Passion and previous difference of opinion should not be the problem. Fundholders and non-fundholders, who were entrenched in desperate battles during the 1990’s, are now solidly pushing the clinical commissioning agenda together. All clinicians must now think very hard about doing the same. The danger to the future of the NHS lies not in those with strong feelings of whatever kind, but in two entirely different quarters.
The first are those clinicians who did not take part in the debate, who are uninterested and perhaps assumed or hoped that nothing would happen. Without their engagement, CCG leadership will be unable to progress and nothing will happen.
The other – even greater – danger is that implementation of the Bill will meet all the traditional forces of inertia that succeeded in paralysing Locality Commissioning, PCGs, and Practice Based Commissioning long before the current reforms. These most powerful forces in the NHS, represented by some senior managers and a handful of clinicians, are not sympathetic to the concept of clinical leadership (especially not with a primary care focus) or the devolvement of decision making to a local level.
After all the debate and all the passion, the greatest danger to the NHS is not whether the sky falls in but that nothing will happen.
Michael Dixon is a GP in Devon and chair of the NHS alliance.
1. Davies P. “From Patient Advocate to Gatekeeper: Understanding the effects of NHS Reforms” – British Journal of General Practice. January 2012: Letters, Page 12.
2. “Competition in the NHS”. Report of the Office of Health Economics Commission – January 2012.