Doctor: we need a roadmap for NHS reform

Health Secretary Andrew Lansley announced today that he would push on with the Government’s wide-ranging NHS reforms, after gathering more than 6,000 responses to the health White Paper.

The reforms include changing the structure of the NHS so that its budget is mainly managed by GPs rather than Primary Care Trusts (PCTs). Mr Lansley also announced today a renewed pledge to fine hospitals if they fail to end the use of mixed sex wards, and the Department of Health Operating Framework is also expected to scrap the response time targets for ambulances.

Hope on debts

The detail of the announcement also provided a glimmer of hope for GPs planning to set up clusters and consortia and take on health service commissioning – basically deciding who provides which service, to which patients – and budgets themselves by 2013.

There have been concerns that GPs would have to take on debts accrued by their predecessors, the PCTs, which run into hundreds of millions of pounds in total and could paralyse the newly formed consortia. GPs’ magazine Pulse has campaigned against this through its Clean Slate campaign, warning that “asking GPs to take over deficits will damage engagement of the profession in commissioning and widen health inequalities, as affected areas lag behind.”

Today, the Department of Health said GP consortia “will not be responsible for resolving PCT legacy debt that arose prior to 2011/2012” and ordered PCTs and GPs to work towards resolving their debts ahead of that date.

‘Not a done deal’

Dr Richard Withers, the chairman of one of the first GP consortia to be established – Borderline Commissioning Consortia in Cambridgeshire – warned however that it was “not a done deal” that consortia would be debt free.

“Debts are different for PCTs across the country but of course we are worried about taking them on. For my cluster, half is in NHS Cambridgeshire, which had historic debts but are in a repayment process which will deliver no debt,” he said.

“There’s no roadmap of what the consortia should be…so we’re no further forward.” Borderline Commissioning Consortia’s Dr Richard Withers.

“The other half is in NHS Peterborough, which is in a turnaround plan now. They have to save huge amounts of money and I don’t know if they will get debt free – it’s a lot of effort.”

He said saving the amounts of money necessary by 2012 would be a “huge challenge” nationally – as would implementing the reforms themselves without further guidance from the Department of Health.

Roadmap

Despite Health Secretary Andrew Lansley describing today’s Operating Framework as a “roadmap”, Dr Withers said that was exactly what he and his colleagues, including local authorities and PCTs, were missing.

“There’s no roadmap of what the consortia should be, and what their governance relationship will be will the individual clusters,” he said.

“So we’re no further forward. We need a roadmap – local authorities are also struggling about how they will discharge their remit in view of the fact they are facing funding cuts. For PCTs as well – they’ve got this wonderful job of having to reinvent the whole thing but at the same time they will be out of a job, so there’s a tension there as well.

“I still can’t work out this relationship, there’s a tension.” Borderline Commissioning Consortia’s Dr Richard Withers

“I want it to work – I’m a taxpayer, a patient, and an employee of the government, part of the NHS. It’s not for me to say whether it is good or bad, I will just try and make it work.”

The problem, he said, relates to the financial risk of setting up consortia. If the consortium only covers a patient population of 250,000 patients, because of the random caseload in a relatively small sample of people, it will statistically operate with a deficit one year in every five. So they will have to be larger – if the patient population is one million, the financial risk is gone. But the risk of the consortia becoming unwieldy and the relationship between GPs and managers becoming too distant grows, he said.

“It’s an age old conundrum for international companies – the local people do stuff on the ground while the management have control, but the people have a sense of ownership,” he said.

“At the moment the PCTs have this control, but there’s no buy-in from the ground, which is what they are working on. But I still can’t work out this relationship, there’s a tension. And this question, which hasn’t been entirely answered, has to be answered for this to work.”