Archive for the ‘NHS Reforms’ Category

National Health Service (NHS) Reform Setback

jeudi, juin 16th, 2011

So the Coalition government has had to step back from its proposed reforms for the NHS, having considered it best to accept the recommendations of its independent commission. This has the benefit of keeping the Liberal Democrats happy and saves the face of Nick Clegg their leader and Deputy Prime Minister. The main concessions then appear to be to:
? Limit competition from the private sector.
? Involve hospital doctors and nurses together with the original General Practitioners (GPs) on commissioning panels for care and managing the associated budget.
? Have no fixed deadlines for implementation of changes.
The government is spinning the outcome as positive saying that health professionals are now back on board (where they should have been before launching the initially proposed reforms of course!) with the proposed changes having the support of patients and professional bodies, as well as back-bench Tory and Liberal Democrat MPs. The legislation is said to have been improved by such scrutiny with the Liberal Democrats claiming a lot of the credit, despite the Coalition only trying to build on what the previous Labour government had started to try and do i.e. to involve the private sector to meet demand over and above what the public sector could support.
One Liberal Democrat back-bencher commented that their efforts had mitigated the effects of untrammelled competition and if local communities did not want competition, they would now be able to call their local health commissioner to account. However, other feedback from the medical profession saw it as now more like a dog?s breakfast!
After all this we are now left with the situation as Nick Robinson the political correspondent of the BBC put it, if the general public did not know before how the NHS worked, they certainly do not understand now:
? how the NHS would have worked with the originally proposed reforms or
? how the NHS will now work in the future with these changes.
If the general public does not understand the problem of the NHS, it becomes an almost impossible task to convince.
The main issue seems to be a broad public unease about profit-making by the private sector in the provision of public services and this includes the Liberal Democrat partners in the governing Coalition, with Nick Clegg calling on Monitor, the health regulator, to promote collaboration among providers rather than competition. However, the UK is unusual among rich democracies in how little private involvement there is in public service provision with e.g. only 4% of acute-care beds provided by private companies. Given that the German economy is held up as a successful example and driver for the European Union of Member States, it is instructive that (according to The Economist of 21st May, 2011) the proportion of for-profit hospitals at 32% already exceeds the 31% of publicly-run ones, with the rest operated by charities and voluntary organisations.
It is ironic that the original idea of putting the care budget of the NHS in the hands of GPs (such family doctors being private operators since the foundation of the NHS in 1947), was aimed at reducing the high cost item in the NHS budget of hospital care by their also finding lower-cost solutions sometimes only involving primary care and not always hospital beds e.g. for elderly patients.

NHS Funding Crisis.

jeudi, juin 2nd, 2011

The National Health Service is facing a £20 billion-a-year funding black hole that will threaten its founding principles unless the Coalition?s controversial reforms are brought in to prevent it, the Health Secretary Andrew Lansley has warned in the Daily Telegraph of 2nd June.This is a sobering message but is anyone listening?
Perhaps Minette Marrin writing in the Sunday Times (minette.marrin@sundaytimes.co.uk) has it right when commenting on what she describes as the horrifying findings of the Care Quality Commission report of last week, on the frequent abusive neglect rather than care of old people in National Health Service (NHS) hospitals. She thinks that the British public has got the NHS it deserves and sees it as the fault of the British voter and the British medico-political establishment.
As the current impasse between the government and entrenched interests within the NHS indicates, reform of the NHS seems almost politically impossible due to what Ms Marrin considers the inflexible, deeply held, quasi-religious beliefs of the public about the NHS. Nigel Lawson, a former (Conservative) Chancellor of the Exchequer, is widely quoted as having once said that the NHS was the religion of the British people, which perhaps explains why Tony Blair, a former (Labour) Prime Minister has said he believed in the NHS. David Cameron, the current (Conservative) Prime Minister in the Coalition government has also said that he believes in the NHS.
However, as Ms Marrin sees it, religion can be dangerous when based only on faith and not taking due account of evidence. On one side then we have the main article of faith of the NHS quasi-religious belief system that all medical care ought to be run as a state monopoly. At the other so-called right-wing extreme, it is argued that nothing should be run by the state. In between, there are for example the health systems of France and Germany where medical care is rated better. Perhaps as Ms Marrin suggests, the lack of constructive critics or whistleblowers among NHS employees is because there is largely only one health employer in the UK i.e. the NHS.

French Health Service

vendredi, mai 27th, 2011

In the previous article (refer to Categories/Chairmans Blog/NHS Reform Problem in the right-hand index column) the point was made that, using the example of the French health service, which has been highly rated by the World Health Organisation (WHO), the introduction of private sector competition in the British National Health System (NHS) is not necessarily a change for the worse. The Prime Minister has also made the case that modernization is essential to save the NHS from rising costs leading to a funding gap of some £20 billion by 2015. In addition, serious concerns have now been raised by the Care Quality Commission (CQC) about the way some NHS hospitals treat elderly people. The CQC has said that three hospitals had broken the law by failing to meet essential standards of care on dignity and nutrition. We will see how the increasing number of elderly people requiring care is already of concern to the French state when we address the French health service further below.
However, the British Medical Association (BMA) representing the medical profession has already called for scrapping of the government proposed Health Bill, saying that required changes can be achieved without legislation. The Deputy Prime Minister & Liberal Democrat party leader Nick Clegg, has added a call for collaboration rather than dog-eat-dog, open competition, in the provision of health services.
Taking the standard of excellence given to the French health service by the WHO, it is instructive to look at the health and other dependency problems also facing the government in France (Les Echos Mercredi 18 Mai, 2011). The number of elderly people dependent upon state care is expected to double by 2060 (+35% by 2030). This is anticipated to result from an increase in life expectancy amongst the elderly which will be accompanied by similarly increasing problems of incapacity whether e.g. with respect to their health and/or ability to look after themselves. From 2025 the problem will worsen when the population bulge from the baby-boomer generation born at the end of WWII will begin to reach 80 years of age and require increasing care.
The French health service itself is considered by the French Health Insurance association to have worsened over the last 30 years and requires rapid structural reform. A protocol agreed on 15 October, 2009 allowed for the opening up of an optional, intermediate level of fees between the sector 1 state level and the higher sector 2 level of private practice. This applied to specialists such as surgeons, anesthetists, gynecologists & obstetricians who would in turn commit to a minimum 30% of their work being charged at the rate reimbursed to their patients by the French state social security. For their remaining work, their fees should not exceed the state social security rate by more than 50%. The association of complementary health insurance would then have encouraged its members such as not-for-profit mutuelles, health insurance companies and institutions to cover these excess charges over and above the state level, the objective being to gain the support of the great majority of practitioners to remain within this optional intermediate level of fees.
However, the net result by 2010 is that the excess fees charged and not reimbursed by the social security already represent ?2.5 billion (17% of total specialist fees) and the average excess charged has reached 54%, compared with 52% in 2009 and ???25% in 1990. The Health Insurance association, therefore, considers the current market for health services a sham in which the main aim of resetting the tariff structure seems to be only to produce fees increasingly in excess of the social security level. Further, the data for 2010 shows that within certain areas of expertise the great majority of new practitioners have opted for the private sector 2 :
? 87% of new surgeons
? 82% of gynecologists
? 66% of anesthetists
On average 58% of the medical profession (excluding general practitioners) have chosen sector 2 in 2010. For surgeons, their excess fees already represent 32% of their total remuneration. Over the last 10 years the most rapid progression within sector 2 has been observed amongst anesthetists and radiographers even though for the latter this only represents 14% of their total practitioners. There is also a regional effect with the average excess fees of private surgeons already reaching 150% above the state level in Paris & its surrounding areas, 110% in the Rhone region and 90% in Alsace.
The question for the Coalition government in the UK is whether it can rely on the BMA to do any better amongst its members to secure change on a voluntary basis i.e. through collaboration and not legislation?

NHS Reform Problem

mardi, mai 17th, 2011

In the previous article on this blog (refer Categories/Chairman?s Blog/Constitutional Reform in the right-hand index column), we quoted the point made by Bill Emmott , writing in The Times, that before proposing a solution first define the problem that must be solved. The reform of the NHS (see also Categories/Chairmans Blog/NHS Reforms in the right-hand index column) proposed by the government is another case and point.
Polls show that satisfaction levels with the NHS amongst those who use it are currently the highest they have been in recent times. This makes it difficult for people to understand the actual problem that requires this government reform as a solution. It is also a matter of people in general being resistant to change preferring instead e.g. to be grateful to wait in the queue for health care available to all, rather than taking a risk on a change for the worse. This is despite the World Health Organisation (WHO) concluding that France and Holland offer a much better health service through a mixed system of public, private and charitable funding.
The non-profit-making, health insurance companies (Mutuelles) in France, provide insurance complementary to that of the State social security and are often are set up for particular professions e.g. students, teachers etc. Since they then cater for a much larger segment of the population over which to spread their risk than the private insurance schemes of the UK, their charges are proportionally lower and more widely affordable. Private sector competition in the NHS is not necessarily by definition then a change for the worse. Nor should there be necessarily a great fear encouraged by political opportunists, of ending up with something akin to the American health system which supposedly would refuse to treat someone too poor to pay for life saving treatment. President Obama has also already used up a lot of political capital to ensure improved access to health insurance for poorer people.
The Prime Minister has added authority from his successful No campaign in the Referendum on The Alternative Vote (AV) but here it was easier to lobby against change, and indeed also essential if reports are true that the Conservatives had concluded that they would lose out under a system of AV, with significantly more Liberal Democrats likely to give their second preference vote to Labour than to the Conservative party. He now has to convince the public that not only is the NHS safe under a Conservative?led government but that improvements are also necessary and can be implemented while still ring-fencing its finances against the current budget cuts. As it is, with professional staff associations and unions accusing the Health Secretary of trying to destroy the NHS or privatize the NHS, his reform bill has been halted and a consultation process is underway to find allies in the medical profession but likely to result in heavily diluted legislation (as also was the case with President Obama who finally had to compromise).
Yesterday, the Prime Minister was already making the case that modernization was crucial to save the NHS from rising costs that pointed to a £20 billion funding gap by 2015. The only option as he put it, is to change and modernize the NHS, to make it more efficient and more effective, and to focus more on prevention, on health, not just sickness. These are fine words but there are still quite raw memories passed down of what it was like before the advent of the NHS for those who could not afford to pay for treatment and this fuels fears of a similar outcome in the future. However, there are still major problems to be resolved such as the increasing costs of treating the elderly as this proportion of the population continues to expand with improving life expectancy. It is also not acceptable in a developed country in Europe that people are forced to pay privately just to get an appointment with a GP or a dentist within a reasonable time or that for non-emergency treatment they can wait months to see a specialist, for the results of medical tests or for a follow-up operation, indeed for the latter in the past sometimes years.

NHS Reforms

samedi, juillet 24th, 2010

Last week Andrew Lansley, the Health Secretary, published his white paper on reform of the National Health Service (NHS).This sets out a policy framework aimed at abolishing Primary Care Trusts (PCTs), giving General Practitioners (GPs) instead the responsibility for commissioning treatment for their patients. Having thus empowered GPs, the Health Secretary then expects them to proactively respond in making informed decisions without seemingly further guidance from the Department of Health. This could lead to the creation of large US-style, privately owned Health Maintenance Organisations (HMOs) which in practice have driven up costs without correspondingly fair and reasonable improvements in US healthcare.
In fact, over the past two years under a practice-based commissioning initiative under the last Labour government, GPs have already been encouraged, should they so choose, to take control of part of the local health budget. For example in Cumbria last year, six teams of GPs each serving a population of around 100,000 have worked with a shadow budget and, as of last April, have been responsible for 60% of the £800 million health budget. A mutual-benefit partnership between the public and voluntary sector is foreseen (evoking the Big Society of David Cameron?) which, e.g. in the case of their more elderly patients would involve Age UK, collocated at favourable rates with the GP team, bringing practical assistance aimed at keeping them in their own homes and out of hospital (a potential saving of £3000-4000 per non-hospitalised patient).
However, the experience gained from the earlier GP fund-holding experiment of the Conservative government in the 1990s, when it was unfortunately decided not to evaluate the actual results from the beginning, also needs to be taken into account. Although the general public received no information on whether clinical outcomes and patient safety or the cost-effectiveness of care were improved, there were suggestions that patients of such fund-holders were often reported as less satisfied with their NHS services, felt knowledge of their medical history worse than before and the willingness of their GPs to refer them to specialist treatment diminished. GPs seemed more concerned with keeping costs down rather than improving care. The complexities of contracting could also lead to any efficiency improvements being offset by high transaction costs between GPs and hospitals, the former often forced to make decisions without accurate information about the quality of the contracting services on offer. Overall, fund-holding was unable to achieve major and sustainable improvements in their hospital experience as far as the public were concerned e.g. in reducing waiting times, something that the NHS reforms of Labour did achieve and that matters to patients.
In summary, therefore, it would appear better to first test these proposed NHS reforms via a limited number of carefully selected pilot schemes, with their clinical outcomes, efficiency gains and cost effectiveness measured against predetermined but realistic targets, to foster the subsequent development and sharing of best practices.