The NHS and reform
The House of Lords is currently grappling with the proposed Coalition reforms to the NHS. But even as their Lordships debate, the new NHS Commissioning Board, which is at the heart of the government’s reforms in England, is due to start work. The Board will have a major role. It will take on the day-to-day running of the NHS, with a staff of around 3,500 and have overall responsibility for NHS care worth £80bn. It will also oversee the new clinical commissioning groups led by GPs and other clinicians who will “buy” care within the NHS, and organising the treatment of complicated conditions such as heart transplants.
The NHS is very good at delivering care within budget but it struggles to enact innovation and its productivity record is poor. At the heart of the reform programme proposed by the Coalition is the belief that plurality in provision in the NHS will foster innovation and productivity. While the medical unions, broadly defined, have run an active campaign against plurality equating it with privatisation and an increase in inequalities, plurality on the provider side is a model used by many health care systems, including France, Germany and the Netherlands, as the best way they know of for delivering health care. In addition, we know from studies of the rest of the economy that much innovation comes from new entry and the exit of poorly performing incumbents.
The actions of the clinical commissioning groups are central to whether change in the patterns of care provision in the NHS change or whether the current incumbents, dominated by the large acute hospitals, retain their grip on provision. And the actions of the Commsisioning Board are critical to whether this will happen or not. The Board could either encourage commissioners to break out of the traditional mould and encourage plurality and diversity or it could stifle it by being overbearing and over-prescriptive.
At present, Sir David Nicholson, chief executive of the Board, seems very mildly interested in plurality. He has said that the Board will publish information about general practice, so that people can compare what their GP provides compared with others in the area and nationally and he has said that “We think this will be a very powerful mechanism for patients to make choices about which GPs they use.” But big deal: such choice and information has supposed to be available to health care users for at least the last 5 years. There is a danger that Nicholson and his colleagues think this is radical. If so, then any hope for plurality is dead, as the real issues that will have to be tackled – such as stopping supporting poor providers and actively allowing people to move away from them, are far larger than simply posting more data on the opening hours of GP surgeries.