What every family needs to know about the great health revolution
It's the biggest NHS shake-up in 60 years and with even medics admitting they're confused, no wonder patients are growing increasingly worried
Everyone knows they’re important — and that they could transform the way you, and those close to you, are cared for when you’re most vulnerable.
Everyone also knows they’re causing one of the most bitter political battles for years. But how many of us actually understand the Coalition Government’s plans to reform the National Health Service
The changes are the biggest shake-up of the Health Service in England and Wales for 60 years. Ministers say their aim is to create a ‘patient-led NHS’ and cut bureaucracy by giving power to GPs and front-line clinicians.
This, they promise, will not only improve care but also slash bills at a time when health costs are rising due to our ageing population and the increased cost of drugs and new treatments.
Critics say the very foundations of the NHS, with its promise of free care for all, are at risk. But they, in turn, stand accused of putting the interests of bureaucrats and health workers ahead of patients.
Meanwhile, even doctors who support the reforms complain that Health Secretary Andrew Lansley has made a terrible job of explaining them, and there have already been hundreds of amendments to the original plans.
So what is all the fighting actually about And what do the reforms really mean for patient care Good Health asked the experts to explain how the reforms affect YOU . . .
GPs will be responsible for buying the necessary treatments and tests for their patients
Your GP will foot your medical bills
One of the biggest changes is that GPs will be given control over around 60 per cent of the NHS annual budget of 110 billion, with responsibility for planning and buying health services for their patients.
As well as using their budgets to buy your drug treatments and diagnostic tests, they will be paying for your hospital care.
This responsibility previously lay with 151 primary care trusts, which are being abolished together with the ten Strategic Health Authorities which oversee them.
Your GP will exercise his new financial power through clinical commissioning groups (CCGs), made up of groups of GP practices covering around 100,000 patients (although there isn’t actually a minimum or maximum size for them). Hospital doctors and nurses will also be involved in the CCGs.
Your GP won’t, however, be responsible for arranging dental services or specialist care for people suffering from rarer conditions such as motor neurone disease, or needing neurosurgery. These will be handled by the new NHS Commissioning Board, which will also oversee the CCGs.
PROS: Giving GPs control of the money means, in theory, that you and your doctor — rather than a remote and bureaucratic primary care trust — will have the power to choose the best treatment for your condition.
For example, this could mean that a man with advanced prostate cancer might now benefit from an effective drug such as abiraterone — even if it is turned down by the National Institute for Health and Clinical Excellence (NICE) because it’s too expensive — if his GP chooses to prescribe it to him.
As Paul Bowen, a GP who heads a CCG already set up in Cheshire, explains: ‘Instead of someone else making decisions about what patients need, my clinical staff and I will work with patients, giving them a wider choice of where, when and how they receive their healthcare.’
Supporters claim this is a long-overdue revolution.
‘The biggest problem we have is the top-down nature of the NHS,’ says Dr Charles Alessi, chair of the National Association of Primary Care, an organisation for those involved in primary care, including GPs and PCT staff.
‘This is really what is behind the reforms — devolution of responsibility to the frontline.
‘I will fight to the death for the NHS, but we have to change the way we do things for it to survive. The challenge of people living longer, and the increasing complexity of illnesses, cannot be met by existing processes and bureaucracy.’
CONS: The main argument against giving GPs control of the money is that while they’re skilled at looking after patients in the community, few have the proven financial and planning skills to manage the business of commissioning services.
The expectation is that GPs will end up employing outside companies to arrange contracts for their patients’ treatment.
‘Our worry is this will mean that GPs will end up rubber-stamping decisions made by vast management companies who have little actual insight about patients and their needs,’ says Dr Clare Gerada, chair of the Royal College of General Practitioners.
There is also concern that GPs, under pressure to stick to tight budgets, will make decisions based on their balance sheet rather than what you, the patient, need.
Another concern is about potential conflicts of interest when GPs commission services from organisations they part-own.
The commissioning groups will, for example, be allowed to own cataract clinics, so could in theory commission their own clinic to provide their patients with treatment.
Meanwhile, rather than cutting bureaucracy, it is feared that the new NHS Commissioning Board will end up as yet another top-heavy layer of management.
Already, it’s expected to employ 3,700 people and have an administrative budget of 492 million. Its responsibilities are growing rapidly, as GPs say they’re not ready to take the reins with commissioning.
A greater emphasis will be made to ensure patients receive the best possible care during any interaction or stay
It’s quality of care that matters
A key aim of the reforms is to shift the focus onto quality of care.
There will be less emphasis on waiting lists and ‘access’ targets (such as making sure you start treatment within 18 weeks of a GP referring you to a specialist).
Instead, the focus will be on performance targets, which measure patient outcomes — for example, how many patients are dying from heart disease.
The original plan had been to abolish access targets altogether, but there has been some back-tracking on that. (It is not quite clear if the 18-week target will remain.)
So how will the NHS ensure you receive better care
The answer is through new guidelines called Quality Standards, which set out the best practice for treating patients suffering from different types of diseases.
For example, if you’ve been treated for early breast cancer, you should expect to be given an annual mammogram for five years after treatment. GPs will be expected to take account of these standards when commissioning services.
As part of the shift to quality of care, patient feedback is also likely to be given more prominence, so you’ll probably find yourself filling out even more feedback forms on the quality of care you’ve received in hospitals.
PROS: In theory, you should receive a better standard of care. The Quality Standards will be concise and set out treatment priorities clearly, unlike the current NICE guidelines on patient care (the Quality Standards won’t replace these guidelines, but will sit alongside them).
‘The intention to bring forward more Quality Standards is a positive step for patients in disease areas like rheumatoid arthritis, which has been overlooked in the past,’ explains Jamie Hewitt, of the National Rheumatoid Arthritis Society.
CONS: Doctors are concerned that asking patients if they’re satisfied with the quality of their care might not actually be a good measure of best care.
As Dr Clare Gerada explains: ‘There are occasions when patients want hospital referrals, when the truth is they don’t really need yet another fruitless visit to a specialist.’
The problem, she suggests, is that they won’t be ‘satisfied’ with their treatment unless they get that referral, even if it’s not what they actually need for best care.
Hospitals will be allowed to go bust
Hospitals will now have to generate all their own funding by offering services to GPs for a fee.
All hospitals will be made into foundation trusts — a legal change that means they have control over their budgets and can borrow money. They’ll also have greater powers to increase their revenues — for example by offering services to private patients.
This happens to a limited degree already (in most NHS hospitals, between 2 and 10 per cent of overall revenues come from private practice), but in future hospitals will be allowed to get up to 49 per cent of their revenue from private work.
For the first time, some hospitals that go too far into the red will be allowed to go bust.
PROS: Money from treating private patients could benefit NHS patients — as currently happens, for example, at King’s College Hospital in London, where profits from the private fertility clinic are used to help NHS patients who have fertility problems.
London’s Royal Marsden, one of the world’s leading cancer hospitals, already gets one quarter of its income from private patients — just short of a 30 per cent cap set in 2003. A spokesman says: ‘The surplus from our private patient income is invested back into NHS facilities and care.’
Letting NHS hospitals increase their revenues from private patients should help make them financially viable. Currently, without Government support, many hospitals, including major teaching hospitals in London, might be technically bankrupt.
CONS: Previously, NHS hospitals have not been allowed to go bust but have been bailed out when in difficulties. Now, if they can’t make ends meet, such hospitals could be allowed to go under and shut down.
‘The former NHS hospital sites will probably be sold off for development — the Bill contains new arrangements to facilitate this,’ says Dr Lucy Reynolds, a health services researcher at the London School of Hygiene and Tropical Medicine.
The public would be outraged by the loss of a local hospital, even one that is losing money.
Critics also say that increasing income from private care could produce a divisive, two-tier system, where patients with the same illness on the same ward receive different treatment depending on whether they are NHS or private.
The Government wants to encourage greater competition throughout the NHS, and encourage the private sector and charities to compete for business with NHS staff and hospital trusts. This was already happening under the previous Labour government.
The private sector won’t compete on price — there will be a set tariff for services and treatment — but on quality of service.
This is one of the most contentious areas of the reforms. ‘What we are seeing is privatisation by stealth,’ says Good Health’s regular columnist Dr Martin Scurr (himself a private GP).
This is a universal concern among opponents to the bill. However, the Government insists that privatisation is not its aim.
PROS: Involving the private sector could free up NHS hospital doctors from carrying out straightforward routine procedures, so they can concentrate on more complex cases — and become more skilled at these specialisms.
CONS: The fear is that the private sector will ‘cherry pick’ easy and high-profit services, such as hernia repair, leaving the difficult and costly areas, such as mental health, geriatrics, A&E and intensive care, to be handled by NHS staff.
Patients will be able to oversee every aspect of their care whilst being treated
More power to the patients
Making sure patients are involved in every stage of their own care — and can influence the way decisions are taken throughout the NHS — is a key part of the reforms.
Frustratingly, the reforms don’t set out details about how this might be put into effect, but possibilities include more emphasis on annual reviews with your GP if you have a chronic disease such as diabetes, and expanding the Choose & Book programme.
Under Choose & Book, you can decide where you want to go to for specific care.
On a bigger scale, the reforms will launch HealthWatch, a new patients’ organisation that has been described as the ‘independent champion for health and social care consumers’.
It is, essentially, a watchdog for patients, with the power to monitor the NHS and to refer patients’ concerns to a wide range of authorities.
PROS: Involving patients in their treatment is widely acknowledged to be important for their health and for saving money. Research has suggested patients who are involved in this way cost the NHS around 20 per cent less.
Most people would agree that patients need a stronger voice than they currently enjoy.
When it comes to making a complaint, patients can find the current system complex and ineffective.
Accountability and public involvement have been ‘muddled’ for the past 20 years, says Patrick Vernon, chief executive officer of health inequality charity the Afiya Trust.
He says that HealthWatch will have ‘real clout’ to ‘influence, challenge and advocate patients’ rights’ in improving care, although this will depend on the strength of your local HealthWatch group.
CONS: Many patients would prefer to hand over difficult treatment decisions to the experts and don’t want to take responsibility for their own care, says Dr Clare Gerada.
Others have expressed concerns that HealthWatch will be toothless and potentially underfunded. This is because its budget is not ring-fenced, so the money could be spent elsewhere.
As Dr Lucy Reynolds explains: ‘This is a missed opportunity, because patients should clearly be given more real powers to partner with the NHS in improving service quality through an independent mechanism with an adequate and protected budget.’
There are also concerns that HealthWatch won’t, in fact, be independent, as it now looks as if it is to become part of the Care Quality Commission, the healthcare watchdog.
HERE'S WHAT THE REFORMS WON'T DO…
Cut waiting times
According to Katherine Murphy, chief executive of the Patients’ Association, the reforms could actually mean you wait longer for treatment as the re-organisation distracts the Health Service from ‘the real changes that need to be made’.
End postcode lotteries
Health watchdog NICE will continue to decide which drugs and procedures should be available on the Health Service, but GP commissioning groups may, as primary care trusts do now, decide not to prescribe certain drugs to patients.
‘Neighbouring commissioning groups may make different funding decisions on vital medication or treatment, meaning your ability to access them will depend on where you live,’ says Katherine Murphy.
The reforms do not address nursing care or training.
Tackle poor out-of-hours care
Most GP surgeries already outsource their out-of-hours services, and the poor provision is having a knock-on effect on the numbers turning up instead at hospital A&E departments. The Coalition’s reforms do not address this problem.