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Rachel Joyce: The Future of the NHS – Efficiency and Quality through Choice, Freedom and Better Commissioning

Joyce RachelDr Rachel Joyce was Conservative candidate at the general election in Harrow West, where she obtained a 5.7% swing from Labour – more than double the London average. She has been an NHS doctor for more than twenty years and has worked as both a Director of Public Health and a Medical Director.

Details of the coalition agreement in regard to the future of the NHS are slowly emerging, with a White Paper expected soon. Changes already announced show that ministers are serious about addressing the democratic deficit in the NHS and are determined to reduce unnecessary bureaucracy. We already know that Andrew Lansley favours a stronger focus on improving patient outcomes based on good clinical evidence (rather than the bureaucracy of process targets), a larger emphasis on patient choice and more freedom and power for GP commissioning. At the same time he wants a larger role for local authorities and locally elected PCT Board members.

I argued on ConservativeHome back in 2006 and 2008 that better performance lies in increased accountability and choice, requiring either localisation of the NHS to councils or elected organisations, or patient choice of commissioner. I am pleased that there are elements of both in the details so far announced, but as with everything in public service delivery, success or failure lies in the model of implementation. I believe the best model would involve health care commissioning largely managed by a range of GP commissioning groups that patients can chose from, with local authorities commissioning for preventive services.

GP Commissioning
GPs showed themselves to be excellent commissioners of basic NHS services during the time of fund holding. They secured better and more patient friendly services for their patients, whilst having a sharper focus on value for money and a reduction in unnecessary referrals. As they took on more and more commissioning functions more expertise was required and a number of multi-funds were being set up and run very successfully. In contrast under Labour Practice Based Commissioning has not led to the same focus on value and GPs have found it very difficult to obtain service developments that would benefit their patients. These differences are in part due to bureaucratic hurdles that were put in the way, partly due to a series of perverse incentives, and geographical restrictions that makes non-like minded practices have to work together.

The Kings Fund has recently considered the lessons to be learned on GP commissioning from both America and the UK, and has concluded that if policy makers do not offer GPs hard budgets with the prospect of personal gains and losses, then “the potential of budget holding to release resources and improve care may not be realised”.  It is therefore clear that GP commissioning groups should be based on like-minded practices coming together - even if they are not geographically close, and an incentive scheme that rewards efficiency and quality. Specialist commissioning support to these GP commissioners could be provided in house, by PCTs, local authorities or independent organisations.

Another element in the delivery of good services is accountability to the end user – ie the patient. Under Labour, tokenistic patient and public involvement failed, and choice has only been given to the patient at the point of referral to hospital. Patients should have more power over commissioning decisions and choice should cover all aspects of the patient’s care.

It is therefore good news that the coalition government are going to make the ability to choose a GP practice easier. A choice of GP practice should also involve the choice of a commissioner that suits the patient. This is where the need for high quality information is necessary. As the King’s Fund states “ the quality of care delivered by budget holders needs to be measured to ensure that financial incentives do not lead to under diagnosis and under treatment of patients”. At the moment there is a postcode lottery for quality of service based on where you live. Instead the only variations between services available to patients with different commissioners should be based on the patients’ own choices and priorities – something that will itself drive up quality.

This means that the new independent NHS Board will have to ensure the production of high quality information on outcomes of care and any process measures that are important to patients or a robust proxy for quality. True choice and competition is only possible when the information available to the consumer is comprehensive and of high quality. The NHS Board will also have to ensure the development and monitoring of minimum standards of patient safety, including the accreditation and registration of provider organisations.

Other commissioning
Provision will still be needed for the more specialised commissioning of the low volume, high cost specialised services of some rare conditions and treatments, and coordination and quality assurance of population screening services. Preventive measures such as obesity prevention and immunisation as well as services such as pharmacy and optometry could be commissioned by either locally accountable PCTs or by local authorities.


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