Dr Rachel Joyce: Doctors, nurses and midwives have genuine concerns about about the NHS reforms. Conservatives shouldn't question their motives.

Dr Rachel Joyce was Conservative candidate at the 2010 General Election in Harrow West. She is also a doctor and has worked as both a Director of Public Health and a Medical Director in the NHS.

To win the next election outright, avoiding a Labour government, or even the Labour/ Lib Dem government under Ed Miliband and Simon Hughes described by Tim Montgomerie, the Conservatives need to deliver on what matters to the public. The economy and confidence in our economic credibility is always vital, but as this improves, voters will further prioritise public services when considering who to vote for. Education reform a la Gove has turned out not to be controversial, as it has been shown to work, and also makes sense. Reforming the NHS will always be difficult - issues are far more complex - but without support from those who work in it and consensus on the evidence this could prove to be one reform too many for the Conservatives.

Most doctors and other health professionals want to provide high quality services, and want to work in a system that allows them to do this. They recognise the need for reform, but the majority of those I speak to are weary of constant re-organisational upheaval - and we certainly had a number under the last Labour government. I personally know dozens if not hundreds of doctors who voted Conservative at the last election, partly because of the promise of no top down re-organisations. Evolutionary rather than revolutionary methods to achieve these aims would probably have been much more popular than the current health reforms which the NHS chief executive said are so large "you can see them from space".

It is easy to portray the BMA, Royal College of Nursing and Royal College of Midwives' opposition to the health bill as a product of grievances on pay and pensions, as they are trade unions as well as professional bodies. But I've spoken to many people in the BMA and although pensions are a big issue for them, that isn't the reason for opposition to the Bill. Last year the BMA voted to work constructively with the government, as did the Royal Colleges. Now they have moved to outright opposition. Now the Royal College of Radiologists and the Royal College of GPs have voted to oppose, after 98% of RCGP members surveyed said they wanted the Health and Social Care Bill to be withdrawn. The Faculty of Public Health is surveying it's members after an Emergency General Meeting voted against the reforms, and the Royal College of Physicians are holding an emergency meeting too. The Royal College of Surgeons have stated they have concerns, but will continue to work to improve the Bill. These are not trade union bodies, but represent their members' views regarding health care delivery.

Dr Rachel Joyce: What should come out of the listening exercise on NHS reform?

Dr Rachel Joyce was Conservative candidate at the 2010 General Election in Harrow West. She is also a doctor and has worked as both a Director of Public Health and a Medical Director in the NHS.

 After the NHS reforms had been announced, and before the pause and listening exercise, I was sitting at dinner next to a well known journalist. He asked me what I thought of the NHS reforms. “The devil is in the detail” was my simple response.

Getting the NHS reforms right is imperative for us, as Conservatives in government, and as users of the NHS ourselves. The aims of the reforms are absolutely spot on – to make the NHS more patient focussed, to involve more clinicians in commissioning, and to use competition to improve services and to increase value for money. I had concerns that some of the details of the reforms needed changing to ensure these aims were delivered in reality. In this article I highlight a few of the areas raised in the listening exercise that are important - to ensure the aims of the reforms are delivered.

Dr Rachel Joyce: How to make the most of the NHS reforms

Dr Rachel Joyce was Conservative candidate at the 2010 General Election in Harrow West. She is also a doctor and has worked as both a Director of Public Health and a Medical Director in the NHS.

The reason we need GPs in commissioning
There’s a saying in the NHS that GPs spend all of the NHS budget (and more) with the stroke of a pen – either by writing a prescription or by writing a referral. It has therefore long been recognised that the answer to ensuring value for money for the NHS budget lies with GPs and their actions – hence fund holding, then Primary Care Groups, Primary Care Trusts, Practice Based Commissioning (PBC), and now GP consortia. Trying to change clinical practice to improve outcomes and provide value for money without GP support would be like fighting against the tide. Areas that have successfully engaged GPs – such as Cumbria - have already done well under PBC arrangements. The question is whether these latest reforms will work to encourage those GPs who have so far been reluctant to get involved to do so.

Conflicts of interest
Involvement of GPs is not however enough – what is needed is for GPs to sign up to commissioning high quality value for money services. GPs are independent providers who have done very well out of Labour’s changes. Generally they now earn more from the NHS than hospital consultants, with one family doctor now on a salary of over £500,000. Many GPs have financial interests not just in their own practices, but also in services that they may potentially commission. A recent report by the GP magazine Pulse reported that almost a quarter of consortium board members have some kind of interest in private providers, with others either shareholders or advisers. One GP in 10 on the boards of new commissioning consortia also holds an executive-level position with a private provider. There are already many examples of conflicts of interest, including reports of overt lobbying to continue with services that they are shareholders in – even if they don’t demonstrate value for money.

Dr Rachel Joyce: Competition, Choice and Transparency are vital for high quality NHS commissioning

Dr Rachel Joyce was Conservative candidate at the 2010 General Election in Harrow West. She is also a doctor and has worked as both a Director of Public Health and a Medical Director in the NHS.

I wasn’t at the Special Representative Meeting at the BMA that called for a change of mind on some of the NHS reforms, but I know a few doctors who were. They were from a wide range of specialties – hospital specialties, GPs, community doctors. Attendees also included many GPs who are in pathfinder GP consortia (ie the first wave). Most GPs in my area have signed up because they care about their patients and they don’t want their surgeries being left behind.

The multitude of motions – which ranged from those that are purely about terms and conditions of service to a few politically motivated motions, to constructive engagement and feedback – represented the multiple roles the BMA has as a professional organisation representing many different specialities, and the complexity of the NHS.

The NHS is one of the largest organisations in the world. It is, I believe, the largest employer on the earth –barring the Chinese Army and the Indian Railways. The structures in place, the accountability arrangements, the regulations and safeguards are not simple, and will still not be simple after the proposed changes. It is therefore a good thing that the BMA voted to continue to engage with the government on the Health Bill, and to lobby on the things that they feel need refining or changing. After all, the Bill has not yet passed, and some of the documents from the Department of Health are still being consulted on.

Rachel Joyce: We must ensure that the NHS does not lose its experts in value for money and evidence based commissioning

Dr Rachel Joyce was Conservative candidate at the 2010 general election in Harrow West. She is also a doctor and has worked as both a Director of Public Health and a Medical Director in the NHS.

The fact that Andrew Lansley and the Coalition Health team are putting so much importance on Public Health is to be welcomed. The Public Health White Paper has recently been issued and is currently being consulted upon. However, so far the emphasis of the consultation and the public debate has been about a future role for local authorities in public health, and not about the NHS role or the need of the NHS for public health skills. The current proposals suggest that all public health doctors will be moved into local authorities, which could leave a significant gap in NHS commissioning expertise.

Public Health is defined as “The science and art of preventing disease, prolonging life and promoting health through the organised efforts and informed choices of society”. But what do public health practitioners (who are usually doctors) actually do? Their work is divided into three domains (and they usually sub-specialise):

1. Health protection – The public will know this as managing outbreaks of disease and pandemics, immunisation programmes, and the management of incidents such as bio-terrorism and chemical incidents that may affect human health.
2. Health improvement – The public will know this as the promotion of health and wellbeing and the prevention of disease – particularly by focussing on investigating and reducing risk factors such as obesity and teenage pregnancy rates.
3. Health care public health – The public will understand this as the optimisation of health service provision to ensure the best clinical outcomes possible within the resources allocated by government. This involves the assessment of health care needs and the clinical effectiveness of different interventions, the development of evidence-based “pathways of care”, prioritisation of resources to focus on the most effective and value for money (cost-effective care) and evaluation of health services and new health technologies. They use medical knowledge (most fully trained public health practitioners are doctors), health economics and statistical analyses, evaluation skills and critical review of the medical literature (this requires five years of additional training on top of normal medical training). [Screening sits somewhere between the second and third domain, and the National Screening Committee and local implementation of screening programmes are public health led].

Dr Rachel Joyce: Andrew Lansley's NHS reforms should give even more power to patients

Dr 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.

The NHS White Paper is welcome to those of us who know the NHS needs to change. Health outcomes in the UK are worse than many other countries that spend just as much or less per head than the UK does for its health care. However, politicians also need to be mindful of the fact that research has shown that the UK public think their health care system needs changing less than in other countries.

The US trust fund, The Commonwealth Fund, conducted research drawing from a large sample of the public in the UK, Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland and the US. Their recent research showed the UK had the highest rates of confidence amongst the public that they would receive the most effective care if they fell ill, and was the country where the smallest proportion felt changes to health care services were needed. Therefore any changes need to take the public with them, and be responsive to patients’ needs.

Various reforms since Margaret Thatcher’s time have attempted to bring the market to health care – but a true market depends on decisions on funding being made by the end user that has a stake in the outcomes. Reforms to date have not made the patient the decision maker – at worst it has been managers who make the commissioning decisions – under the best model to date (fund-holding) it was small GP practices.

The current white paper seeks to emulate some of the benefits of GP fund-holding. However, as with everything in public service delivery, success or failure lies in the model of implementation. The current proposals seem to be heading in the direction of large GP consortia, based on geographical area. This means that although a patient will technically have a choice of GP – and therefore their consortia – in reality all the practices in their area will part of the same consortium, so offering no real choice for patients. As the consortia are planned to be large, the link with patients will be more distant than in fund-holding times.

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

Dr 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.

Dr 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.

Rachel Joyce: The case for a "fat tax"

Dr 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.

The coalition’s much needed emergency budget will be held on June 22nd, with speculation from economists that VAT will rise to 20% this year. It is estimated this would raise £11.5 billion per annum. The Conservative manifesto commitment was for a 80:20 split between cuts and tax rises to tackle the deficit. This was re-iterated by David Cameron on the Today programme only recently when he claimed it was the international gold standard in deficit reduction.

The think tank Reform suggested instead ending zero-VAT rating for food, children’s clothes, electricity, gas and house building (with protection for the poorest), stating this could raise £8billion a year. This has, however, been criticised as a move that would hit the poorest the hardest.

There is an opportunity however to do two things here – raise much needed revenue whilst also changing the country for the better. David Cameron says that we should be using the tax and benefits system to reward people to do the right thing. The emergency budget therefore needs to look at all the areas where a tax rise (and also tax reductions) might benefit the country in other ways.

I would like to put the case for a “Fat Tax” – as proposed by the Food Standards Agency, and supported by the National Obesity Forum. Obesity could cost the NHS in England £6.3 billion by 2015 if no effective action is taken. In England now, almost two-thirds of adults and a third of children are either overweight or obese, and without action this could rise to nine in 10 adults and two-thirds of children by 2050. One option would be to increase tax - the so- called “fat tax” on processed foods, snacks and sugary drinks – those that are high in fats and calories and low in nutrients.

Rachel Joyce: We can cut costs and protect vital public services

Dr Rachel Joyce is our PPC in Harrow West. She has been an NHS doctor for twenty years and has worked as a director of a PCT. She also has two children who are in the state schooling system.

I fully support the notion that we should “live within our means” and George Osborne is right that we should not be looking to increase public sector debt any further. We are uniquely poorly equipped for this recession, and according to the OECD, likely to therefore fare worse than other G7 countries. This means we need more prudence in the management of the public purse.

The Labour party cannot manage anything effectively – their top-down, gimmick-ridden and target oriented policies by their very nature waste resources, whether it be manpower or financial resources. Their large projects such as the NHS IT system, identity cards or defence procurement offer the usual Labour triple whammy of loss of personal and professional freedom, overall failure to achieve the original objective and runaway costs. I agree with Andrew Haldenby’s article that reform of public services is essential to ending the boom and bust of public services. 

The one thing however that Labour can do effectively - is spin. They will be putting forward the charge of “Tory cuts” and unless we are able to tackle this head-on, this will damage us.

Most of my colleagues in the NHS and other public services are dedicated staff who have witnessed in their time important or vital services cut or not funded – often due to an apparent shortage of money. We have seen local hospitals and GP surgeries close, class sizes that are too large, teacher shortages, and police that don’t have time to record, let alone investigate many crimes. They fear public sector cuts and what they may mean for vital services.

These same public sector colleagues and the public would also be the first to agree there is significant waste in public services – not just of money, but also of professionals’ time. In the NHS the main problem is bureaucracy, mostly caused by targets. These same people would like to vote for a political party that will allow professionals to get on with the job, serving the public rather than the politicians. They would like to live in a country that is responsible, and lives within its means. But they need some reassurance before they give us the public purse.

A Government worth having: Health policy

In the latest of our 'A Government Worth Having' series we look at health policy.  Top-up payments, patients being able to choose their healthcare commissioner and strong Matron-like figures are just three of the ideas suggested below. We've previously looked at new directions on economic and foreign policy as part of this series.

Simon Chapman: "The next Conservative government will have to face up to the overwhelming pressures that the NHS faces: demographics, dementia, obesity, technological and treatment advances, and rising expectations. These are already upon us and will only increase.  We will spend over £100 million on the NHS next year. That is highly political. At the moment there is no direct democratic accountability. An unelected NHS Board won’t make that better.  Tax funds are already insufficient to meet demand, although there is undoubtedly room for more effective spending. Decisions about priorities and rationing should be brought as close as possible to the people affected by them. Personal budgets (vouchers) and locally elected health boards are the levers. Co-payments are also inevitable.  Health reform must become a first term priority. The public are ready for honesty and candour – certainly more eager than the current Westminster consensus is prepared to allow.  We need to close the gap between health and social care. Joint commissioning and pooling budgets is one way forward. Bringing both under the strategic responsibility of one department is another: how about changing Andrew Lansley’s job title to Shadow Secretary of State for Health and Social Care? Before anyone shouts, I know that Local Authorities are responsible for social care, but they could be made accountable to a different Secretary of State.  Finally, if we want to improve confidence in the NHS, we need to make end of life care more of a priority. Over half of all deaths occur in NHS hospitals, and over half of all complaints about NHS hospitals concern dying and bereavement care. Hospices are often superb, but they cannot provide a complete answer."

Nadine Dorries MP: "I trained in an NHS which was run with consideration and discipline. The first concern of any nurse was to reassure her patient. To be aware that a hospital was a scary place, that we knew most things weren’t going to hurt and would probably be ok, but that the patient didn’t.  As a night nurse I spent many an hour sat on the edge of the bed of a sleepless worried patient, with tea and toast, listening to the dark worries keeping my patient awake. How long will I be off work? Will this affect my life?  I worked on wards which had dedicated ward cleaners and Auxiliary nurses who took pride in their wards and were in silent competition with the cleaner on every other ward in the hospital.  Nurses never wore their uniform outside of the hospital. A plastic apron was donned every time you treated a patient. Hand washing was automatic, cleanliness imbued throughout every aspect of the ward day. Visitors limited in order that a ward could be properly cleaned. There was no MRSA and poorly patients got the rest they needed.  Matron ruled, Doctors trembled, no nurse failed to give anything but her best. Everyone was accountable via a very clear line of command. Everyone knew who was responsible for what and when.  The NHS of today is driven by targets and process, not patients. Sometimes it feels as though patients are an inconvenience, lying in the way of clipboards and men in suits.  We need to make healthcare delivery totally patient focused. By remembering patients are there because they are vulnerable and ill and by giving patients respect and putting them at the top of the NHS agenda, by removing business suits and replacing with caring  uniforms, we may just begin to see a shift of priorities."

Andrew Haldenby, Director of Reform: "The issue of top-up payments for NHS care is waiting to be grasped by Government or Opposition.  This year a series of cases have proved that the existing rules are a classic example of how bureaucratic inflexibility can become cruelty.  Currently Norman Lamb is the only frontbencher spokesman who has argued for change bravely and positively rather than reluctantly.  A majority of patients and doctors are in favour.  Allowing patients to top up would be directly in line with the modern Conservative ideas of social responsibility and the post-bureaucratic age."

Dr Rachel Joyce, our PPC for Harrow West and a former PCT Director: "The NHS internal market failed because the “commissioner” is a poor proxy for the patient. Bureaucratic rules and targets make meaningful clinical and patient involvement in commissioning impossible, leaving managers to make decisions on what services are provided for patients.   “Successful commissioning” in the NHS is judged by performance against targets and rules. Success, in contrast, as judged by a patient is on good clinical outcomes and convenience.  Therefore much of the increase in health spending has been wasted on the administration of targets, resulting in high comparative costs but poor outcomes.  Patients should be able to choose who commissions their care. If GPs could choose their commissioning organisation, then patients could choose their GP practice (and therefore their commissioner) on the basis of outcomes. An independent NHS Board could be responsible for monitoring outcomes and quality via agreed indicators.  Patient choice of commissioner would drive down unnecessary bureaucracy and inefficient care, and would enable the NHS to provide comprehensive care that is not only efficient, but has world-class outcomes. "