24th February; Friends House, Euston Road, London, NW1 2BJ
This forum was convened as a review of CCG progress in implementing the Health and Social Care Act 2012 reforms. It included speeches by leading NHS England figures; some NHS Trusts feeding back on quality improvement projects; and a Q&A session with group discussions feeding back on the next phase of change: titled the ‘Five Year Forward View’; all hosted by dignitaries from NHS IQ.
Despite the heat generated by this event there was little light emerging to guide our path towards the future. The general scene was one of some rather desperate generals trying to convince their exhausted and broken, but painfully willing, lieutenants, that more of the same was good for them. The leaders from NHS England appeared to be relying heavily on a series of ‘charismatic’ leadership visions and motivational messages to create the necessary political momentum and stakeholder ‘buy-in’ to reinforce the authority of one Royal College against many others.
We were told that as long as everyone maintains a ‘shared vision’ and a ‘shared purpose’, General Practice will retain the purse, resistance will crumble, change will be inevitable and all our problems will be solved. The thorny inherent contradiction of free-market values leading to a fragmentation of ‘purposes’ among health and social care providers was glossed over. However, there were suggestions that it could be solved, at some indeterminate point in the future, by permitting only a limited degree of variation within some pre-ordained commissioning templates (e.g. NICE guidance and CQC regulations?).
There seemed to be a tacit and, unanimously silent, acceptance by the audience, largely composed of clinical commissioners, they were being given very little in terms of a clinical evidence base for making the difficult strategic decisions that were being demanded of them. How is anyone supposed to decide what is the best structure for their local health care services? Where is the peer-reviewed literature that can tell you what purposes to prioritise?
What the participants were repeatedly referred to for inspiration was the ‘NHS Change Model’: which, depending on the political bent, was either received as a radical social experiment in the co-production of local health resources; or a low quality market research campaign that has grown to fill the epistemological and clinical void between growing public health inequalities and vanishing commissioning budgets.
In response to the needs of different CCG’s the NHS Quality Improvement team had invested a considerable amount of their time and effort focussing on the (politically valuable) ‘patient experience’ as a benchmark of progress; to the exclusion of ‘clinical effectiveness’ and ‘patient safety’; these are equally transparent measures of healthcare quality, if not more valid and reliable indicators of NHS productivity.
The main theoretical insight this provided for me was that the common currency for all healthcare commissioning is now dictated by NICE guidance: the amount of Quality Adjusted Life Years (QALYs) that can be purchased within a fixed budget is likely to vary depending on the technological innovations and structural efficiency of any qualified (or ‘preferred’) provider; but the quality of the end product, its safety and effectiveness, will still be determined by more Centralised regulatory mechanisms.
Setting QALYs as the single currency of a common European healthcare market could ensure a shared set of values and purposes and lay the foundations for the increasing centralisation of the European Social Charter. This could help shape the future of public health spending on a massive scale: towards reducing inequalities in life expectancy at national, regional and local levels in all EU member states; allowing each commissioning body to choose their own short range measures in pursuit of their constituents’ goals; and ending the corrosive undercurrent of welfare tourism through a more equitable redistribution of health and social care resources.