Govt White Paper on NHS-reforms will cost billions to implement and will see further privatisation of healthcare.

[ArcticRoll]

Government are selling this to the public that it is about giving power back to clinicians rather than managers but really their main objective is to break up the NHS and line the pockets of shareholders in the private sector.
If the plans go through the focus over the next couple of years will be all abour re-organisation diverting resources from the frontline.

"people don;t want choice, they want quality care at their local hospital, surely?"

I disagree with that, I think people want to be able to assess and select the best options for them.

To give you an example, I'm on the waiting list for two hip replacements, one after the other. This follows undiagnosed developmental dysplasia when I was a baby (picked up age 2) and repeated previous surgery which has had varied success, it's not a standard replacement. I had been living out of the country and was now in a different city from the one I had previously been treated in, so needed to find a new consultant, one that had experience dealing with hip replacements in young people and also with complicted cases.

My GP was very helpful, but said he didn't know which consultant I should see, so would do me a general referal. I did some investigation online and through my previous doctor's recommendations, found the consultant I felt was the best in the field and asked for a specific referal to him which my GP gave. When I was asked by the NHS Choices which hospital I wanted, I picked the one this consultant worked at and the person I poke to tried extremely hard to change my mind as the waiting lists for that hospital were long, and tried to persuade me to try several other smaller, more local hospitals (which I had investigated and dismissed). From their perspective this had nothing to do with services available and, from what I could see, only had to do with keeping the waiting list time down. I had to push really hard to get into my chosen hospital and then had to continue to push until I got to see the doctor that I wanted to.

The procedure that the government seems to want to change to is one that would facilitate this, the GP would have had more information to tell me about the available consultants without me having to do the research myself and his direct referal would have been acknowledged without me having to spend hours on the phone persuading people that I wanted to see this particular doctor as he specialised in my specific problem.

If I was 70 with no complications and wanted an absolutey normal hip replacement then yes, absolutely, quality care in a local hospital would be my priority, but I think in more complex circumstances then the choice is vitally important to make sure that you get the care you need. The current hospital referal system doesn't account for that complexity, while added choice in the system would mean that you and your GP can adjust based on your circumstances.

How these GP consortiums actually end up working is a different kettle of fish, and there isn't enough detail out yet to really condemn or commend them, but from a process point of view, based on my own experiences, I think it could be great for the GPs to be considerably more involved.

Anybody read 'Nudge'? (you should, I think the govt have been reading it).

One of the points the authors make is that 'choice' is all well and good, and makes a market work effectively, only if people are capable of making good choices.

What gets in the way of people making good choices?

Complex arrangements, difficult decisions, around things that don't happen very often.

That would be, like, healthcare then?

Welcome in to confusion marketing, postcode lotteries and a system where the educated, literate, relatively pushy middle class can game the system until they get just what they want, and everyone else gets what is left.

I loath the current dogma of choice.

Flexibility - that's different, an appointment when I want, mechanisms for second opinions and specialist referrals, great, but the responsibility to choose your healthcare is going to have a lot, a lot of loosers in the game. And they will almost certainly be the most needy in society.

yes, just read that

littlebabynothing: re this: "And the social enterprise hospitals will be required to bid for contracts alongside private providers - if they don't win work, they become financially unviable and close.

I can picture in 6 years time, the Tories telling us that the Market and patient 'choice' has determined what services should be available and where - "nuthin to do with us honest" "

At the moment, we have a situation where crap providers deliver crap services and virtually nothing can stop them. You only have to read Phil Hammond's columns to see what a struggle it is to get consultants to stop trying to do stuff they oughtn't to be doing.

I quite like the idea that a GP commissioner will turn round to a hospital and say, "if you can't provide the requisite consultant cover for your stroke service, and meet all the other NICE standards, we won't contract with you". If that stance causes that hospital to have to shut up shop in the end, then good. It should not be providing substandard care just to remain financially viable. In practice, I think what will be more likely is that once the crutch of underperforming services are removed, the hospitals (DGHs especially) will be forced to reconfigure and provide a more sensible array of services which play to their strengths. The other services will head up to tertiary centres or down to community services as appropriate.

Erm, NightLark, where there are complex markets and there is asymmetric information, end users typically get assistance from an intermediary. In insurance, that's a broker. In healthcare, in this country, it's a GP and until recently, a PCT as well. The choice operates at two points:

• when a service is first commissioned, where the decision is taken by the GP/PCT
• when a patient is referred, when the decision is (supposed to be) taken by the patient with the support of the GP

And if you think choice is bad, what about lack of choice? What's it like to be a patient knowing your only option is a hospital that's known to be pretty crap at providing the service you're after? Mumsnetters spend quite a lot of time trying to choose between hospitals in which to give birth. They often complain that they don't have sufficient information to make a meaningful choice. I don't think that telling them they have to use a particular hospital is the right answer; the right answer is to provide them with the information that matters. Like, "this hospital does / does not provide consultant cover for 96 hours per week on the obs wards, which is the minimum requirement for safe care"; or "the rate of harm for this operation (morbidity+mortality) is / is not within the expected bounds"

NightLark - I presume this is where the GPs come in, they will be able to assist people into the best choice for them, and be able to provide guidance on hospital and consultant choice. I agree what we have now is not working, the choice is nominally there, but unless you are able to do the research and push for what you want then you can't take advantage of that.

I think you need to have some element of choice, otherwise you end up with everyone being stuck with a one size fits all, cheapest solution for everyone and everone who isn't a textbook normal case will slip through the cracks with no recourse.

slhilly - there is no 'choice' in the NHS currently. Your experience is extemely rare. As in education the rhetoric of 'choice' is used to make people fell reponisible for thing that are not actually in their control. It is a con job.

Lucky1979 - It's called exception management. One size fits MOST but there needs to be a process to, and someone with the authority to override it.

sorry lucky, I do see what you mean, but I do think at the moment lip service is paid to choice - if that improves, great, and most people will think - what do I know about this and choose their closest.
I suppose what I'm saying is we want choice but not at the expense of quality in general.

TheCoalitionNeedsYou -- what you assert is simply not true. Where are your facts?

Here are mine:
Primary
Most people can choose between at least a couple of GP practices, although doctors often bugger about with closed lists which makes life difficult. But if you don't like your GP, you can change. Increasingly, people do. And so they should! Lots of GPs are fab, but a significant number are crap. People should not have to put up with it.

Acute
Londoners typically live within a few miles of at least three hospitals, if not more. Mancunians live within a few miles of at least two. I grew up in the suburbs south of Manchester -- there was Stepping Hill, Wythenshawe plus the central Manchester hospitals. Liverpudlians have a choice of hospitals. So do Brummies. Etc etc. In every major conurbation, there is choice for the major conditions that you are likely to have. The major conurbations together account for a significant proportion of the UK population. Even in semi-rural areas, like much of the East of England, there is still some choice. If you live south of Cambridge, you can go to Addenbrookes or West Suffolk, for example. And increasingly, there is the choice not to have to go in to hospital in the first place to have your condition treated.

Given all of the above, TCNY, how can you possibly assert that there's no choice at the moment? There's choice now, as there has been for years. The difference is we're now being encouraged to exercise that choice, with the help of GP intermediaries. And a good thing too.

PS, TCNY, I think you were making two arguments but I'm only sure of one of them:

1. you argued that there is no choice (I'm clear that you were definitely arguing that)
2. I think you also argued that it is better not to give patients a choice than to give them a choice, but I'm not sure

Can you clarify, please?

The idea that "bad" hospitals should/can be closed down has been around for years (at least several reorganization white papers ago), but it doesn't happen, because local opposition is generally very very strong and politicians at the national level block any proposals that look like they are going to cause (political) trouble. I doubt very much that GP consortia (which will be much smaller and less powerful that existing commissioners) will be able to do anything at all on that front. It will also be interesting to see where NHS debt is moved. In previous years when a hospital was struggling to get enough patients they got into debt. That debt then belonged to the local PCT (or was spread around the system). Unless that changes I doubt very much that the new consortia will have any power to do anything. The acute trusts have always had the power in the NHS and this reorganisation is likely to keep it there.

Real patient choice would be a good thing I agree, but it would come at a much higher cost. GPs aren't in a good position to provide the support that patients need to make the choices they would like (the meaningful ones about their care options, as opposed to whether there is parking/how long the lists are) it would divert a lot of their time to do it personally (so very expensive) or require support services. Plus the hospitals would need to start producing a great deal more information, and in a consistent manner so that it is useful to someone making a choice. I think that this is somethign that should be done, but the consequence will be lots of new management costs.

slhilly - There is no choice in PRACTICE for most people - most GP practices will refer to only one or two hospitals, usually based on PCT, and usually will not ask the patient which one they want, it's up to the patient to make a fuss if they want a choice.

Very few people will realise that they have any options.

For choice to have any meaning you require sufficient information to make an informed decision, consumers with the ability to understand that information, and surplus within the system to allow for those choices.

Where the choice is between 'good' and 'bad' the answer is not choice, but to fix the 'bad'.

I'm not sure that these proposals are about increasing choice, but reducing cost. Once GP commisioning collectives have negotiated reduced rates from a particular hospital are they more or less likely to refer to that hospital?

TheCoallitionNeedsYou-'I'm not sure that these proposals are about increasing choice, but reducing cost.'
David Nichollson head of NHS announced today that the reorganisation will cost£1.7 billion. How can this be justified at a time when huge cuts are being implemented?
The aim of the reforms is purely ideological-transferring services and money from the public sector to the private sector.

I think the idea is that you spend 1.7 billion to save a billion a year.

The NHS should be privatised.

Like the education system, much of it is currently run for the benefit for its providers, as opposed to its users.

Imagine if food provision was provided by the State, in the same way that healthcare is - do you think we would have more choice/nutrition/value than we do now, or less?

The Private sector is run for the benefit of shareholders not it's users so I don't think that is a reason per se.

BMJ article estimates the costs of the reorganisation to be between 2-3billion pounds.
I really don't think there will savings in long term -it will just mean that money is passed into the private sector and all the knowledge and experience of NHS managers will be wasted.

Whether it's 1.7 or 3 billion that is a small proportion of a 100 billion budget, especially seeing as it's one of the few departments to be exempted from 15-25% cuts.

This is one of those things that can only be tested empirically. If it works, good. If not we need to think again. But better structural change than tinkering around the edges of a system that is failing.

Really of course we need a grown up conversation about the aims and scope of the NHS, but there is shit all chance of that happening.

this business about shutting hospitals down if they don't commission enough services

it doesn't seem to make sense

Hospitals are huge complicated buildings with expensive specialised things like air con in the theatres and millions of pounds worth of equipment. on land worth lots and lots of money.

So teh local hospital fails to get enough commissions to keep running and shuts down.

Then what?

People can't afford to build whole new enormous hospitals with all the associated costs. They won't be able to afford the land in places where people need the services. So a hospital is lost the land developed the equipment sold off and that's that?

That doesn't seem like common sense.

In fact a lot of hospitals are on very expensive land, won't it be tempting just to pull out of the healthcare market, and sell up?

I find all of this very confusing.

Say my local hospital only manages to get commissions for 3/4 of its services, will tracts of the hospital have to be shut up? Then you get into a downwards spiral surely.

And how will it work if you are away from the places that your GP commission services - will you be seen - what is the mechanism for money to be transferred?

What happens to the parts of the service which are notoriously difficult? Will anyone provide them? If not, what happens then?

How are people's notes going to be transferred between the plethora of different services - of different types private, social enterprises etc especially when this govt has explicitly stated that they are right off big databases that lots of people can access?

Won't this end up like the schools, with "good" services being hotly pursued by those with the means to do so, and "poor" services struggling along with sod all money and servicing a different part of the community? Isn't that the result of choice? What's wring with making all the services better in the first place?

The questions just keep coming this idea scares the pants off me.

TCNY, I don't think we're as far apart on this as we might have appeared to be at first. Info is crucial to drive choice. GPs need to support patients to make choices.

One thing I do disagree with is "Where the choice is between 'good' and 'bad' the answer is not choice, but to fix the 'bad'. "

Sometimes that is the right answer. But there is too much capacity in the system at the moment -- for example, too many specialists trying to do AAAs when they don't have the volumes to justify it. There's nothing that can be done to fix the volumes: they just need to get over themselves and agree that there will be fewer surgeons providing the service.

In that sense, I'm arguing that there should be less choice, in the future, not more. I'd like it if the only thing that mattered was choosing the car park, but so long as choosing on clinical outcomes matters, I'd like that info in the public domain and well-publicised.

NHS revolution will cost £2--3 billion and will reduce performance, according to British Medical Journal editorial.

Choice well we have none our surgery is 2 miles away and is the only one

And hospitals dont get we started emergency care is 4 miles one way , but were not allowed any outpatient appoinments there as its wrong Health area so instead have to go a hr in oppsite direction which on public transport with wheelchair takes just over 2 hrs each way

I am no expert but I have worked as a staff nurse for 30 years. Already 3 wards have closed in my County and 2 wards have to lose 10 jobs. Anyone above a HCA grade has to re-apply for their jobs. Thanks David! I also remember nurses struggling for decent pay, while people grabbed the well paid jobs in the private sector. And don,t get me started on PFI Building Schools for the Future. There will be many Porches and Audi's returned or sold!

Agree shilly-think the majority of people would rather have excellent universal services than illusion of choice.