Uncertain times

With less than a week before the Department of Health’s consultation on the latest NHS white paper closes, opinions on its content are coming in thick and fast.

Yet even though ‘Equity and excellence: Liberating the NHS’ runs to 60 pages, and it has been supported by four follow up documents of between 24 and 72 pages in length, there is a lack of detail at the heart of health secretary Andrew Lansley’s proposals.

Perhaps that is why the 400 staff working in primary care trusts and strategic health authorities who responded to EHI Primary Care’s survey on the white paper are distinctly unconvinced by what is being suggested.

Only 2% of those who took part in the survey believed the white paper would lead to a great improvement in patient care – while 53% predicted that patient care would deteriorate.

The overriding emotion that shines through the quantative and qualitative results of the survey is uncertainty about what its proposals are meant to add up to. One respondent said: “I have no issue with change but change to what?”

David Stout, director of the NHS Confederation’s Primary Care Trust Network, sympathises. He says: “At this stage there are quite a lot of questions, so I’m not surprised there is a degree of uncertainty. But if the survey was done again in a year’s time and staff were just as sceptical I would be worried.”

Doubtful investment

The suggestion that further details may make another reorganisation of the health service more palatable is one that those opposed to the reforms may find reassuring.

Another view is that the DH has stayed deliberately light on detail so GP commissioning consortia can fill in the blanks themselves.

This could lead to widely differing approaches across England, both in the way that the new commissioning bodies organise themselves and in the way that they go about their jobs.

What impact such localised decision-making would have on IT remains to be seen. The majority (59%) of the 403 respondents to the EHI Primary Care survey believed that the white paper would lead to a cut in IT investment.

Another 10% believed IT investment would be postponed and 29% predicted that it would be halted and then refocused.

Many respondents were concerned about who would be responsible for delivering IM&T services in the post-white paper world.

One respondent said: “No mention has yet been made of who will take on the existing IT roles, either in supplying and maintaining hardware nor supporting training with software.”

Another added: “My role is commissioning strategic IM&T across a health community that covers two PCTs and a number of health and social care providers. There seems to be no home for strategic IM&T in the new world.”

A third respondent said: “Very difficult to see where services such as IT will sit in an area with multiple GP consortia.”

Roz Foad, chair of the British Computer Society’s Primary Health Care Specialist Group, says her personal hope is that the white paper will lead to a refocusing of IT investment.

She says: “In primary care informatics, the real way to save money is now to concentrate on making full use of existing systems and promoting interoperability, not seeking to impose new expensive solutions.”

Survey respondents, however, were also worried that PCT-led initiatives on aspects such as information governance, data quality and patient choice would fall by the wayside.

One respondent, a data quality facilitator currently supporting 18 GP practices, said: “I work for a health informatics service and the PCT buy our services. I am unsure of how this will fit within the current climate.”

Another added: “Already our contractor colleagues are considering that information governance is not so important any more, and the IG Toolkit does not need to be completed.”

A third respondent, involved in patient choice and Choose and Book, said he was concerned that the NHS would fail to improve patient involvement in choice without PCTs’ input.

He added: “GPs find the whole concept of choice too time consuming and would be happier if it just went away. Without this being the responsibility of NHS staff I believe it will disappear.”

Looking for detail

On a more positive note, 22% of those responding to the survey felt that the white paper proposals could cut needless bureaucracy and 10% thought they would encourage hospital trusts to improve quality.

However, and perhaps surprisingly, when asked to name the biggest potential benefit of the white paper from a list of alternatives, only 7% of respondents selected the decision to give commissioning power to GPs.

Instead many of those who completed the survey appeared to question whether GPs were capable of doing the task or motivated to do so.

One said: “It will take GPs a considerable time to gain the skills they need to manage the service” and another said: “Most GPs are clear they don’t want this change.”

This lack of support for GP commissioning is not reflected in formal responses to the white paper consultation. Perhaps unsurprisingly, formal responses from the BMA and other unions representing medical have given the idea of GPs holding the purse strings more support.

However, on aspects such as the pace of change, the potential loss of skilled staff and the impact of greater private sector involvement, the responses of EHI Primary Care readers have been fairly widely echoed by the formal responses from bodies such as the BMA, the NHS Alliance and the RCN.

Stout says the NHS Confderation also has a lot of questions about the details of the reforms, although it supports the vision of greater engagement with clinicians. He believes it is important for NHS staff not to jump to conclusions about what the reforms will mean.

He says: “There is still plenty of room for clarity to emerge so my advice would be for staff not to be overly set in their views until national and local discussions have been held.”

While the government mulls over the small forest of responses to its consultation, such a pragmatic approach is likely to be the only choice for many NHS staff.