Hello Goodbye

When the Conservative-Liberal Democrat coalition outlined its plans for the NHS in the document setting out its programme for government, attention focused on the abolition of strategic health authorities.

At last week’s NHS Confederation conference, SHA managers were looking reasonably chipper. Perhaps they were upheld by the thought that SHAs will have some kind of future as ‘regional outposts’ of the new NHS Commissioning Board.

Attention fixed, instead, on the future of primary care trusts. An unnamed “senior source” had told the Health Service Journal that they were “screwed.”

In the very last session of the conference, NHS chief executive Sir David Nicholson said the Department of Health was trying to find the source, since the language was unprofessional and inappropriate. What he failed to say was that it the source was wrong.

We’d like to see the future

Although the coalition document says that PCTs will be responsible for commissioning at a “wider level” – and their public health responsibilities will have to go somewhere – they are likely to be pulled apart by two forces.

First, the unfinished business of splitting-off their provider arms into new organisational vehicles and, second, the new business of handing over most of their commissioning functions to GPs.

Health secretary Andrew Lansley is working on a Health Bill that is expected to lead to some 500 GP commissioning consortia being set up to take charge of secondary care purchasing.

One NHS trust chief executive told E-Health Insider that Lansley “meant it” and that when it happened “we will all be living in a completely new world.”

Opinion was evenly divided on whether it would be a good or a bad world. Optimists argued that because GPs are the health service’s ‘gatekeepers’ it makes sense to give them direct control of its spending.

Some pointed out that PCTs have tried hard to engage with GPs, and that the GP commissioners in Cambridge and Cumbria that have so impressed Lansley have been doing a good job.

Pessimists questioned some of the assumptions behind the policy; wondering if large numbers of GPs really want to be entrepreneurs in the commissioning field and whether they are really the best representatives of patient interests.

Pessimists also fretted about losing the commissioning experience that PCTs have struggled to acquire; with the World Class Commissioning agenda consigned to history.

And how to get there

Both optimists and pessimists were united in worrying about how the NHS would get from A to B – from the current system to one that is vaguely defined.

In private, delegates worried about the impact of the changes on their jobs and those of their staff; with more than one senior manager confiding that staff had been to them “in tears” about the future.

In public, they worried about the impact of the changes on financial stability. Lansley’s plans were formed over the six and a half years that he shadowed health in opposition.

In a panel session on what the general election would mean for PCTs, one delegate asked whether they were more suited to a time of rising NHS funding than one of severe public spending restraint.

Nigel Edwards, acting chief executive of the NHS Confederation, joked: “I do not think the collapse of world capitalism should get in the way of your plans”.

But Simon Whale from the consultancy Luther Pendragon wondered whether the Treasury would “have something to say” about handing £70m-£80m of public money to GPs, who are, after all, small business people.

A few hours later, Lansley was asked by conference chair Sarah Montague whether they Treasury would have “something to say.”

Visibly irritated, Lansley insisted that the Treasury “understands that we are committed to transferring commissioning responsibility to the people responsible for most commissioning activity.”

He also insisted that he was well aware of the risks and: “I will make sure we put in place systems of financial control that are better than we have got.”

While keeping control of the money

Another man that will be keeping an eye on the money is Sir David Nicholson. “The Treasury is concerned about financial performance and so am I,” he said in a response to a question after his keynote speech.

“I remember 2004-5 when we lost control of the money and had to fight to get it back. Since then, financial management has been transformed in the NHS. I am not going to put it at risk, and neither will the Treasury.”

The speech itself was intended to rally the troops by stressing Sir David’s personal commitment to the NHS and to the work of its managers.

He urged them to maintain their professionalism and look to lead the changes, engaging and supporting GPs where possible and making the most of any opportunities to improve patient care.

“We do not want to be the French football team of the NHS; we have to get hold of this and we have to lead it,” he said, urging managers to find the “energy” in upholding the core values of the NHS.

Sir David said that managers should try to stick with the principles set out in the final report of Lord Darzi’s Next Stage Review of the NHS, ‘High Quality Care for All’, and the Quality, Innovation, Productivity and Prevention agenda that he outlined at the NHS Confederation’s conference last year.

QIPP is supposed to stop trusts making random job cuts and ‘salami-slicing’ services in response to financial pressures. This year, however, Sir David admitted that the NHS might have to go further.

Most strikingly, he told his audience that the NHS might have to “expand” to take in some social care services as council budgets are slashed. “We cannot have a successful NHS and failing social care,” he argued.

And doing the day job

Several delegates raised concerns about the future of social care. Otherwise, there was surprisingly little discussion of the Budget or the NHS’ pressing need to find £20 billion efficiency savings over the next four years in the main conference sessions.

Despite Sir David’s advocacy of Darzi and QIPP, there was also little discussion of the practical steps needed to push ahead with them.

Strikingly, there was almost no mention of the information and technology demands that the two agendas make; or of the role of technology could play in helping people to stay well and to improve the management of any long term conditions that they have.

The NHS Confederation and its annual conference have always seemed more comfortable talking about policy, leadership, finance and HR than IT, but the absence of interest in technology was more than usually obvious this year.

In the exhibition, NHS Connecting for Health and its major suppliers were notable only for their absence; as were some big technology companies. Informal contact with the IT suppliers that did take stands suggested that delegates were “browsing” the exhibits, rather than looking to do business.

The clock is ticking

Many of those attending the event were hoping that Lansley or Sir David would set out a timetable for the coming changes; or at least announce when the Health Bill will be unveiled. In the end, they could only say it will be out “soon.”

The danger is that when it does come out, the NHS will be consumed by the need to dismantle and set up new structures yet again; just when it really has more pressing issues to worry about.