One of the most striking things about the NHS reforms is how quickly the process has got underway. If you haven’t been to the doctors in a while you might well have blinked and missed it.
Amid the flurry of changes, a question lurks uncomfortably in the background: to what extent are the reforms evidence-based? Might swift action have come at the expense of solid analysis? And might political manoeuvring have been more of an impetus than the facts?
Although Andrew Lansley, Shadow Secretary of State for Health, is emphatic that the evidence supports his plan, the evidence of which he speaks is patchy. Without his changes having been piloted, there is no data from which to draw firm conclusions. And with the predictive power of past models open to question, a hard-line empiricist would be pushed to form an opinion either way.
GP commissioning
GP commissioning is not new: it has been around in various (voluntary) guises since 1991. Most notably, in 2004 the Labour government introduced ‘practice based commissioning’ (PBC), which gave GPs the option to plan and purchase services.
The model, however, was slow to get off the ground. A 2008 report, ‘Practice-Based Commissioning: Reinvigorate, Replace or Abandon?’ highlighted a number of flaws in its design.
Report author Natasha Curry, Fellow in Health Policy at The King’s Fund, points out that “only a handful of GPs were very engaged in it. There were small incentives, but these incentives were modest. More importantly, financial risk remained with the Primary Care Trust so there was a misalignment of the risks and the incentives.”
Curry believes that Lansley’s proposed shakeup may help eliminate these pitfalls. “Aligning financial incentives and risk,” she says, “might overcome some of the issues that were central in practice-based commissioning.”
Her worry regarding the new system, however, is that there will be nobody to take a top-down view. “Will GP leaders emerge in order to take that strategic population approach, rather than reacting to the concerns of their patients? She asks. “The government are hoping it will happen organically. Our concern is that it might not.”
Eliminating PCTs
Under the new proposals, Primary Care Trusts (PCTs) will be abolished altogether. A report by the right-wing think-tank Civitas, suggests that this restructuring may have damning implications. They based their conclusion on what happened in 2006, when a number of PCTs were merged and the total number slashed from 302 to 151.
Through comparing the PCTs, which had been merged with the ones that had not, Civitas suggested that the mergers had led to:
- An absolute drop in performance on ‘quality of service’ and ‘use of resources’ lasting at least one year in PCTs that were merged.
- A period of three years before the relative performance of PCTs that were merged reached pre-merger (i.e. 2005/06) levels against those that were not.
PCT ratings in the years 05/06 and 06/07
In other words, it took a year for the PCTs to deliver the same quality as before, and three years for them to catch up where they could have been. This finding led to the inevitable disturbing headline: ‘Lansley’s plans could set the NHS back three years’.
GP Fundholding
GP fundholding, which was in operation from 1991-97, is not directly equivalent to GP commissioning, but it works well as a point of comparison. It was broadly similar to PBC, except for the fact that funds did not have to be invested back into the system - GPs had a profit incentive. According to various studies, the outcomes of fundholding were mixed. Some studies located variable results; others claimed there was insufficient data to draw a judgement either way.
Conclusion
So is the evidence, in itself, sufficient to support the changes? The question seems rather disingenuous. The relationship between science and policy has always been an uneasy one: whereas politics stands or falls on firm decisions, it is in the nature of science to be tentative in its conclusions.
Katherine Adams, a Hackney-based GP, takes a sceptical view on the situation. “I believe there’s been ideology driving a lot of these changes,” she says. “In the election there was no talk about major reform. Effectively, I think at one point [Lansley] said ‘we’re not going to do a major reorganisation’. So people think there wasn’t really a political mandate for this.”
She has a striking ground-level insight into why the reforms are proceeding so quickly: “This is the biggest radical shakeup in the NHS’s history. And it’s interesting because it’s not being piloted. It’s all rolling out – they’ve actually said to the GPs on the ground, who’s ready to give us a go? And people are signing up because if you don’t sign up you’re left behind. If you have pathfinder status you get a wad of cash that you can use to develop the GP consortium.”
Wad of cash, yes; reams of data, no. If we are focussing on the evidence alone, as opposed to political, economic and ideological factors, we would surely hesitate to be as hasty in our conclusions as Lansley has been. There is little to suggest we can be anything other than fence-sitters when it comes to the NHS reforms.
Image courtesy of Tom Ventura from Wikicommons
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