The Commission’s health working group published Improving Health Outcomes earlier this month – written by myself and Dr Greg Parston, the group chair. The Monday following the report, Secretary of State Andrew Lansley announced his white paper, and the debate has shifted again. So how do the two match up?
Well first of all , we never intended to produce a set of hard policies that the whole group would advocate. It is pretty obvious from the white paper that generating consensus over the direction ahead is hard to do. So what we did was to provide a manual for decision-makers – a set of ideas, barriers, archetypes and instruments that would give people the best chance of taking short term decisions on health reform with broader 2020 goals in mind. The Commission’s shifts in culture, power and finance are at its heart, and the consensus that did emerge was over the need for (1) a more integrated commissioning model for health and social care; (2) more home-based and socially-delivered health and care services; (3) maintaining a focus on social outcomes as a driver of change and a determinant of commissioning.
This ends up looking quite different from the white paper. I have a few reflections:
- The government’s proposals are bold, radical, and certainly blow open the myth that change would be merely rhetorical, and protection of NHS budgets would stifle reform.
- The reforms also follow a market logic (Matthew Taylor has talked convincingly about civic markets recently) – extending choice, empowering professionals, nominally strengthening downwards accountability and provider competition. This is all coherent and could generate benefits, obvious concerns over equity and information notwithstanding.
- However…..
- There are questions around the model of GP commissioning that might emerge. Problems of coordination, legitimacy, scale, access to information and professional and citizen capacity all seem germane, and from what I have read it does not seem obvious at all that GPs are falling over themselves to extend their existing roles within the service.
- But the problem of integration is the most important to my mind. In the Commission, most of our thinking has been about how to integrate across public services – starting with the citizen, working from this point up, thinking horizontally and about people and place.
- Devolving power is positive, but not if the service remains within the traditional silo model. What about all of the thinking being done around integrating health and social care spending within localities? In this sense the proposals feel like they miss out a chunk of really good recent policy thinking.
These are initial reflections, and the medical and policy world are still chewing over the implications of these proposals. The size of the commissioning consortia that emerge will be important, and the impact of NHS restructuring on jobs will be (righly) keenly watched. Our own proposals – backed with Ipsos MORI deliberative work – emphasised the need to engage citizens and professionals in the change they see happening around them. From manifesto to white paper, Im not sure to what extent this has been the case here.