How will the NHS reforms work?


            Mr Lansley’s reforms  revolve around giving the GPs a much bigger role in the management of our Health Service. They will succeed if he enthuses enough GPs to use the new freedoms and  powers they will enjoy. It will go through with little improvement if GPs grudgingly accept the reforms but do not wish to make them work. It will go badly if enough GPs unite to fight the very reforms designed to give them more interesting jobs with more scope to do well for their patients.

           The first challenge Mr Lansley faces is trying to ensure that the big switch from expenditure on administration and layers of management to more spending on health care  provision takes place. Stripping out regional and national administration and controls, and removing PCTs should cut costs. It is important that the new GP commissioning structures are kept within sensible bounds of size and cost so they do not absorb all  the savings. Mr Lansley knows he must avoid big pay offs for those losing their jobs, only for them to reappear elsewhere in the NHS, perhaps with a higher salary.

           The second task is to ensure the new GP commissioning has at at its command the necessary information and IT support, without embarking on a massively expensive new centralised system that takes too long and is way over budget.

            The third is to resist the temptation to intervene regularly from Whitehall when the predictable local rows and worries emerge with the decisions the GPs are making. The system might result in some hospital or service closures, where GPs and patients opt for a different provider or way of treating something. The centre has to stick to the line that this is a matter for local decision, and all worthwhile services and institutions should survive because local GPs will wish to use them.

             The fourth is to carry enough of the union membership with him. They will object to the challenge coming from independent and charitable providers, and can do damage from within the public sector run part of the service.

               It is a complication that these reforms have to go in at a time when budgets will be rising less quickly than at any time over the last 30 years. That is why success in cutting overall admin costs is vital, and why the new system needs to produce a variety of providers offering choice, higher quality and lower cost to work well.


  1. lifelogic
    January 24, 2011

    “Mr Lansley knows he must avoid big pay offs for those losing their jobs, only for them to reappear elsewhere in the NHS, perhaps with a higher salary.”

    This should be avoided by capping redundancy rights at £5,000 this would greatly help the state sector and the whole economy too.

    My experience in business is that gradual improvements to the system – a little saving here and small improvements there were often more effective than major reorganisations. But if anything does need major change it is the NHS. You need to ensure that the money spent is providing what is actually needed by patients and is not run as now for the benefit of administrators the supply companies and the professions. The money needs to follow the patient and the patient needs to be able to go somewhere else (with his money) if the service he is using is not providing what is needed efficiently as and when needed.

    1. lifelogic
      January 24, 2011

      The NHS really must start to charge people who can afford to pay then they might start responding to actual patient’s needs rather than just throwing them the occasional scrap when they feel like it.

      If one can afford to pay for hair cuts, often (too much) food & drink, and make up then they can afford to pay something for the doctor too.

      If some one has to spend ages phoning the doctor just to make an appointment usually made at an inconvenient time then travel and wait half an hour just for someone to look at his throat for 20 seconds and give him a piece of paper so he can go on to the pharmacy to get fifty pence worth of penicillin. With yet more paperwork for the pharmacy to reclaim a fee from the state. Then this is not very efficient use of time for the NHS or for the Patient. This type of inefficiency goes on endlessly in the NHS.

      Nor is it efficient for someone doing hip operations to have endless years of training first – they just need to know how to do that particular job well.

      1. Magnolia
        January 24, 2011

        Buying penicillin is not just like buying some sweeties you know.
        This stuff is a miracle cure that has probably saved my life several times over and many, many of us are living proof of its efficacy and it is still a wonder drug after all these years and even with the development of bacteria that are resistant to it through its overuse. We will really miss it when it no longer works. It’s last spectrum of effectiveness shouldn’t be wasted by the mindset of ‘I want it therefore I’ll have it’ mentality which your comment seems to imply.
        I wonder if you’d really like a surgeon without endless years of training to replace your hip. It’s not like a factory where the production line can be halted when there’s a spanner in the works. Professional medical training has already travelled a long way up this route under Labour with the much shorter run-through training for hospital specialties together with much reduced work experience in training due to the EU working time directive.
        Lack of experience doesn’t necessarily produce good or even good enough results. Superspecialisation has been relentlessly persued during the Labour years with the result that medics are increasingly unable to recognise or understand unusual things that they come accross in the course of their work and this happens more often than you’d think because the living body is complicated and disease often unpredictable. This can be a big problem if the patients on the theatre table with their abdomen open and the specialist for what they really have is somewhere else. This manpower defect will already be starting to impinge on productivity throughout hospitals but no one under labour would have listened because the dogma was that if you had disease X then you had to travel miles to a regional centre that specialised in disease X.

    2. lifelogic
      January 24, 2011

      I see that Sir Richard Lambert outgoing CBI director has got it about right:

      Sir Richard said “policy initiatives had been taken more for political reasons than economic ones, with the government “careless of the damage (the initiatives) might do to business and job creation”.

      But these are actually only silly “short term” political reasons – what probably matters is how people will vote in about 4 years time. This pointless handicapping of business now will cost them, and everyone much growth, many jobs, taxes and thus votes come the election.

      Why do they not realise this? Time is running out.

      1. lifelogic
        January 24, 2011

        I later hear Vince Cable dismiss Sir Richard Lambert’s comments saying the government’s first priority was to sort out the public finances.

        Can he not see that sorting out public finances rests entirely on obtaining private sector growth, which rests on doing pretty much what Sir Richard suggests. In order to create a suitable environment for growth and doing it very quickly now.

        I keep repeating myself but:

        Easy hire and fire
        Cheap (non green) energy
        Banks that lend
        A vision of a smaller state and lower taxes soon
        Fewer silly regulations
        EU free trade only

        A “Welcome Here” sign for the hard working, the rich and the talented rather than the current “Get Lost” one.

      2. waramess
        January 25, 2011

        I think time has run out. the UK will slowly die as an economy that matters as the oil runs out

  2. Braveheart
    January 24, 2011

    This article is entitled;

    “How will the NHS reforms work?”…

    … but given the content and the questions raised, perhaps it should have been;

    “Will the NHS reforms work?”

  3. Brian Tomkinson
    January 24, 2011

    It seems clear that few people understand exactly how these reforms will be implemented practically thereby allowing opposition to grow, which will reduce the chances of success. This seems to be the case for most, if not all, government policy announcements.

    1. John C
      January 24, 2011

      I caught a part of a select committee on BBC Parliament on Sunday (I really should get a life!).

      An MP on the committee asked a reasonable question along the lines of “Will each of these GP consortia (or whatever they are called) have a chief accounting officer who will be the point man/woman for us to ask any questions relating to financial matters?

      A bit of a pause then an answer from a civil servant along the lines of “I should think so”. (I recognised Gus O’Donnell as he was sat near the person who “answered” the question).

      That answer did not give me confidence that the implementation of this change has been well thought through. But, that might not be such a bad thing. The NHS IT system was well thought through and it has reached £12 billion so far (and will probably never be implemented).

  4. D
    January 24, 2011

    “…go badly if enough GPs unite to fight the very reforms designed to give them more interesting jobs….”

    Obviously GPs wouldn’t resist if the “reforms” were unambiguously to the advantage of GPS and the NHS. The fact that you anticipate significant resistance is an admission that you haven’t understood their concerns nor have you made any visible attempt to respond to them.

    Since an MP in your position will have an opinion informed by the internal DHS risk analysis and I urge you to clarify what you understand the risks to be and to what extent you believe you can mitigate them.

    In a mater of such national importance I think it is very regrettable that you will not publish the details of the official DHS risk analysis even in response to an FoI request. If there was ever an issue which would benefit from openness this is clearly one of them, and your disinclination to give out lucid information only inspire speculation as to why not.

    Reply: A significant number of local Doctors in my area have not only welcomed the changes but are applying to be pathfinders for early implementation.

  5. Alte Fritz
    January 24, 2011

    A GP friend has identified GP resistance from politically motivated GPs as a perpetual threat to reform It damaged the fund hlding initiative years ago. You are right to identify ‘hearts and minds’ as the issue.

  6. alan jutson
    January 24, 2011

    Seems to me we have a long way to go yet with working out the finer detail, as to how all of these suggested changes knit together.

    John, do you know if the Government are planning a big bang (all change at once to a new system) or if it will be phased in section by section, over a number of years, or have we not got that far yet.

    Reason I ask:

    The big bang may have massive ramifications if not properly organised.

    The phasing in over a number of years may mean that it is never phased in completely, if the government do not win the next election. We will then have the worst of both worlds (cost and inefficientcy) as Labour (I guess) would seek to change bits of the original plan.

    Whilst I appreciate that the cost, and waste in the NHS has to be reduced, and performance improved. Governments do not have a good track record of implementing any sort of change which actually saves money and improves efficientcy. If anything reorganisation always seems to cost more and gets worse.

    I really do hope that this is though through very carefully, before the die is cast.

    Reply: They will implement pathfinder voluntgeers first.

  7. waramess
    January 24, 2011

    It has been said elsewhere far more eloquently than I can remember but Lansley is simply changing one way of trying to organise a broken socialist effort for another and for this reason it is bound to fail. Will the Conservatives not leave these bureaucratic socialist attempts at beating the free market at it’s own game to the socialists and instead embark on giving the free market a try.

    The Conservatives should collectively hang their heads in shame for the way in which they are drifting to the left. If Margaret Thatcher had adopted the softly softly approach of employing the “art of the possible” we would still have a state owned gas board and electricity board and a very large coal board- something of which no doubt our socialist “friends” would approve

    1. APL
      January 24, 2011

      waramess: “The Conservatives should collectively hang their heads in shame for the way in which they are drifting to the left.”

      Agreed. The poor wee things are so delicate, much easier to make the case (especially on the BBC*) that increased government spending will placate the voracious demand among the public for state intervention than to actually and consistently make the case that the state should not be doing everything, and secondly if it does we end up like the Soviet union, both economically and politically.

      *Notably this ‘Tory’ government has refused to do anything about. Nor has it done anything much about the government subsidy of the Guardian indirectly through the BBC.

      Consaquently, one must assume they are content with the status quo.

  8. English Pensioner
    January 24, 2011

    Whilst it is clear that management/administration has got out of hand in the NHS, I’m wary of moving too much control to GPs. Will they, in turn, simply employ those managers to run their practice, ending up with effectively the same number, but distributed around the country?
    I am also aware of what I was told about the situation in Ireland last year, where if you listen to ordinary members of the public, it would appear that their doctors have far too much control and the service is terrible. The lady with whom we stayed for B&B in Rosslare told us that her pregnant daughter would be coming to England in a few days time as the maternity services in Ireland were so bad that she’d arranged to stay at a B&B in Wales to ensure that she could get treatment if necessary. I didn’t think any European country was worse than us, but speaking to the Irish, they seem to think that their Health Service is, and seem to blame the doctors rather than the government.

  9. Acorn
    January 24, 2011

    There are quite a few part time GPs, particularly married females. They do about three days a week for good money. Very few of them took the job to be quantity surveyors and buyers of the medical type. They are not interested in writing and evaluating supply contract specifications. As I have said before, they will end up affiliated to a private organisation with its own dedicated buying department; and probably, its own hospitals. Perhaps that is the government’s plan?

    A few years back the NAO tried to find out how much a hip replacement cost the NHS system. Some hospitals could not even work out the numbers. You can’t control costs if you don’t measure them. “At a guess, about eight or nine thousand” I hear. Apparently you can get a new hip for about 20% less in France and Germany. In India, 50% less plus travel costs.

    I always remember the line in that ER series on TV. When the consultant tells the new intern; “…you have just ordered $19,000 worth of tests for this patient”. Do you think anyone has ever said a similar line in the NHS?

    1. John C
      January 24, 2011

      “Perhaps that is the government’s plan?”

      I read that these reforms will have to incorporate EU competition laws. What this means is that the GP consortia will be unable to make a deal with the local hospital or other traditional NHS provider as, by EU law, they have to put it out to competitive tendering. If they don’t do this, a private company can ask for a judicial review to force them to open up the tendering process.

      I’m not too sure that this is a bad thing – but it will happen.

      As long as treatment is free at the point of need and available, regardless of ability to pay I’m not bothered who provides it.

      In fact, with the bad service offered by the NHS to a couple of my immediate family in the last five years I’m more convinced than ever that the NHS needs a bomb placed under it to shake them up.

      “When the consultant tells the new intern; “…you have just ordered $19,000 worth of tests for this patient”. Do you think anyone has ever said a similar line in the NHS?”

      I can tell you that my Brother in law, in the last year before he died, went into hospital numerous times and each time, the consultant could not prescribe the antibiotic that she knew was effective (too expensive) until he had gone 5 days under a cheaper antibiotic to show that that drug was ineffective and they could justify prescribing the very expensive antibiotic (£10K per treatment).

      She, my brother in law, and all the family knew that this was ridiculous and caused a lot of suffering to my brother in law as each infection destroyed more of his lung.

      The consultant was powerless to override the rule laid down by some bureaucrat somewhere.

      Don’t believe that the NHS do not think about the costs of tests and treatment. They do. But it is laid down by bureaucrats. Too many people have this mistaken belief that the current NHS run tests regardless of cost. It isn’t true.

  10. a
    January 24, 2011

    posting test

    1. Acorn
      January 24, 2011

      Seemed to work “a”. Now try it with a URL link in it. Not that I am complaining you understand.

      1. English Pensioner
        January 24, 2011

        Would be useful if this site had a pre-view facility like many sites so one coulf check if the html worked!

  11. Petegriffiths
    January 24, 2011

    The NHS certainly does require a major overhaul just as the education system does. However while the approach taken with education appears to be transparent and with enough detail to convince me that this will work by building and adapting the existing framework, the tactics with the NHS are not at all clear.

    What I believe will happen is that some GPs will accept this with open arms but some will resist either through lack of resource or for idealogical reasons. Some will be incapable of such change. The danger is that the GP network will fragment and it will become a post-code lottery.

    My local surgery, which is fairly large, I have no reservations about because I am sure they will accept these changes and work with the proposals, but I fear for the small partnerships in, for example, rural Yorkshire.

    The reports coming from Cumbria are very encouraging where this approach was adopted a couple of years ago, but it is a pretty large gamble on the coalitions part.

    “May we live in interesting times”

  12. DiscoveredJoys
    January 24, 2011

    In this particular case it might make a clearer case if we talked about cutting overheads, not costs.

  13. Harfield
    January 24, 2011

    Let us hope the government have the strength, determination and time to face down the central bureaucracy, an enormous challange and not to be underestimated.

  14. Alan Wheatley
    January 24, 2011

    I agree the principle.

    As to detail, with regard to “the necessary information and IT support, without embarking on a massively expensive new centralised system”, my advice is to concentrate on the data and let the systems take care of themselves. If you define the data format then all sorts of systems can be designed and made by different vendors that will work with the data. A good example, in a different context, of how well this can work is given by the .pdf (portable document format), which enables any page created on any computer to be printed correctly on any printer; well, “any” that support the format, which is almost all.

  15. stred
    January 24, 2011

    You have identified many of the likely problems, but there are more. Has Lansley made a realistic appraisal of the cost of redundancy, pension enhancements and re employment plus the costs of fragmentation with sales and tendering costs? As with the railway breakup, smaller operating units will be knocked off one by one by strong national unions and salaries may increase greatly.

    We can be certain that GPs will not run the administration themselves. To avoid the possible chaos and trousering of staggering payouts, why not split up the PCTs into units, only sacking the top ‘fatcats’ and fix a maximum salary level for various admin levels. The GPs could then become the ‘board’, in charge and able to control waste and poor service.

    Of course, not all GP practises are excellent and some are only here to collect the high earnings in the UK, many now coming from abroad.My GP friend in France earns a fraction of his opposite number in the UK In the Fundholder years, some saved money for patients to spend on their own facilities. I know of one ….. GP who sent her friends from church for minor operations at a private hospital while failing to diagnose or treat cancer in others. Recently, a friend visited his GP to check his condition and was told that he must pay £10 for a photocopy of a blood test analysis. Most of these GPs were from abroad and, as the drive was lined with expensive cars.

    Then, as I found out last year, some GPs are sending out preventive health care letters to patients and so are the PCTs, using their panel lists. Unfortunately for the taxpayer, the patients left their address up to 20 years ago and some returned to their own county of origin. These GPs will be allocated funds for these ‘ghost’ patients, as doctors call them.

    This reorganisation is likely to turn into another farce unless some careful and worldlywise analysis is done. Certainly not on a national scale!

    Would it not be possible to just copy the French, who pay a reasonable national health insurance and have a choice of competent clinicians and clean hospitals available quickly.?

  16. eddyh
    January 24, 2011

    There is a huge amount of waste in management in the hospital service. When I became a consultant in 1973 the hospital was run by a 3 man comittee of consultants (elected by their peers), the Matron and the Hospital Secretary. Now you cannot walk down the corridors without seing hordes of middle managers with their clipboards, all looking for something to interfere about.The end result is that the majority of my consultant colleagues who are still working in the NHS have given up trying to be involved in the management process. They say “I just come, do my clinics or lists, and go home.

  17. andre_michel
    January 24, 2011

    After your recent pieces on your factory visit, I’m surprised that you, Mr Redwood, still concentrate on how much cash is spent, or who controls how it is spent. The quality of health care is very largely a matter of the attitude of the people who provide it, not how much is spent, or whether the buildings are new or old.
    Since 2003, I have had experience of four English hospitals as a visitor and close relative, and two French ones as a patient. I could write reams on the incompetance, appalling lack of care (in the sense of being bothered) and downright neglect my relatives suffered in England in spite of two of the hospitals being shiny new buildings.
    Suffice it to say, I have told my children that if ever I am taken ill while visiting them in England, they must, at all costs, get me home to France, otherwise they won’t appear in my will.
    I don’t know the answer to this – perhaps it’s too late to change attitudes as all the old-fashioned staff have long retired. Perhaps reducing the size of institutions to more human proportions might help?

  18. Paul Saysell
    January 24, 2011

    Why is your website now listed in the ‘restaurants & dining’ category? For some reason I cannot now view your site during lunch on my work computer. It worked fine last week when listed as ‘news & entertainment’

    Reply: No idea, I will have it investigated.

  19. Javelin
    January 24, 2011

    I don’t understand how clinicians being in charge will reduce the current inefficiencies (as I said yesterday i.e. targets, health and safety, compensation, etc). I understand the change in management will make the changes easier, but without changes to the rules causing inefficiencies then nothing can change.

  20. stred
    January 25, 2011

    Dear Mr Redwood,
    I contacted you about the GPs sending preventive health care letters to non existent patients last year, after receiving zero interest from Lansley. Have you had any reply to your contact? By the way, some patients had not returned to their native county- ‘country’ was intended. Also, the four dots in place of the polite phrase I used for the GP (was to avoid being able to identify the GP concerned as I had not heard the GP’s side of the story-ed)

  21. David John Wilson
    January 25, 2011

    There is a huge amount of waste which can be pruned from the NHS. Just look at the Royal Berks. Walk round the block. How many of the large houses are occupied by subsidiary services? Most of these contain their own receptionist, waiting room and conference room. If you attend an out patients’ appointment at the Royal Berks you pass through the hands of at least three people before seeing the consultant. Most of these spend half their time shuffling the patients notes backwards and forwards. These notes are also handled at least five more times before and after the appointment. That doesn’t include the number of times a regular six monthly appointment is rescheduled before it actually happens. I can’t remember when I last attended one on its original scheduled date and time.

    As to Wokingham itself, how many small NHS establishments are there which could easily be moved the Wokingham Hospital?

  22. Lindsay McDougall
    January 25, 2011

    My guess is that what will happen is that GP practices will get bigger so that they can hire an individual with financial skills and the ability to lobby central government, many of them hired from the PCTs that are to be abolished.

    The interesting question is how central government will allocate budgets to GP practices. It’s easy enough when you have area monopolies. They will have the last census, the electoral rolls and expenditure in previous years to help them. If there is competition between GP practices in an area (heaven forbid!), it gets trickier.

    My own GP thinks that the changes will make his job more rewarding – not fiancially but in terms of job satisfaction. He does wonder whether the reforms will in the long term undermine the idea of a community service free at the point of consumption. However, given car parking charges at hospitals and prescription charges, it isn’t really free now, is it?

    I wonder if the budgetary reforms will halt the drugs industry’s insatiable desire to produce more and more expensive drugs with more and more powerful side effects. I wonder if the courts will allow GP practices to respond rationally. Why prescribe expensive drugs for the retired elderly so that they can contract alzheimer’s disease later on? It seems that no one in public life will challenge this nonsense. Slow down the alzheimers, not physical decay, that’s the right idea.

    By the way, I am 64 and still can get work, albeit sporadically. Why are my prescriptions free?

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