What difference will the NHS bill make for patients?

The NHS bill, in a nutshell, passes budgets down to GP commissioning groups (which will be heavily supervised), and increases the scope of private provision in the NHS. What difference will that make for patients?

The government’s argument is that patients will be able to choose which provider they want, and hospitals and other providers of care will be forced to compete for their choices. They argue this will drive up standards of care.

I have profound worries about GP commissioning. I like GPs, but I’d rather them be thinking about my care than buying care for me. The skills of buying care are very different from looking after their patients. When GPs took control of budgets in the 1990s it actually led to a fall in patient satisfaction – we don’t know exactly why, but I’d guess it was something to do with GPs becoming focussed on costs and patients not getting the referrals or prescriptions they expected to (the first year of GP fundholding saw a fall in both). That might be a good thing – perhaps those referrals and prescriptions weren’t necessary? However, I’d really my doctor be focussed on providing care for me rather than having to worry about what it’s costing. At present, we can pool costs by having large commissioning organizations (the much-maligned PCTs), so if my care ends up being expensive, that can be balanced out by lots of other people not needing any care at all. In the smaller care commissioning groups I worry that expensive patients will come to be regarded as a significant cost to their particular GP practices – and that seems to be a bad starting point for thinking about their care.

The first benefit the government are claiming for their bill is that it will increase choice. Choice can be a good thing. For patients with long-term conditions who are able to become experts in their own healthcare, this seems sensible. Should ‘expert’ patients want to choose, having acquired the knowledge to do so, we should support them. But this is already largely the case – the expert patients programme has been in place for ten years now. What about the rest of us?

Let’s take a standard sort of treatment which both public and private sector can provide – a hip replacement. There’s like to be several potential providers here. So you need a hip replacement. Which provider do you go to? Well you might have a choice between waiting times, between recorded success rates (however they are defined) and perhaps might also base your choice on how far you are prepared to travel, or even if you are prepared to conduct your research, the type of hip replacements offered by each provider (ones made of metal seem like a bad idea given recent coverage  – and don’t get my engineer father started on how insane it was to use metal at all for this).

So there we go – a whole bunch of relevant factors. What next? Well you need to work out which are more important for you, somehow weight them, and make a choice.

Now you may find all of that an empowering process. I don’t think I would – I’d want my GP to tell me who would do my particular hip replacement best locally, and to go to them. That’s asking quite a lot of a GP, who is effectively taking the risk for me, as well as having to act as my researcher, but hey – she’s got seven years of medical training and years more post-qualification experience. I’ve got an ‘A’ level in biology. She’s probably better at this than me.

So there’s benefit one – you get more choice. You probably won’t get much of a choice over exactly when you’ll be treated by any particular provider (you’ll probably have to have private insurance for that, and even then the choices you are offered will be pretty constrained), but you can have a choice of which provider you get – provided of course all the information is available – and it probably isn’t. Which makes me wonder how you’d make a choice (and please don’t point me to the NHS Choices website which has very little of the information I’d suggest you’d need above).

Now let’s say you choose a private provider, and things don’t go entirely to plan. What then? This is where uncertainty raises its head. In your basic-NHS model, you go back to the same clinic that did the operation and they be expected to remedy things. If you’ve gone to one of those fancy private providers you may have a problem.

First, the private provider will still have to be there. They do go bust you know. If you are a few years in, there’s no guarantee they will still be around. If they are there, you might have an argument about whether they are responsible for fixing you up. Private medicine is based on profit – I’m sure the doctors working within it have good intentions (except those providing breast implants, given the PIP nonsense) but they do have a strong incentive to pass any problems away from them. So if you need additional care, they will either want to get paid for it, or want to pass you to another provider. This is pretty much what my mother-in-law experienced in the Australian system when her hip replacement was rather bodged. No-one was interested in taking responsibility and helping her – everyone wanted to avoid the cost she might incur for them.

So if something goes wrong, there’s quite a chance you’ll end up at another provider. The local comprehensive NHS hospital won’t be allowed to go bust, but will be under considerable financial pressure. Even so, it is likely to be your best option. You’ll probably have to go back to your GP and make another choice to get a referral, but it should still be possible. Then you can hopefully get some help.

However, the story doesn’t end there. To help recover, you might need rehabilitation. That will need you either to go to a hospital for another service, or more likely, receive a service in your home through a community-based service. The provider you meet with (you may need to make another choice here) for your service will need to know what your needs are, and will need to link up with your NHS hospital to look at your medical records. They may need to refer you on to other services – you may need to access specialist therapy of one kind or another. That’ll need a new contract with another service provider.

The whole point of all this is that, if you think that it can be difficult getting NHS services to join-up now, you ain’t seen nothing yet. Can you imagine what it will take to join up services across multiple providers from different organizations and all the contracts that will entail? And all the ways things will be able to go wrong? I’m not saying the NHS gets this right – but I can at least see how it’s meant to work in theory. I can’t even do that for the new arrangements, unless the mighty IT gods descend and create some kind of super-integrated system. That didn’t work out so well under Labour – over £6bn was spent to little effect.

So, from the patient’s perspective the big gain is meant to be more choice. I personally don’t want it – I want my local NHS to be good enough for me not to have to worry about choice. I’d rather save my choices for when I buy shiny IT equipment. The price of this choice is fragmentation. The more providers we introduce, the more difficult it is to see how the system can be joined up for any kind of care which isn’t really simple. And care, by definition, is seldom straightforward.

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4 Responses to “What difference will the NHS bill make for patients?”

  1. Colin Forster Says:

    Ian, what is the likely size of a CCG’s patient pool going to be compared with the current PCTs?

    • Ian Greener Says:

      Hi Colin. I don’t know if the final number of CCGs has been finalised. There are about 150 PCTs, and if the whole argument about CCGs is that they will be smaller and more responsive, then there needs to be a lot more than that. Gov was originally talking about 380, so that’s more than double (and so, I suppose, less than half the size of PCTs). I confess I don’t know where we are right now though.

  2. Michele Kohler Says:

    Hi Ian,
    I think there are two different issues here. The main one is that the Bill will result in a proliferation of providers and that the patient may not be able to focus on what is important. There will be no way of comparing unlike with unlike. And then trying to join up the treatment. The joining up will become the focus of some entrepreneur who will then make money and be conglomerated by the usual big companies…. But that’s not the same as choice. Sometimes the GP doesn’t know what’s best for the patient – sends you to the only name he knows who is actually in a different sub-specialty from the one you need thus delaying the treatment and making you go round the houses and despair. Or chooses a hospital because it’s the one that’s always been used – or after the Bill the one his colleagues insist he uses. I’m happy to make those choices on my own and tell my GP where I want to go. I won’t bore you with stories….

    So choice works now – but how it will work in the brave new world after this wretched bill is passed is anyone’s guess.

    • Ian Greener Says:

      Hi Michele,

      I agree patients should make choices about where to go if that’s what they want to do, and also that GPs aren’t always best placed to make those choices for them. However, I think you are in a minority being both able and willing to choose, and so saying it choice works right now is possibly not representative of the policy as a whole. I also agree with you that it’s going to be far, far more complex after the bill. My personal preference would be for patients who want to take on choice to do so, and for GPs to be able to make choices based on clear data for the rest of us. But that is an awfully long way off – even with the more limited range of providers we presently have.

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