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On the defensive: Andrew Lansley Interview

On the defensive: Andrew Lansley Interview

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Safely ensconced in his Cambridgeshire constituency office, Andrew Lansley has the air of a battle-weary general. He's been taking some serious flak for the last eight months thanks to his radical NHS reform plan: a barrage that merely intensified with the publication of the Health and Social Care Bill in January. Life under fire is clearly tiring and stressful for the health secretary, and the campaign still has some way left to run.
Safely ensconced in his Cambridgeshire constituency office, Andrew Lansley has the air of a battle-weary general. He's been taking some serious flak for the last eight months thanks to his radical NHS reform plan: a barrage that merely intensified with the publication of the Health and Social Care Bill in January. Life under fire is clearly tiring and stressful for the health secretary, and the campaign still has some way left to run.

He desperately needs to win the hearts and minds of family doctors if his policy overhaul is going to work. But a mid-January survey by the Royal College of GPs (RCGP) found that 60% of GPs are against the "general direction" of the reforms. Meanwhile, results from an Ipsos Mori survey of more than 1,600 British Medical Association (BMA) members, also in mid-January, found that 89% thought increased competition would lead to a fragmentation of service and 65% thought it would reduce the quality of patients' care. Two-thirds also believe that clinician-led commissioning will increase health inequalities.

Lansley gives such reports short shrift. "You can always find self-selecting surveys of people who just say, 'Oh well, the government is doing this, the government is doing that', most of which, in my view, is based on an apprehension about change."

But this seems disingenuous. There is clearly a very vocal, sizeable proportion of GPs that have serious misgivings about Lansley's reforms. The problem is not with the main principle that underpins the policy; clinicians have been calling for a greater say in how the money is spent for years. The issue is with how this will actually work in practice: something that is almost entirely absent from the bill or white paper.

The lack of detail is entirely intentional, counters Lansley. "If it had simply been a case of communicating what's going on in the future we'd be missing the point. This is a co-production with health professionals at the frontline, particularly in primary care."

Trouble is, people have a tendency to fear the worst during times of uncertainty, and health professionals are no different. Both the white paper and the Health Bill only fleetingly mention terms like 'competition' and the 'private sector'. And many have filled in the gaps with dark proclamations of 'privatisation by stealth' and the very end of the NHS as a 'free at the point of need' service.

Lansley is keen to set the record straight. "It's competition for quality. It isn't about privatisation. There are no proposals for privatisation." That's why, he says, the government has committed to making amendments to the Health Bill that would mean any undercutting of the NHS tariff will not be permitted.

'Empowered' pathfinders
But, even if he can win over the privatisation sceptics, he's still got to convince enough GPs to step forward as leaders and give up big chunks of their clinical work. And that's not going to be easy. Even at the swanky Downing Street reception for the first 50 'commissioning pathfinders' held in January, one doctor asked NHS Chief Executive David Nicholson: "When am I supposed to do this? In my coffee break?"

The health secretary points to the number of general practices signing up for pathfinder status as evidence that this argument is being won. "Last October I said that GP practices could collectively come forward as potential pathfinders. If you had asked me at the time, I would have said I knew of some places where they wanted to be GP pathfinders – perhaps about 8% to 10% of practices – but in fact 25% came forward within six weeks and a further 25% within a further six weeks.

"I have no doubt we are not losing GPs. On the contrary, GPs are getting to grips with this; they are doing it. And the more they do it, the more they are realising that actually it's empowering. It is a major transfer of responsibility to the frontline and there are a lot of organisations, including a lot of GP practices, where the environment in which they do their business will change, I think, for the better."

Granted, the numbers make a compelling case. Two-thirds of England is now cloaked by the new bastions of primary care, GP Commissioning Consortia (GPCC) with the latest wave, announced at the start of this month (March), bringing the total coverage up to 177 consortia. But, in truth, the extent to which each and every GP is engaged with the reforms isn't known. So, while such statistics are useful contextual evidence, they are far from conclusive.

Not revolutionary
The health reforms have caused quite a kerfuffle, having been proclaimed by many commentators to be the biggest shake-up of the NHS since its inception. But Lansley himself doesn't really understand what all the fuss is about.

"Whether it was practice-based commissioning, patient choice pilots, initial development of the tariff, or the experience of foundation trusts – if you actually look, most of the major changes are not in themselves new," he says.

The shift of commissioning to GPCCs is "not because what has been done in the past has been all wrong, but because the structure has been highly bureaucratic.

"It has separated the frontline clinical responsibility from the management responsibility. Those two things do need to be brought together around the basis that clinical decisions should lead, and the commissioning decisions should flow from that, rather than the financial cost and volume decisions should lead, and clinicians should have to fit in.

"What is really new is to focus on how they all connect together. I know I am asking the health service to embrace what seems to be, on the face of it, a big change but actually it's in order to arrive at something which is stable and robust for the long term, as we have dealt with the issue of 'how do all these things connect up?'"

It's in this interconnection that the experimentation, which some find uncomfortable, lies. Lansley admits that how things interconnect will lead to "complications" and "what we think should happen" may "not [be] precisely right and we will have to change things as we go along".

Reliable and robust' rewards
One way to get GPs more involved, of course, is to incentivise, as shown with the Quality and Outcomes Framework (QOF). How should GPs be rewarded for the extra work they will take on?

"We will make more progress in negotiation with general practice about how we can make [QOF] more focused on the results and the quality and less about process," says Lansley. "But, in addition, consortia will have a Commissioning Outcomes Framework (COF) because we want... to capture that overall representation of how well the NHS is performing."

The cash release from disbanding primary care trusts (PCTs) and strategic health authorities (SHAs) will be £1.7bn a year in real terms – money that will go back into patient care.
GPs will have £25-35 per patient for management costs, "but there is clearly more work to be done to establish where it lies in that range", says Lansley. "If any of that isn't spent it will be added to the money available for patient 
care. The reward to GPs, in addition to what they receive through the PMS [Personal Medical Services] contract, would be through the contract with GPCC which can award a 'quality premium' in addition to what they receive to pay for their management costs if they achieve results for their patients and continuing improvements in standards, which 
is their duty."

How much this will be and the rules governing it a still being worked on.

"Given that it won't apply until 2013 it's quite important we use the transition period not least to arrive at what are regarded as challenging but achievable results," says Lansley.

Citing the 2004 General Medical Services (GMS) contract negotiations, Lansley says: "People didn't understand how many QOF points GPs were going to get, so the government introduced the contract not expecting more than 750 points and they got more than 950 on average. So it's rather important, on the basis of that experience, that when we introduce the COF that we start with a very clear understanding of the level of achievement now and the basis on which people should be rewarded on outcomes."

The COF aims to provide a "reliable and robust basis" for measuring the performance of the consortium in improving population health alongside what it is doing in individual practices in delivering health and the improvement in results of a practice's population.

On actual cash values it will continue to be a waiting game. "When we have more details we'll publish more details."
Of course, what makes this all so difficult is that the reforms are set within the context of £15bn to £20bn in savings.

"We've got a financial challenge, which means we have got to have really focused work on designing clinical service to deliver improving care more efficiently. That raises challenges and will cause us to do new things in new ways, and we can't be confident yet about how all that is going to be achieved.

"I think it was one of the generals that once said: 'No plan stands contract with reality'. Nothing ever happens precisely as you intend. It would be foolish to suggest that it does."

Victoria Vaughan

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