Brid Hehir, 14 October 2010
The most anticipated Department of Health White Paper for some time, was published in July 2010. Entitled, Equity and excellence: liberating the NHS it sets out the Government’s long-term vision for the future of the National Health Service. It places patients ‘at the heart’, in charge of making decisions about their care. This means focusing on clinical outcomes instead of bureaucratic targets and ‘empowering’ health professionals to give those on the front line, such as GPs, more control.
Many criticisms have been made of the new White Paper. Yet while opposition rumbles on, the General Practitioner Committee (GPC), representing the interests of GPs, the professionals expected to take control of £80bn NHS spending, welcomes the Government’s intention to ‘enter into a dialogue’. The GPC has written The principles of GP commissioning to help move the discussion along. Meanwhile, the union, UNISON, wants a judicial review but on process as opposed to content. In its application to the High Court, it claims the Secretary of States’ refusal to properly consult on the White Paper proposals is unlawful. Unfortunately, neither of these initiatives represents a challenge to this ‘bold vision for the future of the NHS’.
In fact, the White Paper is not at all visionary but very similar to New Labour’s 2010 election manifesto, World-leading healthcare: a patient-centred NHS. The latter focuses on healthcare ‘values’: ‘No longer passive recipients of care, patients will be active partners with enforceable guarantees, real choice, and direct control over services’ (1). The irony of this as a ‘bottom up’ approach to the future of health care is not lost on critics however, who recognise it’s real nature is indirectly driven by the ‘top’. So, GPs, traditionally considered some of the most self-interested, obstreperous health care professionals and conscious their interests didn’t necessarily coincide with those of Government, are expected to take responsibility for a government dictated agenda and become local health care commissioners.
This is a clever government ploy. As a result of a lack of confidence within the medical establishment, frequently exploited by government officials, the old view of doctors as wise, authoritative figures has waned. It’s replaced by a relativistic view of doctors as the ‘facilitators’ of patient choice. The last government played an important role in bringing doctors to heel, aided by Primary Care Trust commissioners. Despite this, GPs in particular continue to enjoy a high level of public trust - one that politicians envy - but can now use to their advantage. In addition to carrying the responsibility for local health care commissioning decisions, GPs will also have to make unpopular ones, like where to save money. The Government can abdicate responsibility, which might well include the closure of local services and hospitals - something that Andrew Lansley, in opposition, said he wouldn’t do (2).
However, there’s nothing in principle wrong with a top down approach. This would work well, if it reflected a broader consensus in society flowing from rigorous discussion. Yet consultations and focus groups have come to dominate to the detriment of a more genuine democratic process. Andrew Lansley’s worried reaction to discovering he would face a hand picked audience on Newsnight soon after the document was published, illustrates how unused politicians are to engaging even with the most respectful of audiences. Lansley claimed he hadn’t agreed to a Q&A. Newsnight’s Kirsty Wark replied (accurately) that he, or his people, had. Lansley responded that he wouldn’t do Newsnight again if he was ‘set up’ like this (3).
In a similar vein, the populist language used in the document is self-deprecating, seductive and ingratiating. We’re told of plans to reduce expensive and unaccountable quangos and get rid of bureaucracy and hierarchies. Doffing his cap in the direction of those who hate being at the receiving end of the micromanagement that the NHS has been subjected to, Andrew Lansley says: ‘So we will dis-empower the bureaucracy, the Primary Care Trusts and the Strategic Health Authorities. I don’t want the whole of the NHS to wait to hear from me. I want it to listen to patients, and to take responsibility for action.’ (4)
So the new HQ for the NHS will not be in the Department of Health but ‘in the consulting room and clinic’. Staff will be set free to use their clinical judgement, to perform jobs to the best of their ability by getting rid of targets with no clinical justification. Yet whilst it’s true staff are swamped by bureaucracy, Lansley’s vision also demands an information revolution to support the patient choice agenda. There will be standards to improve quality, which will provide the information he says patients must have to make informed choices.
In addition to supposedly liberating the NHS from bureaucracy, it’s evident that controlling clinicians and commissioners is a core objective, despite rhetoric to the contrary. ‘Putting power in the hands of patients and clinicians’ is the aim and ‘nothing about me without me’ the motto.
Rebranding patients as consumers, a trend that’s been gathering pace for some time, continues in the Paper. Here, it is justified by the ‘need’ for cultural change - to shift patients from thinking of themselves as passive users to active consumers – a la New Labour. This relabeling is ideologically important. Consumers expect to be able to choose between services and to exercise their consumer rights, voting with their feet where the service doesn’t come up to scratch. Staff also have to rethink patients in a different light: citizens with entitlements, able to select from a ‘choice’ menu whether to have what’s on offer or take their custom elsewhere. Their role of gatekeepers will end.
Rethinking patients as consumers is a logical development to the notion of the ‘expert patient’, promoted in health policy for a decade or so (5). According to the DoH, an observation often made by health professionals who undertake long-term follow up and care of people with particular chronic diseases like diabetes, arthritis or epilepsy is, ‘my patient understands their disease better than I do’. But, as ardent critic of the Expert Patient Programme (EPP) GP Dr Fitzpatrick succinctly writes, despite its common sense appeal, EPP implicitly degrades doctors, devaluing medical science and professional expertise (6). The beneficiaries are not patients, doctors or even society but a few politicians and health policy bureaucrats.
Patients, if they want choice, do so because they’re told by politicians they should and no longer trust health professionals to deliver a decent standard of care. If excellent services were provided everywhere, which is entirely feasible considering the amount of money poured into the NHS annually, the choice agenda would quickly become obsolete. Tellingly, ‘choice’ is promoted predominantly to sick people – who generally don’t want to make such decisions and should be confident they can trust health professionals to care for them until they are well.
However, HealthWatch, the new organisation to represent patients’ interests, is to be an ‘independent consumer champion’ for service users and carers across health and social care. It will replace Local Involvement Networks (LINk) which comprises professional patients who purport to express the interests of patients in general. Yet LINk members are unelected and unrepresentative of patients, unlike local councillors and MPs, so are under no obligation or even pressure to reflect the interests of those they claim to represent.
And in case GP consortia think they’ll be able to make commissioning decisions independently, they are mistaken. They will have a duty of public involvement, with the need to engage patients and the public in their neighbourhoods in the commissioning process. HealthWatch volunteer members of the local community will be expected to provide evidence about local needs and aspirations which the consortia must then take into consideration. How qualified HealthWatchers will be to carry out this role remains unclear.
But it’s not such a rosy picture for these new drivers and healthcare consumers; a quid pro quo approach is expected. In return for greater choice and control, people must ‘accept responsibility for the choices they make, concordance with treatment programmes and the implications for their lifestyles’(Liberating the NHS, p.4). Along with rights come responsibilities.
Public health work - prevention, screening and infection control - is to be transferred back to local government where it was until 1974. This will ‘strengthen democratic legitimacy’ and give councils more say in the services that are commissioned for local populations. The lack of detail in the White Paper about this aspect of healthcare is partially addressed in Andrew Lansley’s speech to the UK Faculty of Public Health Conference (7). He suggests the approach to date is out of balance; the emphasis put on protecting from risk and treating illness is not matched by the emphasis on preventing illness. This is surprising, considering how public health has dominated the health agenda for many years.
Yet it’s colonising people’s minds from an early age to address their low self esteem that’s considered the solution: ‘positive lifestyle choices’ should be encouraged. Ironically, public health is an area where ‘choice’ won’t be on offer. People are expected to make the right choice, one that‘s officially sanctioned and approved. This isn’t to deny some individuals have very real personal problems. But, we must decide whether such problems are rooted in personal behaviour and emotional deficits or in something beyond the individual – be it social anomie, or old-fashioned poverty. Lansley, just like politicians before him, is continuing to focus on the personal problems of the individual and to opt for the ‘politics of behaviour’ as a remedy.
The Con-Dems should take some of their own advice and liberate the health service - from political interference. Managers and clinicians are capable of deciding how to run and deliver quality services, and are more in touch with patients. That they have somewhat lost confidence in their ability to do so is symptomatic of years of interference to the detriment of health care. Being held to ransom to agendas like ‘choice’ and ‘patient centeredness’ stultifies their creativity.
This government, like previous ones, does not have a progressive vision for the future of healthcare. They profess to be moving away from micromanagement but are substituting therapeutic intervention for political direction. It says a lot about the government’s view of citizens that it only seems able to conceive of us as choice-makers when we’re sick, and have temporarily removed ourselves from the public sphere. This is when the government feels it is safe to ‘empower’ people and give us more ‘rights’ and ‘choices’ – at a time when we’re weak, possibly confused, and sometimes even ensconced in an institution. Most of us would prefer some real choice in the real world, and clearer decisions made on our behalf by experts in the medical world.
Governments are continually embarking on crusades that target people’s diets, health, sex lives, parenting strategies, alcohol consumption levels and their attitudes and behaviour towards others. This politicisation of individual lifestyle is directly proportional to the de-politicisation of public life. Instead of spending the next two to three years to ‘flesh out the policy details’, politicians should concentrate instead on developing ideas that politically inspire us. Working out how to rejuvenate the economy would be a good first step.
Meanwhile ‘patients, their representatives and the public’ should shun the sham consultations about the Paper and demand better.
Brid Hehir, head of engagement and patient and public involvement; contraceptive and sexual health nurse, NHS, London
(1) World-leading healthcare: a patient-centred NHS, The Labour Party, 2010
(2) A&E to be saved – health minister Andrew Lansley calls halt to NHS ‘reconfiguration plans’, Camden New Jounral,, 20 May 2010
(3) Reflections on Newsnight and Andrew Lansley, Health Policy Insight, Editor’s blog, 13 July 2010
(4) Speech bythe Rt Hon Andrew Lansley CBE MP, Secretary of State for Health, 8 June 2010: ‘My ambition for patient-centred care’, DoH, 18 June 2010
(5) The expert patient: a new approach to chronic disease management for the 21st century, DoH, 14 September 2001
(6) Empowering patients: New Labour’s unhealthiest idea>, Dr Michael Fitzpatrick, sp!ked, 11 May 2007
(7) Andrew Lansley: ‘A new approach to public health’, DoH, 7 July 2010
"There was an astonishing range of opinions expressed while I was there, some of them pure nonsense, others profound, all of them provocative."
Daniel Moylan, Deputy chairman, Transport for London