Any major changes to the NHS must only be made after a proper public consultation, writes SUE RICHARDS
IN SEPTEMBER the Health Secretary Jeremy Hunt issued a whole set of consultations on changing the technical regulations on aspects of the working of the NHS, changes to facilitate the development of Accountable Care Organisations (ACO) as the preferred model for delivering the commissioning and providing of the NHS at local level.
He is consulting on matters including which staff are allowed to claim travel expenses, who is allowed to prescribe drugs and order disability aids, and the conditions for changing the contracts under which GPs operate under an ACO, but not about whether the ACO is the right thing to do in the first place.
Most readers of this article will not be great fans of the Health and Social Care Act 2012, which attempted to turn the NHS into a market rather than a coherent, planned public service.
But we can all agree that Parliament voted it through, that it is the law of the land, and that if it is to be changed in a major way, as the ACO model would, this should be done through primary legislation.
We still live in a parliamentary democracy. And yet the plan is to bring in the changes in these regulations through parliamentary procedures normally reserved for non-controversial matters.
Technical changes to processes designed to facilitate the development of a major change make no sense at all if that major change itself has not been subject to proper consultation, with a full explanation of what it means, what objective is sought and an assessment of its likely impact. And this should be done before the decision to implement the change has been made, so that it is a genuinely open consultation.
The Health and Social Care Act 2012 has not been a great success — heavy on transaction costs, contractors often delivering poor quality of care, and the fragmentation of services which only make sense if they are joined up.
So surely ACOs would be a good idea if they dealt with these problems? The trouble is that the ACO model is likely to lead to outsourcing on an even grander scale. One single organisation will be responsible for taking a commission to achieve a set of high level outcomes and of managing all or the vast majority of health services (and possibly social services) within an agreed financial cap.
Few public bodies will be capable of managing this complex mix of services themselves, and it seems at least possible that most of our acute, community and primary care services will end up working for a prime contractor — Capita, Virgin G4S or a specially created shell company?
We know from more conventional contracts developed by some of the more “ultra” Clinical Commissioning Groups (CCGs) that this way lies disaster.
Nottingham is a case in point, where the CCG managed to destroy the local dermatology service, as all of the consultants walked out rather than work for such a contractor, and patients in Nottingham had to travel to Leicester for their treatment.
All of the experience of contracting out public services tells us that the private sector does not like a lot of small, nailed-down contracts. Instead, businesses look for exactly what ACOs seem to offer — little real oversight, high levels of discretion and huge opportunities to reduce the cost of public services through down-banding and deskilling of staff, the single biggest item on the budget for health and social care.
We know this leads to poorer outcomes when it is attempted in less complex services like prisons and other security services. Why should we believe that it would be anything other than a disaster in health and social care? If the government does want to do it, we need the fullest possible public consultation on the matter — as required by law.
It is a bit of a puzzle why a government with so little credit in the bank and no parliamentary majority should be pursuing this initiative at this time.
The answer to such questions often comes from following the money. The Naylor report on NHS land and property, published earlier this year, focused on the high value of NHS assets, which have accumulated over time because of the complexity of disposing of assets while retaining the proceeds.
When even Simon Stevens of NHS England and Jim Mackey of NHS Improvement are willing to say publicly that current levels of service are undeliverable on current levels of funding, how tempting this pot of gold must be. But most of the assets belong to acute providers. Why would they voluntarily give up their gold to help out other parts of the system? — unless they were all part of the same governance structure, that is.
“Selling the family silver” in order to veer into running costs is not good accountancy, for obvious reasons, but it could help the government deflect the blame that comes its way from the underfunding of the NHS.
It is clear that many residents of Whitehall resent the significance given to public consultation in the law relating to the NHS. How can people possibly understand the complexities of the decisions that have to be made in the NHS?
We might not understand it all, but being consulted about such significant changes — affecting our lives and our deaths — is a recognition of our common humanity. We are citizens whose voices must be heard, not subjects who will meekly follow instructions from on high.
nProf Sue Richards is one of a number of proposed claimants who have written to the Secretary of State to enforce the right to a full public consultation before any measures are taken to create ACOs.