Primary Care and the NHS Reforms: A Manager’s View

Royce, R.

Monograph
March 2000

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Writing on the future of Primary Care Groups/Trusts, and of Labour’s health service reforms in general, invites subsequent ridicule by those blessed with the clarity of vision hindsight provides. The fact is that only the brave or foolish posit with any certainty how these latest changes to the UK National Health Service (NHS) will unfold. Nevertheless, this paper paints some scenarios, and at the end attempts to predict the future of the reforms.

It is ironic that the same politicians who are so keen to express their confidence and belief in the UK’s system of primary care to the rest of the world have instigated a series of reforms which will potentially fundamentally change it. Underlying all the reforms of the Labour government is a tension between what might be labelled the control and command mindset and a model emphasising delegation, innovation and local empowerment. The author does not attempt to reconcile these two but instead highlights the dichotomy and gives his view of the likely winner in what remains an enduring battle for supremacy.

In the first chapter of this book an attempt has been made to set Labour’s recent NHS reforms into a general policy context. Significant features include: vehement public opposition to the ‘internal market’; a desire to increase the accountability of clinicians within both primary and secondary care; and the consequences of the well established dissonance between the rhetoric politicians adopt when discussing the NHS and a more objective analysis of the issues. This first chapter also highlights that much of what the current government presents as a radical departure from Conservative policy can, in many cases, be seen as an extension of those same policies and mindsets. Whilst to some this is of little consequence – merely reflecting the realities of political presentation, which by its nature requires simplification and selectivity – this text endeavours to show that this is an important feature of the reforms. It points to a sustained tension between what is being said in public about the nature and direction of NHS policy and its reality for staff and patients.

The first chapter ends with a review of the new performance assessment framework (PAF) as a mechanism for holding NHS organisations accountable for, and improving, their performance. The technical difficulties in producing a robust performance mechanism are highlighted and the question asked as to whether in reality government ministers and NHS Executive will fall back upon the traditional measures of NHS performance – waiting lists, financial position etc. – whilst paying lip service to a ‘balanced scorecard’ approach.

The second chapter looks at Primary Care Groups (PCGs) in some detail. There is particular consideration given to the economic model which underpins PCGs and the Primary Care Trusts (PCTs) into which they are intended to develop. The strengths and weaknesses of such an approach are considered. Alongside the inherent problems of a devolved model of commissioning for a health service which places universality and uniformity of provision as ‘core values’, the tensions relating to the manner and timing of the reforms are explored. This chapter establishes the aim of effective management of the clinical process as lying at the heart of the reforms. This tends to be an overarching concern that all governments have with their health care systems. Thus, Labour’s reforms can be seen as part of an international drive to place accountability and responsibility, incentives and penalties, at the door of those who most directly commit resources: clinicians in general and primary care general medical practitioners (GPs) in particular.

The third chapter examines the manner in which Wales, Scotland and Northern Ireland are taking forward the reforms. Significant variations from the English model are discernible, particularly in Scotland.

The fourth chapter provides some practical advice to those charged with taking forward PCGs (and their Celtic cousins) in terms of make or break issues – managing referrals, construction of a Health Improvement Programme, understanding the financial position, etc.

Chapter 5 is given over to prescribing, given its importance both within general practice and to government if it is to keep costs under control. Issues relating to setting and then managing practice level budgets are considered, as are the options available to PCG executives when prescribing patterns deviate from plan. This chapter concludes by considering the potential for PCGs to use disease management programmes and considers why there has been so little progress in this area to date.

The final chapter looks to the future. The similarities and differences between PCGs/PCTs and American Health Maintenance Organisations are explored in this context. A growing role for a mixed private/public model of health care provision is considered, as is an imposition of a command and control system set squarely within the public sector.

Overall, the aim is to give credit where sensible changes have been put forward and levy criticism in equal measure where it is due. Hopefully, the reforms will have been seen within a context that may sometimes be provocative but will also be informative.