Dr Phil Hammond, broadcaster and sessional GP in Bristol

Everyone wants to work in an integrated health service

I'm writing this from the speakers’ lounge a day and a half into the NICE conference. It’s my fifth outing as Chair and this year has had a bumper turnout despite—or perhaps because of—the recession. Everyone wants to know how to use the best evidence to make that tricky saving of £20 billion over the next 5 years.

The answer appears to be integration between primary and secondary care, healthcare and social care, and the inclusion of charities and private companies if they can improve care at equivalent or lower cost. On a show of hands, everyone in the hall—nearly 1200 of them—want to work in an integrated health service where we share resources, expertise, and risk. Yet most are sceptical that the Health and Social Care Bill will provide it, at least not in the short term.

The most pressing problem is money. Integrating services requires time and space for colleagues and patients to get together to redesign services, but most NHS staff are overburdened just doing the day job and few organisations are willing to invest heavily in training, even if they had the money for locum cover. One GP spoke of having to give up his place on the consortium because his colleagues were buckling under the pressure of just being GPs and they needed him back on site.

GPs are a hardy bunch and there are those in pathfinder consortia who are way ahead of the curve, opening up their board to hospital consultants, pharmacists, public health experts, and social workers to make sure patients get the best treatment in the most appropriate setting at the least cost. Their worry, it seems, is the ‘any willing provider’ clause in the Health and Social Care Bill. Not because the NHS is worried about private competition—if you levelled up the playing field and made the private sector contribute to training, research, and pensions then the NHS would compete very favourably. The problem is European competition law. Because health is a member-state issue, countries such as Scotland and Wales can opt out of it but as soon as you declare your health system to be a regulated market, you have to comply by the law. So innovation and integration could be significantly delayed as bids are put out to tender and challenged. Hardly helpful given the pressing need to save money quickly.

All successful companies have clear lines of accountability, but the NHS is full of confusion. The Secretary of State is trying to opt out of being responsible for comprehensive provision, but no one’s sure how the balance of power will play out between the central commissioning board and the consortia. In one listening session with Professor Steve Field, everyone in the room thought the NHS might become more centralised and top down as a result of the Bill, rather than the promised bottom-up devolution. Some foundation trusts will sit on their profits, others will go bankrupt. Will they be allowed to fail? Will Monitor sell them off to the private sector?

NICE is central to the reforms, hastily developing 150 quality standards, each with 10 stems, which will be translated into pathways that allow you to access the 734 pieces of NICE guidance in a more streamlined way. NHS Evidence is also being revamped to allow rapid computer access to relevant nuggets of information in real time, but healthcare is often more complex than any policy or strategy. Patients have multiple conditions and may be on several pathways at once. So making NICE ‘bottom up’ is a big challenge, but there is evidence that ‘doing the right thing right first time’ could save the NHS billions of pounds. So we all have to account for our use of resources.

The best thing about a NICE conference is that it adopts an evidence-based mindset. Politicians who turn up and say ‘there is evidence our reforms will work’, are likely to be shot down. I’m waiting for Earl Howe to deliver today’s version of the health reforms, but whatever he says, we only know that the next few years are going to be very tough financially, and we don’t know whether the reforms will work. But we musn’t be bullied into complying with anything that clearly isn’t working. The combination of rapid reform and huge debt is the perfect storm for another NHS disaster. So let’s work together to improve care but shout loudly if ideology triumphs over evidence. G

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