Disclosure of Payments to Medical Professionals
I met recently with Ben Goldacre and the Association of British Pharmaceutical industries to discuss the importance of open data in drug trials and the need for them to allow full access to clinical study reports for all drugs in current use. Please read the background to why this matters and consider signing up at http://www.alltrials.net/
I also asked the industry for greater transparency about payments to NHS professionals and the following is their response:-
Background information from the Association of the British Pharmaceutical Industry
Collaborative working between healthcare professionals and commercial organisations, across the life sciences sector, has long been a positive driver for advancements in patient care and the progression of modern medicine through innovation.
As an industry we committed to ensuring the transparency of relationships with healthcare professionals. That is why, across Europe, the industry has announced its intention to disclose payments to healthcare professionals by 2016 for payments made in 2015 onwards. The default position will be public disclosure on company websites; however, our ambition is to work in partnership with health professionals to increase transparency. Ideally this would be through a single, searchable database which includes payments from other commercial organisations working in healthcare. The Ethical Standards in Health and Life Sciences Group (ESHLSG), a group of twenty organisations working together to improve how healthcare professionals and the pharmaceutical and life sciences industries work together, is currently consulting approaches to disclosure of payments to health professionals at an individual level. You can access the consultation here.
As part of this journey, in 2013, ABPI member companies are taking the early step of disclosing the total figure paid to all healthcare professionals during 2012, for sponsorship to attend meetings and fees for services provided by the healthcare professional. Companies will also disclose the number of healthcare professionals that received payments.
Public reporting of financial transaction at an individual level is complex covering many thousands of interactions. It has to be done accurately and in consultation with stakeholders.
Reporting in 2016, means collecting the data in the required format from 01 January 2015. Proposals to change the European Federation of Pharmaceutical Industries and Associations (EFPIA) Code on disclosure are in development and the results of the ESHLSG consultation will not be known until mid-2013. This will allow 18 months (June 2013 – January 2015) to design and test systems for disclosure that can accurately report on a substantial number of interactions across a broad range of stakeholders..
In parallel to the technical development of systems there will need to be a detailed dialogue with health professionals. UK and European privacy laws means disclosure of payments to identifiable individuals will require consent from the individual healthcare professionals. As a consequence, many contracts will need to be reviewed to ensure they include the necessary consent.
We are aware that 18 months is a very demanding time frame to complete the consultative, technical and legal challenges behind creating a system of public disclosure, particularly if stakeholders in the UK, aim to partner on the creation of a single, searchable database of payments. However, despite the challenges; the industry is committed to making disclosure of payments a reality as part of its wider commitment to increasing transparency across its activities.
Public Accounts Committee
On the 12th December a joint letter was sent to the Chair of the Public Accounts Committee to ask whether the Committee would consider conducting an inquiry into the waste of NHS resources caused bt the concealment of trial data for drugs, medical appliances and implants. This letter was signed by myself and my colleagues, The Rt Hon David Davis, Barbara Keeley, Adam Afriyie, Julian Huppert and Valerie Vaz. A transcript of the letter appears below:-
Rt. Hon Margaret Hodge MP
Chair of the Public Accounts Committee,
House of Commons,
London SW1A 0AA
12th December 2012
We are writing to you in your capacity as Chair of the Public Accounts Committee to ask if your committee would consider conducting an inquiry into the waste of NHS resources caused by the concealment of trial data for drugs, medical appliances and implants.
For many years the scientific community has been pressing for open data in drug trials. Please find enclosed a briefing from Dr Ben Goldacre, also sent to the Department of Health, which provides an excellent summary of why trial data transparency is vital to ensure patient safety.
This issue also has major cost implications for the NHS. The decision to stockpile Tamiflu is the most high profile example of how significant NHS resources can be spent on drugs without full disclosure of clinical trial data. In 2009 the government spent £500 million on Tamiflu, a drug manufactured by pharmaceutical company Roche and licensed for the treatment of influenza. In the UK, Roche are allowed to claim that Tamiflu can reduce the risk of complications from influenza, such as bronchitis and pneumonia. In the USA, Roche is not attempting to make this claim. It is thought that the American drug licensing body, the Food and Drug Administration (FDA), has had access to different data to that made available to the relevant UK authorities.
Roche has conducted over 123 clinical trials, of which at least 60% remain unpublished. The company has refused to disclose full information on these trials to Cochrane researchers, despite promising to do so in December 2009. Without this information, UK regulators and doctors cannot properly assess the clinical benefit (if any) of Tamiflu. It could be that the previous government spent 0.5% of the entire 2009 NHS budget on a drug which the manufacturers were aware was no better than a placebo. Without all the clinical trial data, we cannot draw firm conclusions, but it surely cannot be right for a pharmaceutical company to receive £500 million of taxpayers' money if it withholds information about its own products.
In the event that your committee finds Roche has deliberately concealed evidence which shows Tamiflu to be simply a placebo with side effects, you might wish to consider a recommendation that the Government seeks repayment of the £500 million cost.
Tamiflu is just one example. There are many other drugs which pharmaceutical companies have sold whilst withholding trial data which showed those drugs provided patients with no benefit, or worse, caused significant harm. Implants of all kinds are also used inappropriately because trial data is concealed or never collected, as in the case of PIP implants.
In August 2012 the British Medical Journal published a report questioning the medical and cost effectiveness of TAVI, an aortic valve replacement, which has been adopted around Europe despite a lack of published trial data. The authors tried to get further data out of the manufacturers and failed. The same thing happened when the BMJ investigated the medical benefits of certain hip prostheses.
The concealment of trial data relating to implants has serious cost implications. Unlike generic medicines, which tend to be cheaper, implants generally increase in price over time as implant manufacturers tweak the design and increase the price accordingly. Furthermore, there are extra costs associated with morbidity. In the case of hip prostheses the NHS has had to pick up the bill for revision procedures, along with the costs of incapacity and care.
These failings are partly a consequence of how medical implants have been regulated (the Science and Technology Committee has issued a report on this) but also of the lack of transparency regarding trial data. Doctors and patients are left to decide what treatment they should use based on what the manufacturer is prepared to tell them.
There are failings at every level, from ethics committees which allow trials to proceed without insisting on data being published, to organisations like the National Institute for Clinical Excellence and the European Medicines Agency which do not insist on receiving all the evidence - and then making it available to all interested medical researchers - before granting regulatory approval for drugs, appliances and implants. Sharing information can be a very powerful way to protect patients, because then "many eyes" can be brought to bear on what are often complex questions. Problems with Rosiglitazone, Tamiflu, Vioxx, and many devices were spotted by the global community of independent academics, rather than by individual countries' regulators acting behind closed doors.
Most manufacturers claim they release data. However, unless they publish relevant data in a form accessible to UK regulators and researchers, it may be useless or incomplete
The Public Accounts Committee could provide vital insight into the level of waste resulting from the concealment of clinical trial data, and hold manufacturers and regulators to account. We would be happy to meet with you to suggest expert witnesses who may be able to advise on further lines of inquiry.
Community Hospitals; Right Care, Right Time, Right Place
There are over 300 Community Hospitals in England.
Before changing from GP to MP my practice covered the smallest hospital in England at Moretonhampstead in the heart of Dartmoor, so I know just how important community hospitals are, especially to isolated rural communities.
I may have lost one Community Hospital since changing my job but I now represent four; Brixham, Totnes, Dartmouth and South Hams in Kingsbridge.
I know the value of community hospitals but more importantly I know that communities around this Country will be judging the success of the Health and Social Care Act by their own experiences of how well they can access the services that matter the most to them.
Community hospitals may vary in their size and in what they do... not all of them have inpatient beds, they may serve urban as well as isolated rural communities but there is an important theme underpinning their success; they are rooted in those local communities and supported by extraordinary levels of volunteering and charitable donations through their Leagues of Friends.
The reason for that support is that people value their personalised approach and they want to be treated closer to home.
Small is beautiful but superficially it can also make for a tempting way to save money and that is why it was important to raise their importance in Parliament and set out why we should be expanding their role. Community hospitals are integral to delivering the kind of community based services that will be needed if we are to cope with the unprecedented challenges ahead.
I was still a practicing doctor in 2009, well before the General Election, when I first read about the so-called Nicholson Challenge to save £20 billion. The reality couldn't have been more stark, that even with a protected budget, the NHS would have to make efficiency gains of 4% year on year.
The temptation is to salami slice existing services but as the Health Select Committee report has made clear, backed by many others including the Kings Fund, these savings are not about doing less of the same but about spending what we have in a different way in order to meet the challenge of an aging population and a drugs budget increasing by £600 million a year.
The number of people aged over 85 is set to double to over 2.6 million over the next 20 years with more than a ten-fold increase in the number of people aged over a hundred.
This matters because older people face particular challenges in travelling to remote hospitals and understandably are the most in need of services.
Increased life expectancy is wonderful, but the number of years spent in ill-health has also increased as well as the number of people with multiple long term conditions which is set to rise to 2.9 million by 2018.
Around 70% of total Health and Care expenditure in England is attributed to people with long term conditions and many of those have profound implications not just for sufferers but also for their carers. 570,000 people in England live with dementia and this is expected to double over the next 30 years.
The burden of disease has shifted away from life-threatening conditions to long term conditions so we need to shift our response. The need will be for facilities to help those with multiple, long term conditions.
That will require action on prevention and on supporting people in their own homes, delivering higher standards of primary care and crucially for today's debate making more effective use of community health services integrating care around the needs of people within their communities.
Of course we will always need acute specialist centres. But more than half of 100 acute hospitals inspected by the Care quality Commission in 2011 were non compliant with standards of dignity and nutrition for older people, or were found to give cause for concern.
Community hospitals perform well when it comes to personalisation, dignity and respect.
We can and should do all we can to prevent the need for admissions in the first place and where that is not possible, retain the ability to admit to smaller local community hospitals where appropriate, where people can remain close to family and friends and receive that personalised care.
Community hospitals are so much more than small inpatient units. They need to be if they are to survive.
Just because a hospital is called a 'memorial hospital' it doesn't mean that it should be set in stone. We must move beyond the bricks and mortar and highlight examples of good practice and innovation. The trouble for the NHS is that good practice so often happens in isolated pockets failing to rollout to benefit other areas.
It is harder still for that to happen unless someone is keeping an overview and showcasing excellence. One such organisation is the Community Hospitals Association. The most recent grant to the CHA was for £20,000 in 2008 to profile community hospitals; it is vital to maintain such a web-based database of these important national assets at a time of rapid change in the NHS to keep track of their ownership and current roles.
The CHA needs to be supported in its work particularly to allow them to keep their database up to date and so that they can continue to provide support for our community hospitals and researchers, promote innovation and spread best practice.
There are some extraordinary innovations that have been led from community hospitals:
Torbay's nationally recognised integrated Health and Social Care model grew out of an initial pilot based at Brixham Community Hospital.
The then Chief Executive, Peter Colclough, had the vision to improve the experience of older people with complex needs and decided to test out whether bringing front line teams together in one team could make a difference to how people accessed services, increasing the number who could stay in their own homes whilst reducing emergency admissions and long term residential placement.
The pilot moved health and social care teams into one location, created a pooled budget, a shared community care record and a single point of access for the public and health care professionals alike, including GPs. It worked and was rolled out across Torbay.
The fact is that there is no one single magic bullet to delivering integrated care but a series of changes that need to be in place. A cultural shift is required to put the patient at the heart of everything and design care around them rather than for the convenience of the organisation or jealously guarded professional boundaries.
Brixham's philosophy remains to deliver the right care at the right time in the right place with that care focused on preventing hospital admissions by delivering rapid assessments and an average delivery of equipment of 62 minutes. Torbay has the lowest rate of hospital deaths of any local authority in England, minimal delayed discharges from hospital and the fewest excess bed days in the South West.
Brixham demonstrates that Community hospitals are not just about inpatient beds, they should be community hubs delivering both health and social care. They also deliver outpatient services, diagnostics, therapies such as physiotherapy and act as a base for community mental health services.
South Hams hospital in Kingsbridge allows patients living with cancer to receive chemotherapy, avoiding the long round trip to Derriford hospital in Plymouth as well as hosting the wonderful Triangle centre for wider cancer support for patients and their families.
Rowcroft hospice are expanding their role across Southern Devon to providing much needed expertise and palliative care for patients and families closer to home. There is great potential not just for palliative care but for a range of other services and clinics to expand within community hospitals.
All the community hospitals in my constituency provide treatment for minor injuries. From Dartmouth the trip across the estuary and onward around Torbay's congested roads is particularly difficult and access to a minor injury unit, diagnostics and therapies is particularly valued.
Totnes hosts many clinics and diagnostics, a base for GP out of hours and like all the community hospitals in my constituency, inpatient beds for those who cannot manage at home.
Those beds relieve the pressure on acute hospitals providing step up and step down care.
There are barriers to Community Hospitals achieving their potential and the Government needs stress their commitment to helping community hospitals and other community health services compete on a fair playing field.
We know that the DoH estimates that around 25% of hospital patients could be better cared for at home or in the community, that patients would prefer this and that it can be more cost effective so what practical steps can be taken to support community services and the community hospitals role in delivering them?
There are four areas that must be addressed;
The ownership of the community hospital estate
The way we fund NHS treatment through tariff reform
Issues of accountability and
Looming problems with the number of GPs we will have to act as commissioners and to staff community based services
Most community hospitals do not own the buildings from which they operate. At first sight that may seem reassuring for those who wish to see all property retained by the NHS but it does disadvantage them compared to other providers who own their buildings and estates because it affects their ability to raise capital to create new services. Most will be dependent of NHS Property Services Ltd setting affordable long term rental charges and may be restricted if they wish to change the way that buildings are used. This will have a particular impact on social enterprises since they currently have no right to any NHS property portfolio. There are many examples of community ownership of community hospitals we need greater flexibility in the future whilst of course recognising the need to safeguard these valuable assets for local communities. Second, we need to change the way we fund NHS Treatment.
A significant proportion of NHS activity is funded by a system known as 'Payment by result'. It finances care through a nationally agreed tariff and was introduced in 2003/04 with the intention of ironing out the variation in prices paid around the country for treatments. Unfortunately it had the distorting effect of encouraging hospitals to do as much as possible, even where that was unnecessary of could have been done better elsewhere...crucially within the local community. Patients were called back to unnecessary expensive hospital follow ups for example.
Community services were paid by block contracts with no incentive to provide unnecessary treatments but also crucially not paid their fair share of any treatments provided when patients transferred out of the acute hospital into the community. No wonder it became increasingly difficult to justify transferring patients for rehabilitation even if that was what they so desperately wanted in order to be nearer to loved ones.
Reform of the way tariffs are paid is absolutely essential if we are to drive integration of health and social care and change the way that hospitals and community services are able to cooperate in order to provide the best care for patients. Especially when finances are tight it cannot be right to have hospitals, community health services and social services retreating to silos to protect their own budgets. We can only deliver joined up care where the payments look beyond short term goals to fund whole pathways of care. Better still if they encourage pooling of budgets across health social care and housing as recommended in the Health Select Committee Report.
We need to see real progress being made to drive a pricing system in the NHS which will not disadvantage the kind of care that is delivered in the community and does he agree that tariff reform is an essential ingredient for integrated care delivery?
On the third issue of accountability, we will hear later from community hospitals whether there are concerns about multiple providers operating from a site where that can lead to no single organisation taking responsibility. We know that it can be a risk that if 'everyone is responsible then no one is responsible' because blame can appear to be shunted to others within a pathway when things go wrong. It is preferable to have a single individual or organisation responsible overall for the way that care is delivered within a community hospital.
Finally on the issue of the GP workforce; 90% of all patients contacts are within primary care but we have a looming crisis in around the numbers of doctors who can deliver the community based services essential for the future. There is already a 12% vacancy rate for GPs in the Southwest and we face a bulge in the numbers due to retire from general practice in 4 to 5 years time; just when we want GPs to get involved with designing care pathways and commissioning services. They won't all need to do this directly but there is a risk that those who have the enthusiasm to get involved won't do so if they cannot be spared from direct clinical duties.
There is also the recognised need to move to a 4 year training program for GPs. We need to increase training opportunities and direct recruitment into primary care training posts after medical school so that we can plan ahead for a workforce fit for a primary care led NHS. Without GPs to support community hospitals and commissioning our Community Hospitals will lack the skilled staff essential for patient safety.
Likewise the greatest challenge in building up minor injuries services can be a shortage of the highly skilled nurses to treat those who desperately want to be treated closer to home.
No discussion of community hospitals is complete without acknowledging and thanking their Leagues of Friends. They are at the heart of our community hospitals, contributing millions of pounds not just to fund the extras but the absolute essentials. In Brixham, the league of friends has funded more than £1.3 million of improvements since its inception. The new hospital building could not have been completed without the League which has provided a modern physiotherapy Department including a fully equipped gym and a fully equipped Audio and Speech therapy unit alongside medical equipment ranging from special pressure relieving beds and syringe drivers to everyday comforts like coffee machines.
South Hams League of Friends have donated a total of £2million since 1973 again with a host of specialist equipment like defibrillators, ultrasound, reclining baths through to direct financial support of £20,000 per year to the Triangle Centre providing direct support for cancer patients and their families.
In Totnes and Dartmouth the League of friends has funded everything from ward upgrades, diagnostic scanners and near patient testing equipment through to specialist beds and mattresses and other vital equipment.
As we move to meet the challenge to provide the right care, in the right place at the right time we must look to our community hospitals to be at the heart of that care.
This is a call to arms for people in those communities to remind their GPs and Commissioners how much they value their community hospitals and to ask them to deliver more, not less, in the way of services close to home. We will always need our acute specialist centres of excellence but the Health and Social Care system must focus on how we prevent people needing to be admitted in the first place.
I recently wrote a piece for the Times,the following is the longer version of that piece:-
I don't know any GPs who want to privatise the NHS.
The GPs I know who will be commissioning or 'buying' care for their patients do not want to see vital NHS hospitals destabilised or to commission services that lead to fragmentation.
During the pause in the Bill to listen to the concerns of all health professionals it was agreed that GPs should not be left with sole responsibility. After all, they are a branch of the health service that has always been 'privatised' if you follow some definitions. General Practices are small businesses independently contracted to the NHS and always have been since the NHS was founded. GP commissioners will now be joined by nurses and hospital clinicians in designing how care is provided and those decisions will also be guided by networks of specialist groups.
Not only will these NHS doctors and nurses be buying the care but there will be far greater public involvement.
So if NHS doctors and nurses don't want to commission a takeover by the private sector and if local people and councils can see what they are doing, why would this happen? Imagine the furore if a Commissioning Group decided to force a selloff of their local hospital to the highest bidder? Why would they do so?
I opposed the first draft of the Bill because I did not think that Monitor, the health service regulator, should have competition at the top of its remit. It was absolutely right for the Bill to be amended so that integrated or 'joined-up' care pathways trump competition and that allcompetition should be on the basis of quality not price. The commissioners will now be free to design integrated healthcare using NHS services without being told that this is anticompetitive if this is best for their patients.
EU competition Law is with us irrespective of the Bill. The whole point of a sector regulator like Monitor is that it can help to protect Commissioners from the threat of legal action now that its priorities have been redefined to prioritise integrated care.
Of course ultimate responsibility for the NHS should remain with the Secretary of State andBaroness Williams' amendment will make this absolutely clear.
For years doctors have been complaining that NHS decision making needs to be in the hands of clinicians. To drop the Bill at this point could kill off meaningful clinical commissioning forever.
Whilst some are worried that all GPs will be tied up in administration rather than treating patients, the reality is that only a minority will be commissioners. There has always been a shortage of doctors prepared to engage with designing health services beyond their surgery doors. Those who do are often the sort prepared to sit through long thankless evening meetings after a full day seeing patients; they do so because they really do care about the way the health service works for their patients. I am horrified to see the way that some of these GPs are being treated by colleagues. If the Bill was dropped and commissioning continued by regionalised clusters of PCTs then meaningful local clinical involvement would be lost as many of these committed and enthusiastic individuals would simply walk away.
Of all the accusations flying around about the reforms the most damaging is that we couldend up with an American style health service and lose the right to free healthcare. Because this is what people fear the most it is being cynically manipulated. As someone with firsthand experience of what that kind of privatised service means perhaps I should explain?
When my mother developed life threatening complications on a flight to the States and foundher health insurance did not cover her treatment, my parents shared what thousands of uninsured Americans experience every week; that she would receive basic resuscitation and be wheeled to the hospital doors unless she could afford to pay. To imply that this wouldhappen under the reforms is a deliberate lie, as is the assertion that only a monolithic NHS can guarantee decent healthcare.
Some of the delays, inconvenience and indifferent attitude to returning medical investigationresults to patients are both unacceptable and avoidable. Where this is happening doctors would like to involve more efficient providers. I do not mind if my MRI scan is offered free of charge by an independent provider if that can happen within a fortnight and the result is emailed promptly to my doctor without repeated reminders. If that appointment is offered on a Saturday or midweek evening I might need to sit down as that rarely happens where services are arranged for the convenience of staff. Furthermore, cancer patients are already being referred routinely by one independently contracted service, GPs, to a charity sector provider, the hospices. Does anyone seriously believe that GPs and hospices have led to fragmentation of the NHS? The point is that there are very many examples in the NHS of how not for profit, charity and private services can play a role in improving life for patients and they matter more than union vested interests.
The unions claim that the sky will fall but 5 years from now, patients will still be visiting their GPs to be referred to the NHS hospital of their choice. The choices will be wider but GPs and those advising and watching over them are the very best protection against undue fragmentation of our NHS.
I recently submitted the following article to the Western Morning News:-
It is a long standing principle of the NHS that it should treat patients without making value judgements about the lifestyle choices that may have been responsible for their condition. If that were to change as a result of the calls for the NHS not to treat women who have had cosmetic breast implants I think that would be a great shame. After all, where and who would draw the lines? Should we refuse to treat those who take part in high risk sports such as hang gliding or even riding? Would we decline to treat smokers or the person who contracts hepatitis from a dodgy tattoo?
Of course private clinics should be held accountable; they have an ethical duty to treat their former customers free of charge should their use of low cost French breast implants be shown to have an unacceptably high risk of rupture. But if those clinics, along with the manufacturers PIP, have gone into liquidation, then where women are at risk the NHS should not, in my view, leave them stranded if they are unable to afford to have faulty implants removed.
The final advice on the need for removal will depend on an expert review panel convened by the Department of Health but the news that some private clinics are admitting to much higher rupture rates does add to the concern for the thousands of women who have implants. Many have had these fitted following reconstructive surgery for cancer or other serious conditions and several women have contacted me to tell of the worry they face whilst waiting for confirmation of the type of implant they themselves have in place.
At present there is no national register for implants as there is for some other types of prosthesis which makes it more difficult to track which device any individual may have in place. It also makes it more difficult to follow up the true rate of long term complications. The current system involves voluntary reporting to the Medicines and Healthcare Regulatory Agency MHRA, but private clinics may have little interest in long term follow up.
In my view, the private cosmetic surgery industry needs to be held to account for this avoidable scandal. If they have been concealing data of reported harm from former patients and not then sharing this with prospective clients, then both the courts and the GMC should take action. In future perhaps all women opting for cosmetic implants should pay a compulsory insurance premium to cover the costs of replacement should the implants fail or cause problems so that the NHS would not have to pick up the tab on behalf of the multi-million pound cosmetic industry. Such a premium could also cover the cost of maintaining a register.
The two professional bodies representing aesthetic or 'plastic' surgeons should reappraise the ethics of cosmetic implants, particularly where these are promoting a dysmorphic 'plastic' image of women. After all there is a long history of implants failing and anecdotal reports for years from women who claim that they have damaged their health.
There are those who argue that cosmetic surgery is just an extension of the right to make any decision about one's appearance and that it is no one else's business to interfere. That may be the case except that this industry does impact on wider society by encouraging and colluding with an artificial and damaging stereotype of women.
Of course it is ultimately the responsibility of individuals to make decisions about their health and live with the consequences but I can't help feeling that those decisions may have been based on inaccurate follow up data and therefore false reassurance about the safety of implants. I hope the GMC will take action if surgeons and their clinics are shown to have failed to pass on reports of pain or leaking from PIP implants because this should surely have been an ethical responsibility even if not a legal duty in order to fulfill their duty of care to future patients.
For all those women facing the agonising wait for news about whether their surgeon fitted cheap PIP implants filled with industrial grade rather than medical grade silicon, this will be a nerve wracking few weeks.
Ultimately, whatever anyone's views about cosmetic surgery, I feel we should all support the principle of the NHS being there to support us, free at the point of need and regardless of our ability to pay ....and without feeling that its staff will be making judgements about us.
On the 5th April 2011 I submitted an article to the Telegraph and they published an edited version, below you are able to read the full version.
"I am delighted to say the Government have committed themselves to a listening exercise .
If you would like to get in touch with your thoughts, I am happy to forward them on your behalf.
"The Health and Social Care Bill will need some emergency surgery if it is to regain the support of patient groups and the professions. This could and should have been carried out during its recent committee stage.
The Bill has, however, emerged 'unscathed' except for those amendments tabled by the Government and this begs the question; what purpose was served by whipping through the Bill clause by clause rather than subjecting it to objective professional scrutiny?
The Health and Social Care Bill could pave the way for a shift in the way that legislation is scrutinised in Britain. If Government wants to avoid accusations of U-turns, then a commitment to effective scrutiny involves an open and honest discussion of concerns and an acceptance that some of those concerns might be justified. If members of Bill Committees were expected to leave Party Politics at the door and apply independence of spirit in weighing up the evidence, we could have less confrontation and more of a consensus in our political process, with better legislation as a result.
I hope that the Prime Minister will look carefully at the Health Select Committee report, published today. This Committee has taken a step back from Party Politics to examine some of the complications inherent in the Bill and suggested some changes that might steer the NHS super-tanker into safer waters.
The Select Committee listened to evidence from many experts over the past few months; they do not all agree and it would be naive to think that there is some mythical 'third way' of complete harmony in healthcare policy. Equally, railroading through the current proposals may result in 4 years of dissatisfaction, with the Tories taking the blame for any service failures. It seems unlikely that it would be acceptable in its current form so surely better to amend now with good grace than slug it out with a grudging trickle of amendments that end up satisfying no one.
A key concern is the potential impact of expanding Any Willing Provider, AWP, upon the ability to commission logical high quality integrated care that ensures patients have a seamless journey through the health and social care system. This week's British Medical Journal highlights how integrated health and social care has worked so well in Torbay, improving patient care and saving money by reducing the need for hospital admissions and giving patients a better and safer service at home.
There is a danger in promising patients improved choice and assuming that competition will improve outcomes and save money in the NHS. One senior hospital manager explained it as follows; if half of his patients go elsewhere for care, his own overheads are not reduced but falling patient numbers and a reduced 'tariff' per head mean that the sums just don't add up. If his hospital is a designated rural hospital...in other words, one that is not allowed to fail, then he could get more per patient to support the hospital and this then would then just increase the overall cost to the taxpayer.
There is only a limited pot of money and this has to be effectively reduced by around £15-20 billion in order for the NHS to meet the demands of an aging population and rising costs of treatment.
The only way for the NHS to meet this need is to focus on how to get the best possible results from existing resources. I cannot agree that the proposals in the Bill will achieve this end.
The intentions at the core of the Bill are welcomed by almost everyone; clinical input into commissioning and a change from meaningless targets to rewarding the outcome of care...In other words, does it work and what does it feel like to be a patient. Of course it is a bonus to have choice but this could be between competing pathways of care and not via an uncontrolled expansion of profitable but unconnected pockets of care.
The Government should return to the Bill's core principles and rethink the proposed competitive enforcement role of the economic regulator, Monitor. Rather than turning the NHS into a regulated industry like water or gas with Monitor at the helm, this organisation should help to set the tariffs for treatment and oversee logical pathways of care that deliver the best value for patients and the wider NHS.
I have no ideological objection to involvement by charities, social enterprises or the private sector... there is no reason why they could not be incorporated into pathways of care. But a pick and mix approach to healthcare is expensive, results in poor continuity and ultimately no one taking responsibility if things go wrong. The Secretary of State has made it clear that it will not be deemed anticompetitive for commissioners to design care pathways but it makes no sense for commissioners to be working to control costs when they are consigned to writing the cheques for a smorgasbord of services chosen by patients under AWP.
The fragmentation of the NHS would have far reaching consequences. One surgeon summed it up as follows; he was committed to the ideal of the National Health Service and happy to work far beyond his contracted hours, he would not feel the same about a Commercial Health Service.
We fragment the NHS at our peril."
I submitted an article to the Guardian newspaper which was edited and published on 30th November. The full text of that article reads as follows:-
"I received an email this week asking me to stop the privatisation of the NHS.
The Coalition is not privatising the NHS, but it is in danger of failing to make that clear. It is no surprise that an announcement made in May 2009 by Sir David Nicholson, that the NHS needed to make efficiencies of between £15-20bn over 3 years, should be rebranded a Coalition rather than a Labour cut.
The fact is that despite years of throwing cash at the NHS, productivity was flat or declining between 1997 and 2007. The proposed reforms are a serious attempt to address the problems with commissioning and improve outcomes for patients.
However, it is one thing to attempt such a root and branch reform in a time of plenty, it is another when you are simultaneously trying to deliver efficiencies of over £15bn just to keep pace with demographic changes, new treatments and rising expectations on a near flatline budget. Andrew Lansley argues that you need the whole package of reforms to deliver the efficiencies. He should not be afraid to listen to patients groups and professionals and review further aspects of his proposals. Changing the plan from central to local commissioning of maternity services was welcomed rather than derided as a hand brake turn.
I gave up teaching medical students about the structure of the NHS long before hanging up my stethoscope to become an MP because the chances were that the structure would have changed before they graduated. The lesson from all those reorganisations was that they distracted management from their key task of improving the service for patients and cost far more than expected. PCTs are already in trouble and many are losing their staff in an uncontrolled manner just at the time when they are most needed to advise GP commissioners on their new roles. We must ensure that the best managers are actively retained and feel valued rather than derided. If they all disappeared and GP commissioners had to rely entirely on private sector commissioning support, it really could start to look like privatisation.
The fact is that GP-led commissioning is already happening in many places and delivering service improvements and savings. In places as diverse as Torbay, Cumbria and Hackney, clinical leadership combined with good management is making a difference without the need for a revolution. Most witnesses however, felt that the change to clinical leadership would have been unlikely to happen nationally without a significant shove from above. Geography matters and I hope that Andrew Lansley will ensure that consortia are geographically logical as there is a danger that they could be distorted by fears about inheriting historic debt.
Treating patients with chronic illness closer to home and preventing unnecessary admissions saves lives and money but it will only be achieved alongside improvements to community services. The problem is that whilst commissioning a new community service is popular, the corresponding withdrawal of its hospital based counterpart is not. Change needs careful explanation and consent. New services are expensive to set up and might not even benefit the service that foots the bill. If the Local Authority offers a rapid home assessment service to prevent admissions, it will be the NHS and not the Local Authority that benefits financially. Integrated care works but requires negotiation and less rigid separation between commissioners and providers, especially at a time when Councils are also struggling to make efficiencies.
Choice can be an illusion, too. For most of my former patients in rural Devon, the only practical choices were dictated by geography. In inner cities, choice is often exercised most effectively by those with the least need. Choice is great, but a high quality accessible service is what most patients really want and the chance of a second opinion if things do not go to plan. Choice is also strangely at odds with commissioning. In Hackney, GP commissioners work closely with colleagues at Homerton Hospital on care pathways, only to find that their wealthier patients often choose to be referred to flashier teaching hospitals with no benefit in terms of outcome but huge uncontrolled costs to the PCT. Andrew Lansley is confident that his reforms will remove the perverse incentives for hospitals to over-treat patients. I hope he is right, not least because this is the mechanism for delivering 40% of the 'Nicholson Challenge'. Whilst London might be able to afford to lose a hospital, rural areas cannot and careful oversight will be required to ensure that hospitals are slimming back those services that are better provided in the community and not cutting essential but unprofitable services.
As for the question of whether GPs even want to become commissioners and take on the sharp end of rationing; most do not. They don't have to. But there will need to be a critical mass of clinical leaders. Management cuts are supposed to deliver considerable efficiencies, which does not bode well for enthusiastic participation from the managers concerned.
I know many GPs who are keen to roll up their sleeves to tackle redesign of care pathways and even the issue of failing colleagues, but I do not know any that are remotely interested in EU competition law. If commissioners cannot design pathways of care free from the spectre of law suits from disgruntled private sector providers, they will quickly hand over to commercial commissioners prepared to take the rap. If those private commissioners turn to private providers at the expense of NHS providers then my email correspondent might not have been so wide of the mark after all.
If Andrew Lansley wants to reassure the public that his reforms will not lead to the privatisation of the NHS, he should make it clear that GP commissioners will be liberated to choose NHS providers where they offer the best quality and comprehensive service without fear of legal challenge from private cherry pickers. He should also give patients' representatives a clearer place in his reforms with a seat on the board at every level of the NHS."
It was concern about the NHS that brought me into politics. Despite an unprecedented increase in funding, many who work in the NHS have been disappointed by the wasted opportunities.
The Coalition upholds the values and the principles of the NHS; based on clinical need, not the ability to pay, available to all, free at point of use, and have pledged to increase health spending in real terms in each year of this Parliament.
We all want to see an NHS achieving results. For anyone looking in more details at the proposals outlined in Andrew Lansley's White Paper follow this link to the Department of Health website. It has an executive summary about commissioning.
To summarise, the proposals will radically change the structure of the NHS and also the information and control available to patients. We want patients to have choice of any provider and of consultant led team and more involvment in their treatment. In order to make informed choices patients will need better information (unless patients are able to rate hospitals and clinical departments according to their real experiences, others will not be able to make informed choices about their care.)
We would like to see patients having more control over their care records and a culture of openess so that patients are told when something has gone wrong. In order to achieve these results we believe that it is better for services to be commissioned by those who are closest to their patients, namely General Practitioners. This is the opportunity that GPs have been seeking for many years and I hope they will now get involved with their commissioning groups in order to deliver the care that is right for patients in their own area.
For too long we have seen a health care system that is focused on the need of those who live in cities, rather than recognising that the needs of patients in rural areas are often very different. Patients in rural areas want services that are accessible, so it is all the more important to ensure standards are maintained when there are fewer geographically accessible centres to choose from.
The Coalition believes that the NHS needs to be held to account against clinically credible and evidence based outcomes. We will remove targets with no clinical justification in order to provide an incentive for better quality of care. Those looking after patients should be paid according to the outcome of care, not just the number of patients treated.
Of course, many have expressed concerned that £80 billion is a vast amount of money to hand over to General Practitioner Commissioning Groups, this is why an independent and accountable NHS Commissioning Board will be there to hold Commissioning Groups to account. They will also have to work closely with their local authorities who will be there to promote an NHS that delivers more'joined up' health and social care and local health improvements. Other safeguards will be in place and include monitor for Hospital Trusts and Health Watch both locally and nationally. All of these services will come under the umbrella of the Care Quality Commission.
Travelling around the constituency and talking to doctors from across the region, it is clear that many have concerns about possible creeping privatisation and the potential to de-stabilise the financial security of NHS hospitals. There are issues about the 'historic' debt of some institutions then acting as a barrier to others wanting to join them to form commissioning groups. Doctors also have concerns as to whether this will cost more than initially envisaged and would prefer to have seen the scheme piloted, rather than rolled out nationally. Above all, they look forwatrd to seeing more of the detail.