The sun was shining in Liverpool for the NHS Confederation Conference last week but inside the conference centre clouds gathered as NHS managers congregated to review the issues of the day. Dark mutterings of discontent could be heard in the corridors and seminars about the prospects of managing cost and efficiencies and in particular the removal of commissioning from Primary Care Trusts, the Confederation’s main constituency, to GPs – regarded by some as the biggest fly in the ointment of efficient and cost effective distribution of care.

Attention focussed on the arrival of the new Secretary of State for Health Andrew Lansley, the purveyor of the unwelcome reform and shortly of a controversial strategic White Paper which is to set out the transferral of some £60- 80 billion pounds to GPs control and said by one ‘unnamed’ yet ‘senior’ Department of Health source to herald the end of the age of PCT autonomy. Besides being a surprise to many commentators, who believed that the freedom given to PCTs under the Labour Government would be continued or even extended under the Coalition, the policy raises as many questions as it answers with details of the practicalities and process of reform remaining unclear.  In the absence of clear information, an air of panic prevailed as delegates attending discussions expressed doubt that a cooperative relationship between primary and acute care could be continued and asked whether they would be wise to jump ship from PCTs before it was too late.

The press presence at this year’s conference was unusually high for what was otherwise agreed to be a relatively low key event and it promised to be an intriguing show-down as Andrew Lansley faced a sceptical crowd. Mr Lansley had made an uncertain visit last year shortly after deviating from Conservative Party policy on Departmental spending and someone was heard to remark that he might bring a bodyguard and leave his car running for this year’s speech – given the likely hostility of his audience.

In the end, Mr Lansley’s speech was deemed by many to be underwhelming and uninformative. He was clearly keen to win over the delegates, who refrained from heckling but made their feelings clear by grumbling to themselves and roundly applauding those questioners who expressed their doubt about the direction and feasibility of his plans.

No one left the conference much clearer on the implications for PCTs or the wider NHS although they were soon greeted with the news that the Treasury are reluctant to give Lansley the GP money after all – which did not surprise the assembled health commentators and gifted the Opposition health spokesman, and former darling of the NHS Confederation, Andy Burnham, with a wonderful opportunity to pitch in and help boost his profile ahead of the forthcoming Labour leadership election.

Overall, however, the Treasury’s decision didn’t make the delegates much happier as, whatever the outcome of the White Paper, they know they will face competing demands to cut costs whilst remaining flexible enough to accommodate a new system which may threaten their existence. It is clear that Andrew Lansley already faces a battle to keep the NHS workforce onside, from executive level through to the grass roots, and the success of any reforms depends on their cooperation and agreement. In the end, his more detailed proposals may not meet with as much opposition as he faces now and there are many elements – GP consortia for example – who will view it as an interesting opportunity. But for now, in the shadow of a Budget of heavy cuts, it is the lack of information and the fear of being thrust into ill-thought out and articulated reform that is as much a factor in the anger of NHS managers as any.

Posted by Administrator on behalf of Isabella Sharp

Last Wednesday saw the publication of the inquiry into the failures at Mid Staffordshire hospital where over 400 patients needlessly died.   The inquiry was ordered by the Secretary of State in response to the public outcry.  The recommendations are, of course, worthy and have been well received by both patient and professional groups alike.  But as there is still appetite for a further inquiry – relatives, families and the Conservatives are calling for a full public inquiry – what was the legal basis for the first?

Mid Staffordshire is a Foundation Trust Hospital.  Foundation Trust Hospitals were created specifically to be independent of the NHS, and of the Secretary of State. The creation of Foundation Trusts was one of the most bitterly contested NHS reforms introduced by Tony Blair. At the time they were opposed by Conservatives and many within the Labour party, now both political parties want to make every hospital a Foundation Trust.  But Foundation Trusts are different; they are accountable to their local communities, not to the Secretary of State.  So while the urge for politicians to interfere in these matters is intense, their powers are necessarily limited.

The policy of creating Foundation Trusts was designed to create a new set of structural relationships within the NHS.  The development of the new structure was, amongst other things, an attempt to create a new culture.  But the old culture of tight central control – the one that NHS managers and civil servants feel safest in – still remains dominant within the Department of Health,and within the minds of Government Ministers as well.

As we pointed out last week, the fundamental failings at Mid Staffordshire were those of the system of hospital oversight and scrutiny, not the policy of Foundation Trusts.  On the whole, Foundation Trust hospitals are much more highly performing than those remaining under tight central control.  So how do we create a culture where the NHS can adopt more of the changes that allowed Foundation Trusts to flourish?   Well, what if the architects of Foundation Trusts were to reveal all in a new Policy Exchange pamphlet later this week…

Henry Featherstone is Head of the Health Unit at Policy Exchange. “Future of Foundations: Towards a new culture in the NHS” will be out this week.

The Department for Health did not have a good week last week.  It started with hospitals being accused of putting patients’ lives at risk, for failing to comply with safety alerts issued by the National Patient Safety Agency.  And it has ended with the DH accepting that it must agree a way of measuring and reporting hospital death rates, after Policy Exchange released a series of official documents, obtained under the Freedom of Information Act, which criticised the NHS for a ‘pervasive culture of fear’ and obsession with targets rather than a focus on patient safety

The documents, submitted to the DH by three internationally respected healthcare organisations, detail a litany of failures in oversight mechanism.  The first report said there was a ‘pervasive culture of fear in the NHS and certain elements of the Department for Health’ and regulation was ‘light-handed’.  It highlighted the flaws in the system of allowing hospitals to declare whether they were compliant with national standards – as two thirds of the assessments made by regulators did not agree with the declarations.

The second report found that the health service did not have a clear idea of what good quality health care meant so resorted to the default position that “quality means meeting the targets”.  This report too stated  “The NHS has developed a widespread culture more of fear and compliance, than of learning, innovation and enthusiastic participation in improvement”, and that “Most targets and standards appear to be defined in professional, organisational and political terms, not in terms of patients’ experiences of care”.  The final document criticised the Department of Health for being more interested in costs than clinical quality and that assessments of health care seemed to be motivated by political rather than health concerns.

As we’ve pointed out, it is astounding that there is no system of performance improvement in the NHS.  But suppose there was. If we could, say, spot increased mortality at any hospital on a monthly basis we could prevent temporary problems turning into scandals – and so avoid the tragedies like the ones at Tunbridge Wells, Mid-Staffordshire and Basildon & Thurrock.

And there is already a way to do that.  The Hospital Standardised Mortality Ratio (HSMR) was developed here in the UK.  It accounts for different risk factors so that hospitals undertaking complex operations, or dealing with critical patients, are not painted in a poor light.  It measures the hospital’s actual performance against what is expected – and so can give an early warning to inspectors, regulators, clinicians, and patients.   HSMRs have been around for many years and consequently they have large evidence base which shows that they are reliable and robust.

More and more countries around the world are adopting and publishing HSMRs as part of their hospital performance improvement plan.  Whilst it is welcome that the DH has finally admitted it must do the same, we can’t afford for the Government to drag its feet any longer – the sooner we have a proper means of seeing hospitals’ performance rates, the better.

Natalie Evans is Deputy Director of Policy Exchange.

On a slightly different note to what I  normally write about…

I had heard about this but yesterday went to see it. The Living Wall in the new Anthropolgie store on Regent Street is amazing. The shop itself is full of slightly odd things, but they have an amazing three-storey high wall of plants growing inside.

These photos don’t really do it justice – it is enormous! Apparently there are fourteen different types of plant in it.

I suppose it’s really not that different to having a load of pot plants, but it’s a great way to decorate and be green. It’s fed with rainwater from the roof, so is completely self-sustaining.

I’m thinking of trying the same thing one day at home. I suspect it’s more complicated than just attaching some pots to a wall. But a study from NASA has found that indoor plants can improve your air quality significantly. So what isn’t to like about a decorative feature that also improves your environment?

A Policy Exchange report has proposed a radical new framework to tackle the inequality of primary health care provision.

The overwhelming majority of NHS activity takes place in primary care, for just 11% of total NHS costs.  But whilst the Government has channelled an enormous increase in funds into the NHS the positive impact of this has not been felt by patients needing primary care services in the most deprived parts of the country.  Despite increases in the number of doctors, the number of full-time GPs per 100,000 of the population is falling.  And at present, the most deprived areas have fewer doctors per head according to need than Primary Care Trust in more affluent areas.

By changing the way we allocate NHS resources, we could deliver better outcomes and increased public satisfaction at lower costs.  We could also encourage greater patient engagement in their own healthcare, and give real choice to the people who want it most.

The proposals set out in the report recommend that the majority of NHS funding (£84.4 billion in 2010–11) be distributed on the basis of a patients’ age and postcodes, and that GPs be financially incentivised to set up practices in areas of most need through a ‘patient premium’.

Patients should also be actively encouraged to choose at which surgery to register, and have access to improved information about the primary care services on offer in their area through the use of Health Trainers and a patient feedback and ratings website, run by an independent organisation such as the Consumers’ Association.

A full copy of the report can be found at www.policyexchange.org.uk