"The NHS will last as long as there are folk left with the faith to fight for it"
Aneurin Bevan

Monday, 24 October 2011

Yet Another Lansley U-turn?

I thought it was a mistake for John Healey to be so effusive about Lansley in his speech to the Kings Fund earlier this year. In that speach Healey said

"No-one in the House of Commons knows more about the NHS than Andrew Lansley – except perhaps Stephen Dorrell. But Andrew Lansley spent six years in Opposition as shadow health secretary. No-one has visited more of the NHS. No-one has talked to more people who work in the NHS than Andrew Lansley."
Healey went on to say that "these are the wrong reforms at the wrong time", but the damage had been done, from this point onwards the Prime Minister would quote the first part "no-one knows more about the NHS than Lansley" and not the latter part "these are the wrong reforms at the wrong time". It was incompetent speech writing to compliment Lansley in any way at all, for he is wreaking irreparable damage to the NHS. And what's more, Lansley is extremely incompetent having entered the Department of Health with a totally unworkable policy that has had to be mutilated to make it work, replacing the existing workable policies with policies that barely work.

One example of this is GP practice boundaries. Consistently, over the last year, Lansley has defended his plan to give patients choice over GPs. A year ago, this choice could be any GP anywhere in England, which lead to some commentators speculating that GPs who looked favourably on complimentary treatments would get patients from all over the country. Lansley had deliberately avoided mandating that GP Consortia should cover practices from a geographical area so it could have been possible for a consortia to cover GP practices from all over the country. The Future Forum recognised that this was nonsense and reluctantly Lansley changed this policy to say that Clinical Commissioning Groups must cover a geographical area and preferably those practices within a local authority boundaries.

The issue of practice boundary (rather than commissioning group boundaries) has raged on for a year now. Fairly early on it became clear that abolishing GP boundaries would have a knock-on effect on the planned 111 urgent service. The problem is that if a patient needs a home visit from their GP this would be completely impractical if the patient is not local to the GP. So the 111 urgent service had to changed to cover patients in a geographical area effectively replicating the GP home visiting service provided by GPs. Lansley's intransigence on GP boundaries was adding expense to the new 111 service.

GP boundaries have an effect on commissioning. If a GP practice can have patients from any area this means that the Clinical Commissioning Group that contains the GP practice will not cover a population in a defined area. Local services commissioned by the CCG will by necessity cover a geographical area, but with a disparate patient list these would be difficult to commission. GP boundaries also have a significant effect on funding. If patients have a choice of GPs they may "shop around" for the GPs with the higher budgets. If a practice has a patient with an expensive long term condition this will mean less money for other patients, this may mean that other patients will move away to practices without expensive patients. If patients move from a practice this will compound the problem because as a practice patient list shrinks the expensive patients will take up progressively more of the shrinking budget. Abolishing practice boundaries will make it more likely that GP practices will go bankrupt.

A lot of GPs have been worried about the practice boundary issue because it is the essence of risk pooling: the money not spent on health patients can be spent on patients with health problems. At the RCGP Annual Conference last week Lansley was challenged on GP boundaries and issued what is clearly a u-turn (Pulse):

He said: 'I'm clear that whatever we do, general practice must always remain rooted in local communities. We need to think carefully about how to manage home visiting, about how patients who don't live locally to their practice can receive urgent care, and about how information is shared. We will make sure it is done in a way that will preserve the responsibility for CCGs for the health of their local population.' When pushed to clarify his position, Mr Lansley said: 'I am not abolishing, or about abolishing, practice boundaries. I am intending to extend patient choice.'
Clearly his position has changed. For a year now he has insisted that practice boundaries were 'a solid wall of defence' against patient choice and therefore he had to remove them. Now Lansley is admitting that boundaries must be retained but now he needs to 'think carefully' on how to extend patient choice of GPs.

This is clearly a case of incompetence, abolishing practice boundaries was never a policy that could work while GP practices are paid through a capitation (a fixed fee per registered patient). Abolishing practice boundaries may work if patients with expensive conditions are given personal healthcare budgets, but at the moment no one knows how, or whether, personal budgets will work, and currently they are unpopular with patients as a way to fund healthcare.

It really is time that Labour stopped praising Lansley for his "knowledge" of the NHS and start criticising him for forcing on us an incompetent policy. As one comment on the Pulse article says:
"This is another example of how Lansley has no idea how the system works at a grassroots level. Words alone fail me when trying to express how fundamentally flawed Mr Lansley and his health bill are, and just how deluded and misguided he is! He simply does not have the knowledge, competance or experience to usher in this "top down" reorganisation of the NHS - something which his party's manifesto pledged it would not undertake."
This says it all, Labour needs to echo these sentiments: Lansley is incompetent.

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