Q: Do you think the Government’s ‘listening exercise’ will lead to any major changes to the proposed NHS reforms? And what elements would you advise the coalition to change or revise in order to satisfy critics?
A: The difficulty is the fact that the Prime Minister (PM) has aligned himself so closely with the reforms. To back off now would be an admission of defeat for him personally, and that is politically not do-able. Of course, there is the other dimension of the Lib-Dems and there has to me some attenuation of the reforms to demonstrate that the Coalition is not a one-way street.
What would I expect? Some widening of the board membership at consortia level to include nurses, maybe, although Lansley is in no mood to mollify them after being beaten up by the delegates at the RCN conference. I would also expect some involvement from hospital consultants, which the PM seems keen to include, and the public, which is a big Lib-Dem ‘thing’.
If the Bill stays as it is Monitor has the power to impose competition at any level of service delivery. This might change following the review to passing the decision to commissioners to decide.
The final issue is that the Bill allows the Secretary of State to surrender his ‘duty’ to provide comprehensive healthcare, to working ‘with a view to’ providing services. I think the status-quo might remain.
Q: With the emphasis moving from hospital care to community-based support, do you think the social care estate is up to dealing with the increased pressure? And how do you imagine industry will finance the new care and nursing homes that will be needed?
A: Let’s face it, the ‘estate’ issue is in a mess. No-one seems to be able to decide on what the solution is. I guess it will end up a ‘local’ thing.
No, I don’t think the social care estate is up to it and I expect the Government will look more and more to the private sector for solutions. They could incentivise buildings and ownership with tax breaks possibly. The fact is the industry is already fragmented and is in the hands of either companies funded by venture capital, and they are unstable and unlikely to absorb the shockwave of more cuts in fees and tightening of criteria; or Momma-Poppa shops that will struggle to survive the inspection regime at the Care Quality Commission.
Most analysts mark this as a growth sector and, in terms of numbers and demand, that is right, but they will struggle. I see no prospect of capital being available to the public sector in the foreseeable future, although expect a loosening in the 2014/15 financial year prior to the next election.
I also expect new models of funding to become available. Not full PFI, but some other builder-operator model with the debt secured against contracts with local authorities and healthcare.
Q: Do you think hospitals will be forced to close and, if so, how many and how will the services they provide be replaced?
A: Up to a third of the secondary care estate might be vulnerable. The exact number is impossible to predict, but a good indicator will be the number who fail to make foundation trust status. Closures will be dressed as rationalisation.
It is probably true that advances in paramedical techniques means ‘play and stay’ is now safer than ‘scoop and run’ and ambulances can travel further to bigger and better-equipped A&Es and take patients to episode-specific locations – heart attacks to cardiac suites and so on. Thus fewer A&Es are a potential and that opens the door to rationalising services that sit behind the blue-light front door and centring instead on excellence; putting elective surgical care in one place.
The demand for beds will grow around medical elderly care and some of the hospital estate is likely to be taken over for that specialist purpose.
Q: With so many new players coming into the marketplace, and following the axing of the National Programme for IT, do you think organisations will have the technology they need to provide joined-up care? If not, what is the best way to ensure coverage, but protect vital patient data?
A: Thank goodness we still have the spine. That is the one thing the NHS has in common. I think the industry will have to get its act together with platform standards, otherwise we will end up with an electronic Tower of Babel.
GPs are quite IT savvy. They made excellent progress with products like EMIS and others and they recognise the benefits. So, I think they will look for IT compatibility and start insisting, as commissioners, on better use of IT, with electronic discharge papers and so on. They may well drive the changes from the ground up.
Access to patient data is, in my view, over emphasised. I see no reason why our patient records should be the property of the Secretary of State. I think they should belong to us. If they did, where they are stored would change. Google and Microsoft Vault are often spoken of as a possibility. Why not?
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