The Health and Social Care Act 2012 - its effects on equity and efficiency

[rachaelbhoswald]

To what extent do you believe the latest reforms the NHS is experiencing now will improve equity and efficiency in the NHS as an institution, in theory and in reality?

I have posted the following summary of the reforms below from parliament website:

Summary of the Health and Social Care Act 2012

The Bill proposes to create an independent NHS Board, promote patient choice, and to reduce NHS administration costs.

Key areas

• establishes an independent NHS Board to allocate resources and provide commissioning guidance
  
  increases GPs’ powers to commission services on behalf of their patients
  
  strengthens the role of the Care Quality Commission
  
  develops Monitor, the body that currently regulates NHS foundation trusts, into an economic regulator to oversee aspects of access and competition in the NHS
  
  cuts the number of health bodies to help meet the Government's commitment to cut NHS administration costs by a third, including abolishing Primary Care Trusts and Strategic Health Authorities.

[John Short]

Well there is nothing like starting the New Year with a challenge! 

This question relating to equity and efficiency in the NHS as an institution, in theory and in reality could be applied to health provision anywhere and the funding of the UK National Health Service out of general taxation rather than insurance provision should not stop the question being addressed from different funding regimes.
The question was posed the same day the following questions were asked by Lech Mintowt-Czex in The Times of 31 Dec. under the heading There are no easy prescriptions for local hospitals: “So You want a hospital that offers excellent treatment?  You want one fully staffed 24 hours a day, every day of the year so you get that excellent treatment whenever you fall ill?  You also want that brilliant hospital to be a tiny hop from your home?  Oh, and you’d like the government not to spend every penny it has on the NHS?  Sorry but something has to give.”  The rest of the article covers the (successful) emergency treatment to Lech’s son when his local hospital was downgraded and specialist services were concentrated in a larger hospital covering a much wider area.  This is something which is at the centre of the debate on the health service and relevant to the initial question posed by our colleague.

We are talking about the allocation of resources not only to different health sub programmes but also in the spatial context where need (demand) is different due to health indicators and often income.  Added to that is the separation of social care provision from health in terms of delivery with its move to local government while continuing the notion of joined up services. 

The theory is probably a lot simpler that the practice!  What we have is to allocate funds to preventative and (simple) curative in the General Practice system and to the elective curative and accident and emergency in the Hospital system so that patients go to (or are referred to) the appropriate service given their condition.  This means that A&E is not used as an alternative to GPs which puts pressure on an A&E system which is already understaffed, which in turn means that access to GPs is less time bound that it may be.  But this may have as much to do with health education for the public as much as the provision of services by doctors and nurses!  It also means that elective specialisation is centred on regional rather than district hospitals (as experienced by Lech).  Added to this is that the demand curve against income is likely to be U shaped – lower income groups (proxy for deprivation) may require higher health spending, but higher income groups demand higher health spending.  This is one the politicians have more power over and should ensure that the funds allocated to health is based on health indicators so that funds are not transferred from the poorer regions such as the North East to the richer regions like the  South East as it appears to be the case.

Cutting costs though removing layers of bureaucracy may well be achievable, but placing more burdens on the GP system (from the Hospital) system will reduce hospital bureaucracy spending but will undoubtedly raise GP bureaucracy spending.  No matter what balance is settled upon there has to be spending on management and good management will be essential to a well-functioning system.  It is an easy political sound bite to say cut bureaucracy but to what level?  In my experience the NHS where I live provides great service – from the GPs system (doctors and practices nurses) through to the local hospital in the nearly by town and then on to the specialist referral hospitals some 25 miles away in the city.

So over to my PFMBoard colleagues – what is your prescription for allocating resources to the health sector no matter what country you are in?  Let’s have a debate on an important topic – it is not only President Obama that needs your inputs!

[FitzFord]

John,

I spent a half-a -day reviewing all of the papers and reports that have been summarized in the newspapers here, with regard to the "Obamacare" program. I recall reading one that focused on the history of the process from the first attempt in the US to have gov't supported health insurance but it has chosen this morning to be absent from my stacks of newspapers. It would not, if my memory is somewhat accurate, have provided much help in assessing the British situation but it may throw some light on how the current US system has progressively been warped from the initiation of government support of health insurance by the industry of insurance and medical care providers. I recalled thinking after I read it, that Canada, Germany (allegedly the best)  and/or the UK, must have substantially better systems than one gerrymandered by interest groups. I think it would be useful to try to establish a set of criteria that a publicly supported heath care system should be required to meet. At least it would give us a base case to which systems (existing or proposed) could be compared. Doesn't take us very far right now, but there are lifetimes ahead...

Fitz.

[John Short]

Interesting report on BBC Today programme on this topic this morning – should be available on BBC IPlayer or playback feature timed at c07.20.  (The whole of the Today programme was very different today!)  Mention was made of comparative health studies by a Coleman Pratt.

[John Short]

Two reports published today - on supply side issues (by PAC) and on demand side issues (by ODI).
Also cross country study published in The Lancet.

[petagny]

In an interesting development (and a sign of the times?) the National Institute of Clinical Excellence may be moving away from cost-utility analysis and towards an approach that is closer to cost-benefit analysis to assess treatments.

http://www.telegraph.co.uk/health/nhs/10562382/Fears-for-the-elderly-under-new-NHS-drugs-policy.html

The approach up till now (although the value has never been published officially) has been to approve any treatment that delivers a QALY (quality adjusted life year) at a cost of less than £30,000. NICE say that “We have been asked by the Government to review the way we assess medicines to reflect more fully the value they bring to society.”

The article in the Daily Telegraph is suggesting that this might mean that the elderly are denied expensive, life-prolonging new medicines. Naturally, the pharmaceutical industry is not keen on this and the Patients Association has this to say:

"This is a disturbing announcement. Using 'burden placed on society by illness’ as a criteria could be a very discriminatory approach affecting older people disproportionately in terms of access to treatments.
“Older patients deserve to be treated in exactly the same way and have the same access to drugs as any other age group.
“Human life cannot be assessed in terms of cost and benefit. We urge Nice to reconsider the proposals to ensure that the most vulnerable group of people in the society are not subject to unfair disadvantage when accessing health care.”

The health ministry seems to be running for cover:

 "This is irresponsible scaremongering based on pure speculation about a consultation that has not even started. It is absolutely not true to say that older people will not get treatment because of their age.”

This is obviously a very emotive issue, but how to make sure that the burden of health costs in an ageing society remain sustainable? I absolutely want the best for my ageing parents (and myself further down the line!), but I also want the potholes in the road outside my street mended - and quickly. Somehow the circle has to be squared.

[John Short]

The head of NICE interviewed on The Today programme this morning categorically denied the inference in The Telegraph article.  Age was not an issue just the effectiveness of treatment!

[petagny]

I wonder what reflecting 'more fully the value [medicines] bring to society' means then, or have NICE been misquoted by the Telegraph?

What would perhaps be a good start would be for NICE to be more transparent about the criteria they use already.

[John Short]

Latest NAO report
Many hospitals are struggling to cope with increasing levels of demand for accident and
emergency (A&E) services when budgets are coming under increasing pressure. Bed
occupancy rates across hospitals continue to rise year-on-year and the ambulance service is
also under stress. While all parts of the health system have a role to play in reducing
avoidable emergency admissions and helping to manage more effectively those people who
are admitted to hospital, financial incentives across the system are not aligned so attempts
to ensure patients are treated without coming to accident and emergency departments are
not yet working. The improvement of A&E services is hampered by the lack of specialist
A&E consultants, the slow introduction of round-the-clock consultant cover in hospitals
and a lack of quality performance data. Accountability and responsibility for driving the
changes needed remain diffuse and unclear. Without this clarity, the service
transformation vital to coping with constrained NHS budgets will not be achieved in the
necessary timescale.