Friday, February 22, 2013

Why Equality Will Suffer In A Fragmented NHS

Strategy

Joined up thinking across all areas. A dream receding into fond memory

There are, as I type, just 24 complete working days before the NHS undergoes the substantive part of the biggest reorganisation it has experienced since 1948.

On March 31st, 152 Primary Care Trusts and the 10 English regional Strategic Health Authorities which supervised them will cease to exist. They will lose their statutory powers to even turn out their own lights. In their place a rats nest of new organisations will take over.

Fragmented

From April 1st, the bulk of commissioning decisions will be undertaken by approximately 212 Clinical Commissioning Groups, supported by a raft of Commissioning Support Units and overseen by a new quango, the NHS Commissioning Board.

The functions hitherto carried out by Strategic Health Authorities (which included regional strategy to join up education and education commissioning; public health strategy; and performance managing PCTs and those provider trusts which were not Foundation Trusts) will be scattered to various new bodies whose names will gradually become familiar.

The processes of strategically planning, budgeting, procuring, and assuring the education of the nation's clinicians will fall to a new organisation, Health Education England, which will operate at regional level through new Local Education and Training Boards (LETBs).

Responsibility for Public Health passes to a new body called Public Health England, which will oversee the strategies formulated by local authorities, who'll receive the 20% of the NHS budget spent on this activity.

The bulk of the work involved in determining local needs for services plus procuring, paying-for and checking on them will become the responsibility of the new Clinical Commissioning Groups. These CCGs will liaise with local Health and Wellbeing Boards (another new concept) to, theoretically, take account of local needs identified in Joint Strategic Needs Assessments before specifying the services they want to buy and signing the cheque.

The responsibility for contracting local GP practices, Dentists and Pharmacists, previously fulfilled by PCTs with SHA oversight, will pass to the NHS Commissioning Board, which will spring 27 'Local Area Teams' (LATs) in order to cope with the size of this work and ensure it is carried out reasonably locally.

And this doesn't include explaining the role of Monitor or the Care Quality Commission (CQC), or clinical networks and senates, or health watch.

None of these organisations yet have any experience of working with one-another. Many CCGs still haven't been authorised yet. They will start groping their way around and building relationships with their various points of contact in April.

Elderly experienced NHS staff, who have seen many reorganisations in their time, say that no previous change was anything like this. Those who can are grabbing the money and retiring.

Goodbye integration

The old system which is about to be closed down was far from perfect. No big organisation is.

However, from the point of view of trying to promote equalities in the NHS, the old system had very distinct advantages, which the people I've worked with these past few years were able to exploit.

The advantage of Strategic Health Authorities (SHAs) was that, within a region, they had a very complete picture of the whole NHS. You could strategise all of the functions illustrated in the diagram above.

SHAs were effectively offshoots of the Department of Health. They received money from the Secretary of State to oversee the entire health service in their region. There are ten English regions, administratively, so there were ten SHAs.

SHAs brought everything together in one place. They held the budget for planning and securing the training and continuing education of doctors in their region. They performance managed the way that services were commissioned by Primary Care Trusts (PCTs). And they performance managed those NHS provider trusts which hadn't achieved the qualifying criteria to operate independently as Foundation Trusts. (The Foundation Trusts could also be influenced at second hand by performance managing the PCTs who commissioned them).

Some people hated the extent of this much power in one place. However, if you want to plan something strategically then there are immense advantages in having that kind of structure. It certainly benefits equalities work.

Equality is a strategic issue

Equality.

It sounds such a simple idea.

The NHS was founded to provide a service to everyone at the point they needed it. That very idea embodies the committment to provide the same experience and quality of outcomes for all. Equality isn't something you bolt on to the NHS. It is fundamental to its purpose.

Equality also applies to the NHS's own workforce. And with good reason. In order to create such a universal service with the skills and capacity required, the NHS has always needed to lead in taking on staff from wherever the skills existed.

The NHS of the 1940's, 50's, and 60's invited thousands of Doctors and Nurses to come to Britain from the former Commonwealth Countries. And that legacy continues today. It changed the face of the nation. A very large proportion of the NHS's clinical staff still come from a Black or Minority Ethnic Background. Trying to ensure that all staff have the same quality of experience and opportunities in such a large institution reflects the challenges in wider society.

The advantage of tackling equality from the vantage point of a Strategic Health Authority was that you could set out to try and address issues which require joined up approaches. You could work across the disciplines of public health, commissioning, providers and workforce education and bring people together easily, even though some of the problems might still take years to address.

Joined up no more

The problem in the new landscape will be that everyone will henceforth be limited to working within their own silo. To work outside of those limits will require complex partnership arrangements to be worked out. The de-centralisation will make this hard to achieve on any large scale. It will be particularly difficult for small stakeholder groups to engage with.

Health Education England and Public Health England have so far made no announcements about equality. And there is nobody with the power to insist that they do … except to the extent of checking they've ticked the boxes to claim that they comply with the Public Sector Equality Duty.

This means that two important parts of the health system are unlikely to approach their work with any professional grasp of the equality implications in what they do.

The recruitment and education of doctors and nurses will most likely be planned without much thought to the diversity of applicants, why it is important for the workforce to reflect the population, and how an understanding of diversity affects the quality of outcomes for patients. With the right knowledge, education commissioners can have a big effect.

Public Health strategy will most likely be made without much understanding for the differing underlying determinants of health inequalities. People will shake their heads at how intractable some health inequalities appear to be. If you doubt me then study a few Joint Strategic Needs Assessments turned out by local authorities who should know better.

The NHS Commissioning Board is the only organisation that has so far given any indication of planning an equality strategy … though the signs so far indicate a dogs breakfast of delayed decision making and muddled organisation. Even if the organisation belatedly sorts out some structure for itself, however, its influence is limited to the left branch of the diagram above.

The NHS CB can influence how commissioning is carried out. It can influence how GP, dental and pharmacy services are contracted and performance managed. Anything else will require negotiation.

Low expectation

It is for these reasons that I have low expectations of anything genuinely transformative happening in the NHS in terms of equality … at least for years to come.

The managers will very probably talk the talk. They will talk high-mindedly of 'values' and 'change' and 'transformation'.

Stakeholders will roll their eyes.

The truth is that the managers don't have the keys to all the cupboards.

The equality dimension of Public health … tackling the immense health inequalities which we know exist … will be outside of their direct influence. Anything you want done will depend on the local authorities running local public health strategy. And I'm sure they will have their own ideas of how to spend their money. There will always be islands of excellence, but no national transformation.

Education … recruiting and training a diverse and culturally competent clinical workforce … will be outside of their direct influence. If the past experience with the old Workforce Development Confederations is anything to go by, there may be islands of good practice. LETBs are like WDCs reinvented. However, the good practice will simply underline the missed opportunity on a wider stage.

And I don't hold out much expectation for what the NHS Commissioning Board will achieve either. The manner in which the creation and recruitment of an equality and health inequalities team has been put off repeatedly and then botched at the last minute doesn't smell of roses.

We'll see.

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