Comment / Fear and owning

For some, the proposed shake-up of the NHS adds up to a scary prospect. But it offers the potential for real clinically led commissioning.

As the de-icer spray is once again retrieved from the garage, thoughts turn to next year’s financial planning cycle. In Wales and Scotland, HFMA members are desperately trying to interpret the implications of draconian reductions in headline levels of public spending, while colleagues in Northern Ireland wonder if they will ever see a 2011/12 settlement. In England, following an ‘as good as it gets’ spending review announcement, the 2011/12 tariff and operating framework are awaited with trepidation. 

While in other home nations delivering productivity gains (and surviving Assembly elections) is the main concern of finance professionals, in England we also face huge system reform. In fact, for the English service the anticipated mid-December announcements are likely to represent more than rules of engagement for the next 12 months. Members are braced for a clear signal of how NHS business will be conducted in the next decade. It may well herald a new world.

Providers will note the ‘sale’ of Hinchingbrooke to healthcare provider Circle and social enterprise models emerging from former PCT services. Watch out for a mushrooming of small, ‘niche’ operators skimming work (and turnover) from established providers and a consolidation of foundation trusts.

On the commissioning side, it will be fascinating to watch GP consortia taking shape and to see whether their commissioning militia are sourced from refugees from PCTs,  the ‘big four’ accountants or even the retail sector (Virgin Health and Sainsbury’s are taking an interest, among others). My guess is for a mixed economy of models across the country, which will ask many questions of accreditation and governance.

Then we have the potential re-emergence of a ‘proper’ market. Future iterations of the national tariff are likely to set the maximum that can be charged by ‘any willing provider’ in a locality.  It won’t be long before larger providers subcontract loss-making or clinically vulnerable services or look to exit those areas of the market. At the least, there is likely to be an impact on choice and we keenly await any entry and exit rules and the required failure regime.

If all this sounds scary, well, it is. But there is much to be optimistic about. The Liberating the NHS white paper and resulting health bill has the potential to put GPs at the very head of NHS commissioning for the first time. Importantly, family doctors, the front line of the service, will be responsible for £80bn of expenditure, not just aspects of elective care, as under the last Conservative administration. At last commissioning healthcare will be clinically driven and providers will undoubtedly respond by fielding their own clinicians in the annual contracting process. There is real hope that clinical colleagues will finally ‘get’ the need for improved productivity in the NHS, as public spending diminishes.

But while finance and chief executive communities display ownership of the efficiency agenda, many clinicians remain in denial. Under the new proposals, clinicians can actively promote and lead the transition to leaner patient pathways. If they genuinely engage, the result will be a re-engineered NHS that is more efficient but also safer for patients.

The HFMA has a major role to play in supporting the NHS finance community through the challenges, providing an outstanding source of personal support and professional sustenance. It is a unique and treasured institution and it has been a great pleasure and privilege to serve as your President in 2010.