Next April, the Government’s much-discussed NHS reforms come in to full effect.
But preparation is already underway for what many see as one of the biggest changes to the NHS’s structure in its lifetime.
Staff around the NHS are being given new roles and responsibilities. Old regional structures are being replaced with newer, local ones. And – in keeping with these austere times – belts are being tightened.
Given the nature and scale of these reforms, earlier this year we asked a team of independent academics at the Health Services Management Centre at the University of Birmingham to investigate how they were affecting cancer care on the ground.
The Birmingham team did two things. First, they analysed publicly available data on waiting times and budgets across the NHS. Secondly, they conducted more than fifty in-depth interviews with key NHS staff from a variety of roles around the country, asking them how things were faring.
Their findings are mixed. As well as good news, there are areas of real concern.
On the one hand, waiting times for most things seem stable. This is reassuring, particularly given the growth in the UK population (which is also getting older – meaning increased cancer rates).
On the other hand, cancer budgets have decreased in real terms, and there’s widespread anxiety among interviewees about the potential loss of expertise, and fragmentation of services.
Below we’ll take a deeper look at the report’s findings. But first, we’ll briefly discuss what the reforms mean, and how the NHS is changing.
What is ‘commissioning’?
Each year, different parts of the NHS decide how much to spend on different ‘services’, and this process is called commissioning.
For example, a given NHS organisation will have to work out how much to spend on x-rays, compared to hip replacements, compared to ‘flu jabs, and so on. These services are then provided by local hospitals, clinics, dental surgeries, etc.
Commissioning requires a detailed understanding of the population in a given area. For instance in a younger, less-affluent area, where people tend to have more children, the NHS will need more maternity services and vaccinations than, say, geriatric or palliative care.
High-quality commissioning allows proper planning and balanced budgets. Do it properly and everything runs smoothly; get it wrong and money can be wasted, while waiting lists can rise.
In a system that emerged over the 2000s, the NHS became organised into 152 Primary Care Trusts (PCTs), overseen by a smaller numer of Strategic Health Authorities (SHAs).
Running through all of this have been 28 regional Cancer Networks – groups of experts with a remit to support cancer care around groups of PCTs.
Under this system, commissioning is done at several levels – and since it’s so complex, cancer commissioning is spread throughout the system, with some parts of care being commissioned by PCTs, and others at SHA or national level.
This system had its strengths, but some felt it could be made more responsive by bringing clinical knowledge into the mix, involving local GPs directly in commissioning decisions.
The ‘new’ NHS
In 2010, the new coalition government proposed radical changes to these NHS structures.
Alongside new legislation called the Health and Social Care Act, PCTs and SHAs are being replaced with local ‘Clinical Commissioning Groups’ – known as CCGs – effectively giving doctors a far more prominent role in commissioning than before.
Overseeing things is the new NHS Commissioning Board, which will have regional and local offices to liaise with local CCGs (see diagram, left).
In addition to taking over PCTs’ budgets, CCGs - who will ultimately be in charge of about 80 per cent of the entire NHS budget), will buy services from any ‘qualified’ (i.e. suitable) provider, as well as their local hospitals. The idea is to make the NHS much more agile, and more responsive to the needs of local communities.
And on top of this, the Cancer Networks are to be replaced by 12 ‘Strategic Clinical Networks’, who will have some cancer expertise.
We’ve blogged in depth about these reforms – here’s our initial reaction to them, our thoughts on how they could affect cancer care, our concerns about ensuring a successful transition, our work persuading the NHS Commissioning Board to bear cancer-related issues in mind, and the ultimate publication of, and our reaction to, the Commissioning Board’s ‘Mandate’.
But we haven’t had any hard data on whether or how the reforms are affecting things on the ground… until now.
The first thing to say is that we’re hugely relieved the report shows that waiting times for most cancer-related measures holding up – and even improving – over the last few years. This must be seen in context of the huge improvements in cancer care over the last decade – things really have got better, especially under the leadership of Professor Sir Mike Richards, National Cancer Director at the Department of Health.
The report shows that, in recent years, the NHS has been carrying out more diagnostic tests for cancer. But although the proportion of people waiting more than six weeks for access to them has fluctuated (including an increase during 2010/11), for most services this is currently back to normal.
The only cause for concern is endoscopy, where waiting times increased in 2010/11 and haven’t yet returned to their previous level.
A similar picture emerged among suspected cancer patients referred for further investigation. Patient numbers have increased, but waiting times have held up and, in many cases, even improved.
This is a huge testament to the staff working across the NHS, who appear to be carrying on their excellent work as normal.
But one worrying figure did emerge in the Birmingham report: the proportion of NHS money spent on cancer has dropped in real terms.
As the graph shows, over 2008/9, the cancer budget grew by 2.9 per cent. In 2009/10 it grew by 11.2 per cent. But in 2010/12 it shrank by 2.6 per cent.
Given the increase in cancer cases expected as the UK population ages, this is potentially a problem.
The reaction from staff
The picture painted in the interviews, however, was less positive – and the NHS reforms appear to be provoking real anxiety among NHS staff.
In many ways this is to be expected given the extent and speed of the reforms – and the report’s authors acknowledge the substantial evidence of anxiety during organisational change in their conclusions.
However, various themes emerged across the interviews, which the researchers grouped into six separate strands:
Scale of the change
Almost everyone felt that this was a huge change – probably the biggest in the NHS’s history. “I’ve been in the NHS a long time… This is completely different [from previous reforms],” said one interviewee.
Others highlighted the potential impact of the reforms during a period if financial hardship (the NHS is supposed to find £20bn worth of cost savings by 2015). In the words of one participant, the reforms were placing “a huge burden… on an already financially stressed NHS”. Another said, “We’re in a much more contested environment, where… there’s a feeling that there’s no money around.”
Many interviewees said that the recent improvements in cancer care had been driven by an increase in “joined-up thinking across” the healthcare system. But many felt that the reforms jeopardised this, and that there was a risk of fragmentation. “We need the CCGs working together effectively… so we need to make sure that we do maintain and strengthen what we’ve got,” said one.
Loss of knowledge and expertise
A real concern for many was the fact that the NHS is losing so many employees, along with hard-earned expertise. Some spoke of a ‘gap in the middle’, where PCTs used to be. Others said it would be “a tragedy” if the Cancer Networks were “dismantled or diluted”, while one remarked that they feared the potential loss of the leadership of Professor Richards. “All the organisational memory for large chunks of the system is taking a retirement package,” warned another.
The final theme was a loss of the ability to plan, particularly while the new structures found their feet. “People lack the confidence to start anything new, because they’re not sure they’re going to have a job,” said one, while another told a story of a project that could have saved £170,000, but which was “put on the backburner because the PCT decided it couldn’t make the decision because of the transition to CCG”.
The ultimate effect of all of this, said many participants, is that the improvements in cancer seen over the last decade could stall, potentially for as much three years. However, several interviewees pointed out that this didn’t necessarily mean things would get worse. “We’re not running into huge delays delivering radiotherapy or chemotherapy, but that’s just because people are working six times harder,” said one.
What happens next?
This is an incredibly valuable report, that adds a huge amount to our understanding of what’s going on ‘on the ground’ in the NHS. It highlights several areas of real concern for the future, but also shows how the NHS appears to be absorbing the impact of the reforms without – yet – impacting significantly on frontline cancer care.
Obviously, we will be keeping a very close eye on data, but the latest figures – released since the report was completed – continue to show things holding steady. And a second report last week showed continued improvements in lung cancer care.
Summing up, the report’s authors conclude that:
“The findings in this report present a mixed picture. The insights from interviews raise questions about the cost at which service performance is being held, as well as the long-term sustainability of this situation.
“There is a very real possibility of fragmentation in cancer services at both a local and national level. There is a need to ensure that the right structures, levers and incentives are in place to enable and encourage joint working. Equally, the issue of who will provide the local system leadership and coordination on which integrated models of cancer care depend must be addressed.
“These should be urgent priorities for NHS leaders and policymakers as implementation of the reforms progresses”.
We agree. We’ve published a series of recommendations on our website, and we’ll be working hard over the coming months to make sure the potential pitfalls identified by this report don’t become a reality.