Opportunities and challenges of the NHS reforms
by David Shaw Head of Service Development
The healthcare landscape is undergoing a radical transformation which may significantly affect the work of healthcare charities. Alongside the NHS restructure, an increasingly competition-based healthcare service provider market presents opportunities and challenges for charities. The fundamental premise of successive governments is that the introduction of competitive elements in the healthcare market will promote efficiency. Based on this principle, the Health and Social Care Bill has given an economic regulator significant power to promote competition 'where appropriate'. Indeed research has shown that competition can, in the right circumstances, improve quality. However competition is not an end in itself. If productivity in the NHS is to increase, competition between networks of providers or integrated delivery systems should be encouraged. The risk is that providers, regardless of the sector they are from, misinterpret this and resist forming partnerships or integrating services. Our experience at Marie Curie suggests that end of life care requires a diversity of providers. The diverse needs of an individual at the end of life cannot be met by any one organisation and there are many providers, be they public, private or charitable organisations, who must work together to ensure that the individual receives the best possible quality of care at the end of life. Indeed, Marie Curie has been working for almost a decade with partners in the NHS and charitable sectors to develop an integrated approach to end of life care through our Delivering Choice Programme. We’ve shown that a provider partnership approach is often the best way of delivering the joined-up care patients need at the end of life. It is essential that all providers of end of life care must operate within and be bound by ethical standards and safeguards. Our patients are amongst the most vulnerable and are not always in a position to exercise or indeed articulate consumer choice. The patient is always at the centre of Marie Curie’s services and we take decisions on their care based solely on their wellbeing. The current proposals include clear sanctions for those who fail to meet quality standards and these must be effectively enforced, to ensure that the quality of patient care is protected. Furthermore, for the third sector, it is not necessarily the existence of competition that is the problem, but rather the effect it may have on small charities. In a market-oriented system, small charitable organisations could be at a disadvantage as some might struggle to meet the guidelines required to qualify as an Any Qualified Provider (AQP). The government also believe that opening up the healthcare market to a wide range of service providers will help to drive up standards of care. However, in my view there is a hierarchy of choice in end of life care. First and foremost, the patient must be able to be involved in the decision-making around the environment and manner in which they are cared for at the end of their life. The salient issue is that services are well coordinated and accessible to patients so that they are in the best possible position to receive the necessary end of life care.
A recent Nuffield Trust study, for example, has shown that the Marie Curie Nursing Service helps to reduce hospital use at the end of life, and helps more people to die at home. The research compared the hospital use and place of death of over 29,000 patients who had used the our nursing service with the patient outcomes of over 29,000 individually-matched controls who were similar in all respects, other than not being Marie Curie patients. It concluded that Marie Curie patients were twice as likely to die at home as matched controls, (77 per cent versus 35 per cent) and fewer than 8 per cent of Marie Curie patients died in hospital, compared to 41 per cent of matched controls. By contrast, I think most people at the end of life are less able to make choices between one provider and another. So whilst the choice between multiple providers is attractive, in practice this decision is of secondary importance at the end of life. This raises the question of how healthcare charities can ensure that they remain key providers of community services. Now is the time for charities to establish consortia and to work in partnership with both third sector healthcare providers and other willing providers, who meet ethical standards and safeguards. Clinical Commissioning Groups (CCGs) will not look to commission complicated, fragmented care packages. Therefore charities will need to make a coherent, joint offer to CCGs in order to be able to continue providing the most comprehensive, quality care to patients. It seems that moving forward into the new commissioning landscape will require collaboration with both the NHS and the third and private sectors in order for charities to continue to provide the expert, patient-centred care which defines our work. This post first appeared on the commissioning.GP blog on Friday January 11.