Where's all the "Equity" when the NHS has been "Liberated"?

This is a guest post by Christine Burns MBE, an Equality and Diversity consultant currently embedded in the NHS war zone.

Since Andrew Lansley’s NHS White Paper was published last week, most of the public commentary has inevitably centred on the alleged savings to be achieved and the open door which the plans will create for privatisation.

The White Paper, “Equity and Excellence: Liberating the NHS”, proposes to remove two tiers of regional and local governance from the structure of the health service and to pay the lion's share of the NHS budget direct to GPs, organised into consortia to commission services from a wider market of providers.

Do the changes make sense?

Already there is a hot debate about whether GPs are willing or able to handle such a massive managerial responsibility. GPs themselves seem divided. It’s widely expected that the new consortia will contract functions like commissioning and purchasing out to private sector companies, for whom a bonanza is predicted.

I’ll not try and add much to that side of the debate, as it is being covered so well by others. It’s important to establish two points though.

Firstly, although many don’t realise it, the NHS is already part-privatised.

Every one of 34,000 GPs in the land is a private contractor. They’re the people whom the coalition propose to hand £70bn a year of our taxes to spend. Foundation Trusts (who run most of our hospitals and specialist services) are presently allowed to do a small percentage of private work; the new Government proposes to open that up and allow a flood of new private sector providers into the market.

Second, the argument that the NHS has too much managerial overhead just doesn’t stack up.

The NHS is the world’s second largest employer. It employs 1.4 million staff. It spends almost all of the annual £110bn health budget on the treatments we receive, with a relatively tiny chunk on public health promotion and disease prevention. Less than 2% of the total actually goes into management.

The best estimate for savings from shedding 45% of NHS management is £1bn. This to produce a system which is, by definition, less managed.

In reality the saving from all those redundancies is likely to be closer to £250m. Yet the NHS Chief Executive, Sir David Nicholson, is reported to be setting aside £1.5bn to cover the cost of dismantling the existing system of 10 SHAs and 152 PCTs (where all that management currently occurs) and to replace it with an estimated 500 GP consortia.

All those consortia will require significant numbers of managers - whether directly employed, or on the staff of private companies contracted to manage a massively complex system for them.

That’s madness.

Diversity is not a minority affair

Lots of people are commenting on those aspects of the biggest revolution in the NHS’s 62 year history. What nobody is talking about is whether the new system will produce better outcomes for all those groups in society who presently get a less than fair deal from the NHS.

Before you switch off and think I’m talking about minorities that don’t concern you, however, think again. Let’s do the numbers.

An average of 7% of the population in England has a Black or Minority Ethnic (BME) background (over 30% in some cities). 20% have some form of disability that would be covered by the Disability Discrimination Act. At least 6% of the population is Lesbian, Gay, Bisexual or Trans. Within the decade almost half of the population will be over 50 years of age.

In fact, the North West Development Agency calculated a while ago that only 20% of people now match the old-fashioned stereotype of the working age population: white, male, non-disabled, straight and aged between 18 and 45.

Count the equivalent 20% of women and it’s immediately apparent that around 60% of the population don’t fall into that white, middle class vision of the population which the NHS was designed for in 1948.

Does that matter? Well, yes it does, because the evidence is that the NHS is serving many of that 60% of the population very poorly. And, if a better understanding of what goes wrong were applied in the existing system we could save a heap of money.

Understanding diversity produces better outcomes, saves money

Take prevention. The evidence is overwhelming. Here are a few examples.

A disproportionate number of BME men find themselves sectioned into mental health services. Why? Well, it’s not because they’re more susceptible to mental illness. In fact, if you don’t know why then I advise finding out.

What’s the point of having Mental Health services that don’t know how to prevent admissions for a massive chunk of the population?

Most GPs don’t know enough about sexual orientation to understand that lesbian women are susceptible to cervical cancer like their heterosexual counterparts. They don’t understand that, among the 20% of older women who don’t undertake breast screening, lesbians are significantly over-represented. The result in both cases is cancers being detected far later than they could be.

Massive expenditure on trying to treat less treatable tumours. Lower success rates. All avoidable.

What about something that may be closer to home for some: what’s the point in screening women for chlamydia if you don’t screen the men who have an equal part in spreading it? Yet many public health professionals will bleat that they don’t know how to reach those men, because they seldom go to see their GPs.

Failure to understand the different ways in which women and men relate to health services is endemic. That alone suggests that 50% of public health ineffectively is ineffectively spent.

I could go on listing such examples, but it would get boring. Besides, any competent Equality and Diversity practitioner should be able to reel them off, point to the documentary evidence and tell you about the innovative solutions that will work.

Directors of public health, commissioners and finance managers are too busy to ask though.

Issues that transcend the ways the NHS is organised

You’re going to point out that this is all going on in the present NHS. And you’re right. The existing system often performs quite badly in terms of identifying the need for smart interventions and delivering successful (cost and life saving) outcomes.

But before I discuss whether the new NHS structure would be any better, it’s important to understand why the NHS (and practically every other public service) fails in this way.

The problem is not to do with any lack of policies, processes or inputs. In fact there are lots of those.

The Public Sector Equality Duties have encouraged lots of consultation and planning on equality over the last eight years. Organisations have been able to satisfy those public duties by producing nicely printed Equality Schemes, ticking the “compliance” box and putting them on the shelf.

What hardly anyone has done has been to measure the actual outcome performance of NHS organisations. Scratch the surface to look for evidence of reducing inequalities and the results are plain as day.

Whilst E&D practitioners undoubtedly work very hard, they are often unable to present evidence of their organisations actually achieving anything in terms of identifying and reducing adverse effects of a ‘one size fits all’ approach.

It’s not the structure that matters

Yet at least the existing NHS system has all the tools and levers to tackle the problem. The present NHS is built for accountability and governance.

In the present NHS, the Department of Health oversees Strategic Health Authorities as regional outposts to determine policy and manage performance. It’s just that nobody has used that line of accountability (from the centre to the regions) to performance measure and manage equality outcomes, and to make sure they achieve them.

The ten Strategic Health Authorities can likewise set performance measures for Primary Care Trusts and hold them to account on the results. It’s just that they’ve not been doing this till now.

The Primary Care Trusts, which were split into commissioning and provider bodies, manage their own local health economies, but have not been effectively managing E&D outcomes in outcome terms.

A methodology called World Class Commissioning was launched a couple of years ago to improve the effectiveness of commissioning managers in other respects. This included language about using evidence of needs and understanding one’s local population.

The Department of Health mysteriously failed to make the connection between these words and the idea of diversity competence.

This means that commissioning has not been used as effectively as it could to mould the design of services around a sophisticated understanding of needs and circumstances. Likewise contracts with providers have not been used all that effectively to drive up equality outcomes.

What’s not measured doesn’t get done

In the absence of equality performance management, few PCTs have thought to manage provider services in this way. The current picture is therefore not very good. But that isn’t the fault of the NHS structure. The fault lies in the failure to have utilised the lines of accountability in that structure effectively. E&D professionals undoubtedly work very hard in our PCTs and providers. Without performance management, however, there’s not been the strategic focus.

So will the new NHS structure fix all that? Well, sadly no it won’t. In fact it could make it worse.

The new structure, whilst it does have some forms of scrutiny around the edges, provides precious little where it matters: holding GPs to account. After all, Andrew Lansley listened to the GPs. The GPs (understandably) told him they didn’t like being managed. So the Government is not only removing the management but giving GPs the ultimate power of holding the purse strings.

Ask anyone from any equality target group and they will regale you with examples illustrating that Britain’s 34,000 GPs have a very poor record in terms of their attitude towards diversity. Most GPs live a life of privilege, with large salaries and a place in the community which sets them apart clearly as “Us” rather than “Them”.

Andrew Lansley claims that his new proposals will empower communities to scrutinise their local NHS. But when he talks about communities he really means people who also have privilege. The people who typically turn out to consultation meetings and can have their voice heard.

And the scrutiny on offer appears to be at second hand. The existing SHAs and PCTs all have statutory responsibilities to consult with the public they serve before they make changes. The Public Sector Equality Duties ensure that includes people from all the equality target groups. Yet, when questioned recently, a policy manager from the Equality and Human Rights Commission was uncertain whether GP Consortia would come under the ambit of the Public Sector Duties.

Lansley has not defined yet whether and how GP Consortia will be expected to consult and involve, aside from the broad sweeping statements contained in the White Paper.

Members of the equality target groups, many of whom don’t have the resources to take part in consultation with 152 PCTs and hundreds more providers, are hardly likely to have the capacity to hold 500+ GP consortia to account. And, whereas NHS Provider Trusts currently fall under the Public Sector Equality Duties, the expected rush of private sector providers won’t do.

This means that, even where accountability to equality groups is theoretically there on paper, many communities will simply lack the capacity to advocate for themselves.

A bleak future

The future is therefore bleak. I can forsee an NHS branded health system which will increasingly focus on what’s easy and what GPs visualise as “deserving”.

Some of the details of how any scrutiny will work have not been set out in detail yet. However, when those details are consulted upon (if this Government still understands that concept) it is vital for men and women, those from all races and ethnic backgrounds, disabled people, young and old, lesbians, gay, bisexual and trans people to all look very carefully at the small print.

Ask yourself how will my local GP consortium take account of my needs and experiences when commissioning services that will affect me? Will anyone expert from my community be able to advocate on my behalf?

Ask yourself how will GPs in those consortia be trained to go beyond thinking of equality and diversity principles as ‘Political Correctness’ and see such understanding as part of their job.

Ask yourself how well can Local Authorities advocate on my behalf when they scrutinise services. Are they equipped to understand the vital nature of diversity in designing and delivering services that work for everyone.

Ask yourself whether the Care Quality Commission, charged with overseeing provider services, will have the capacity and the means to see that adverse outcomes are identified and dealt with.

Ask yourself whether the Equality and Human Rights Commission, though outside of the new NHS system, will have the capacity and capability to investigate organisations where discrimination occurs.

Ask yourself whether the GP consortia will have the capacity and capability to manage the provider sector through their contracts, especially the private sector providers who will otherwise be outside of public sector duty responsibilities.

And, finally, ask yourself how any of those areas of scrutiny can be performed effectively by anyone if there is no consistent and objective means for measuring the outcomes that matter in each organisation.

Remember, the existing NHS has splendid lines of accountability and governance but has not performed well on equality because there was no performance management framework.

The new system will be much harder to hold accountable. Therefore the need for an objective performance management system measuring real outcomes is all the more vital.