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NHS at 'huge risk' from reforms, says healthcare chief NHS at 'huge risk' from reforms, says healthcare chief
(about 4 hours later)
The National Health Service is entering a period of "huge risk" as government reforms start to bite, according to the new chair of Nice, the National Institute for Health and Care Excellence. The National Health Service is entering a period of huge risk as government reforms start to bite, according to the new chair of Nice, the National Institute for Health and Care Excellence.
Professor David Haslam said ensuring that all the new bodies would be fully functioning and working properly together on 1 April would prove a major challenge. Professor David Haslam said ensuring that all the new bodies were fully functioning and working properly together would prove a major challenge.
"It is a time of huge risk," he told the Guardian. "We know in medical care in hospital that the greatest risk is when patients are being handed over from one person to another. It is a risky time for the system, so it is important that the big players work together. We are certainly trying.""It is a time of huge risk," he told the Guardian. "We know in medical care in hospital that the greatest risk is when patients are being handed over from one person to another. It is a risky time for the system, so it is important that the big players work together. We are certainly trying."
In a wide-ranging first interview since taking the job, Haslam also expressed concern at the complexity of the reforms and said that drug companies face a reputational problem akin to the banks and needed to demonstrate to the public they can be trusted. In a wide-ranging first interview since taking the job, Haslam also expressed concern at the complexity of the reforms and said drug companies faced a reputational problem akin to banks and needed to demonstrate to the public they could be trusted.
But his immediate focus is on the structural changes to the NHS. He said it was critical that all the new organisations – the National Commissioning Board, clinical commissioning groups and local authorities, which take on responsibility for public health, together with various advisory and monitoring bodies – work closely together, avoid duplication, encourage communication and focus on quality.But his immediate focus is on the structural changes to the NHS. He said it was critical that all the new organisations – the National Commissioning Board, clinical commissioning groups and local authorities, which take on responsibility for public health, together with various advisory and monitoring bodies – work closely together, avoid duplication, encourage communication and focus on quality.
Nice itself will be a different organisation, he said, taking on responsibility for setting quality standards in social care as well as health, in addition to the drug appraisals for which it is best known.Nice itself will be a different organisation, he said, taking on responsibility for setting quality standards in social care as well as health, in addition to the drug appraisals for which it is best known.
There would be challenges even in bringing those two worlds together, he said. "Professionals from the different sides see the world slightly differently. They even use language differently. People use the same words but mean different things." But it was important the two areas should be integrated – so the treatment and care of an elderly person with dementia, for instance, should be seamless. There would be challenges even in bringing those two worlds together, he said. "Professionals from the different sides see the world slightly differently. They even use language differently. People use the same words but mean different things." But it was important that the two areas should be integrated so that the treatment and care of an elderly person with dementia, for instance, should be seamless.
Haslam outlined the way the new organisations are supposed to work together after the changes are introduced. "I see Nice as setting the standards, the commissioning board as supporting the work that leads to care being delivered to those standards and the regulator checking that it has been done." But he added: "Would that it were that simple." Haslam, formerly a GP in Huntingdon and past president of the Royal College of GPs and the British Medical Association, outlined the way the new organisations are supposed to work together after the changes. "I see Nice as setting the standards, the commissioning board as supporting the work that leads to care being delivered to those standards, and the regulator checking that it has been done."
He warned that complexity in the new arrangements could be a problem. "I really feel that if you can't explain how things work on one side of A4 without going down to a tiny font, you have got it wrong," he said. If people at the top of the tree don't understand how it works "how does a patient at 33 Acacia Avenue know how it fits together?" The Francis inquiry into deaths in Mid Staffordshire had revealed "a huge amount of confusion", he said. But he added: "Would that it were that simple."
He warned that complexity in the new arrangements could be a problem. "I really feel that if you can't explain how things work on one side of A4 you have got it wrong," he said. If people at the top of the tree did not understand how it worked, "how does a patient know how it fits together?" The Francis inquiry into deaths in Mid Staffordshire had revealed a huge amount of confusion, he said.
The Francis inquiry also recommended much more clarity about the standards of care patients can expect. The National Commissioning Board will be asking Nice to set standards for about 180 different medical conditions, so that hospital trusts – and the inspectorate, the Care Quality Commission – can assess whether what they are doing for their patients is appropriate.The Francis inquiry also recommended much more clarity about the standards of care patients can expect. The National Commissioning Board will be asking Nice to set standards for about 180 different medical conditions, so that hospital trusts – and the inspectorate, the Care Quality Commission – can assess whether what they are doing for their patients is appropriate.
Haslam, formerly a GP in Huntingdon and past president of the Royal College of GPs and the British Medical Association, said "the really critical thing is working with patients and the public". Nice has always involved them but would need their help even more – to find out, for instance, what good care looked like from the perspective of an elderly man with multiple long-term illnesses such as heart disease, high blood pressure, high cholesterol, kidney disease, arthritis and depression. Haslam said: "The really critical thing is working with patients and the public." Nice has always involved them but would need their help even more – to find out, for instance, what good care looked like from the perspective of an elderly man with multiple long-term illnesses such as heart disease, high blood pressure, high cholesterol, kidney disease, arthritis and depression.
"What does 'good' look like for him when the treatment that might help his hip would make his kidneys worse and making his kidneys worse will make his hypertension [high blood pressure] worse?" asked Haslam."What does 'good' look like for him when the treatment that might help his hip would make his kidneys worse and making his kidneys worse will make his hypertension [high blood pressure] worse?" asked Haslam.
"You can't do this summatively. You can't say, for my patient, let us apply the guidelines for each of those conditions and add them together," he said. Otherwise you would end up with somebody taking 58 tablets a day but without a good quality of life."You can't do this summatively. You can't say, for my patient, let us apply the guidelines for each of those conditions and add them together," he said. Otherwise you would end up with somebody taking 58 tablets a day but without a good quality of life.
Haslam said much of the hostility to Nice – triggered by headlines about refusals to approve expensive drugs for the NHS – had gone. Haslam said much of the hostility to Nice – triggered by headlines about refusals to approve expensive drugs for the NHS – had gone. "Generally I think most people now respect Nice, recognising that there is a job that has to be done. I've had this discussion with my own patients in the past, when someone will say it is absurd that Dad can't have such-and-such a treatment because it is too expensive. How do you put a cost on a human life?
"Generally I think most people now respect Nice, recognising that there is a job that has to be done. I've had this discussion with my own patients in the past, when someone will say it is absurd that dad can't have such and such a treatment because it is too expensive. How do you put a cost on a human life?
"Of course as a relative, as a human, I completely understand that. But if you are not going to spend 100% of the UK GDP on one patient, you are going to have to have some sort of boundary.""Of course as a relative, as a human, I completely understand that. But if you are not going to spend 100% of the UK GDP on one patient, you are going to have to have some sort of boundary."
Haslam had been surprised, he said, that Nice got the blame for saying a drug was too expensive. He had been surprised, he said, that Nice got the blame for saying a drug was too expensive.
"It is not Nice that sets the price. It takes two to tango," he said. The drug companies had done some remarkable things – in finding drugs for HIV and for childhood cancers, for instance. But it was vital that they were now open with all their clinical trials data, about successful and failed drugs. "It feels to me that they have a reputational problem, a bit like the banks have a reputational problem, and there is a solution to that which is to demonstrate that you can be trusted." "It is not Nice that sets the price. It takes two to tango," he said. The drug companies had done some remarkable things – in finding drugs for HIV and for childhood cancers, for instance. But it was vital that they were now open with all their clinical trial data, about successful and failed drugs. "It feels to me that they have a reputational problem, a bit like the banks have a reputational problem, and there is a solution to that which is to demonstrate that you can be trusted."
The reaction of friends outside the medical profession to his taking the job had been, 'My goodness you are brave', he said. "I don't see that at all. Challenging yes, fascinating yes, endlessly varied yes, but I don't think bravery comes into it." The reaction of friends outside the medical profession to his taking the job had been, 'My goodness, you are brave', he said. "I don't see that at all. Challenging, yes, fascinating, yes, endlessly varied, yes, but I don't think bravery comes into it."