In this special edition of Panorama, troubleshooter and businessman Sir Gerry Robinson examines the government's plans for the biggest shake-up of the NHS in its history.
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I'm Gerry Robinson. I have been in business all my life. I have turned
around failing companies, and I've managed billion-pound budgets.
Three years ago I spent months inside a hospital for a BBC series
trying to work out how to make the NHS run more smoothly. Now, as it
faces its biggest transformation Since the Government announced the
Health and Social Care Bill last year, there's been fear and anger
amongst the public about where our Health Service is headed. If you
have money driving your decisions, they won't be the best decisions
for the patients. The reforms aim to save �20 billion over three
years, but are GPs the right people to put in charge? What
qualifications do people have to manage something of that scale?
What qualifications do you have to... That's an extremely good
question and one that I often ask myself in the middle of the night
when I'm not sleeping very well. I'll find out where our Health
Service is failing... So you think procedures are happening either
carelessly or deliberately that don't... Deliberately. That don't
need to happen? Correct. I meet the man who is staking his political
reputation on these reforms. We've opened the Pandora's box, you know.
Every worry about the NHS is now coming in to be part of the
question of how do we deal with it I've never seen an organisation
like the NHS, as dysfunctional as it is loved. I don't know what
these reforms are going to do to the Health Service, so I think it's
important that I get out there and meet the people who, you know, when
the dust settles are going to have to put these reforms into practise.
As the Government's health reforms have generated debate, I have been
travelling around the country to form my own view on the Bill. I
think these plans have been very poorly communicated. It's -
everyone is confused by it, and that confusion is simply not
helpful. Despite the Government's listening exercise as the Bill goes
back to Parliament, the key aims remain the same, from what I can
see - most important is a bigger role for GPs. They'll be at the
heart of the new bodies that will replace Primary Care Trusts in
making decisions on behalf of us, the patients.
And there's one GP who our Prime Minister wants us all to know is
right behind the plans. Calm down, dear. Calm down. Calm down.
LAUGHTER Listen - calm down and listen to
the doctor. Howard Stoate GP a says this, "My discussions with fellow
GPs reveal overwhelming enthusiasm for the chance to help shape
services for the patients they see daily."
Will you tell me how you have been, George? Fine, absolutely fine. I
have been having physiotherapy, physiotherapy treatment. Tell me
how you found the physiotherapist? Very good indeed. Howard Stoate has
been a GP for 29 years and was a Labour MP for 13 of those. Here in
the commuter belt of Bexley, the PM's poster boy for the reforms and
his fellow GPs have had control over patient care since 2008.
morning, Gerry. Welcome to the Albion. How does it work in
practise? Instead of GPs saying what services are available to this
patient, and say this hospital provides this service that hospital
provides that service - that's actually - we think - the wrong way
around. If you start with a blank piece of paper, how would you best
design a service, not pick a service off a menu of a service
that exists, - how would you design a service from scratch that meets
the patient's needs, and you start from there. The NHS budget for,
butly alone is �350 million a year, and up till now, while GPs here
have been making the decisions, the Primary Care Trust has still been
signing the cheques. In future, Clinical Commissioning Groups led
by GPs like Howard will control the money.
I have managed budgets of this size, and I know what it requires. I
can't help wondering if GPs are the right people to take control.
What qualifications do people have to manage something of that scale?
What qualifications do you have to - to... That's an extremely good
question, and one I'll ask myself often in the middle of the night
when I'm not sleeping very well because it is a great concern to me.
What I would say in my defence is that GPs are very good at what GPs
do. GPs are very good at understanding patient needs. GPs
are very good at talking to their patients to know exactly what their
needs are. To prove to me just how well GP commissioning can work,
Howard sent me to look at a local cardiology scheme that's won
countless awards. It's the brainchild of one of Howard's
colleagues who felt his local hospital had him and his heart
patients over a barrel. When we tried to get a breakdown of
the Bill we used to get for cardiology, it took us 18 months to
find out why we're paying the money. GPs should have the power to look
at the books and see where every penny of taxpayers' money is going
to. Kosta used to refer his heart patients to his local hospital,
where consultants usually ordered an angiogram, an expensive,
sometimes painful, test where dye is injected into a vein.
So Kosta used his new commissioning power to bypass the old system. Now
he has a top cardiologist from a London teaching hospital come to
Bexley to examine his patients on the spot and decide what tests are
needed. It's meant fewer costly angiograms, but that's not the only
change. When the consultant sees the patient, he decides whether he
needs further investigations, and if he needs angiography, instead of
sending them to the hospital, he sends them to Harley Street with
the transport provided by the service. Welcome to the weekly
heart bus to Harley Street courtesy of Kosta. I caught the bus to meet
the specialist who decides who gets on - cardiologist Dr David Brennand
Roper. He's convinced the scheme's better for the patients and better
for NHS finances. When they analysed the costs of sending a
patient to the chest clinic, they found that the average saving
versus the average cost of a journey through the hospital
including various tests, they saved about �1,000 a patient.
So what do the patients make of it? Are you surprised to be going to
Harley Street or not on the NHS? It's a nice surprise. I didn't
expect that I was going to Harley Street, but yeah, it will be
interesting. And there's also bonus for patients like Angela. Unlike
the hospital, the Harley Street clinic has a high-tech low-
radiation CT scanner which makes invasive angiograms unnecessary.
I'm just going to move you into position. The clinic's scanner can
scan a heart in a single heartbeat while giving a fifth of the
radiation dose of Angela's local hospital version. But it means NHS
revenue going out of the system to a private provider simply because
they've got better kit. I don't really understand why we
can't have similar facilities available within local hospitals
within local hospitals within the NHS itself. We spend �100 billion a
year on the NHS. A few million here or there is hardly noticeable.
Savings could be made in other territories. It seems to me
extraordinary that we haven't got more of them because we're still
sending patients for these unpleasant angiograms when this it
can is available to do it a lot more pleasantly.
For the hospitals, it might be worse than just having inferior kit.
The way they process heart patients might need examination too. With
the transparency that's come with gaining control of patient care,
Kosta claims to have found some alarming hospital practise. He
believes angiograms were routinely ordered at the local hospital
partly because they're a source of income. You know full well that
that bill is artificially boosted. So you think procedures are
happening either carelessly or deliberately that... Deliberately.
That don't need to happen? Correct. Angiograms - they used to do
angiograms in your local hospital. And when you look at the figures,
500 angiograms of which 180 were actually necessary. The rest was
just to create revenue. So when - when we talk about the potential
for saving, you think there's a huge potential for saving in the
NHS... Billions. Without harming the patient? Yes. The Secretary of
State for Health and architect of the new reforms, Andrew Lansley,
agrees with Kosta that the current system can encourage this sort of
wastage. Well, it can happen, and it happens because of the way the
payment system in the NHS works at the moment because it pays for
activity so, of course, if you incentivise somebody just to do
more work, they'll do more work. What I'm talking about is us
getting to the point where what the payment system focuses on is
delivering quality and the results for patients, and that's a
different matter, of course. Currently, PCTs pay hospitals a set
tariff for most of the procedures they carry out, so if hospitals
aren't rigorous in weeding out anything unnecessary, the potential
for waste is huge. The South London Healthcare Trust
told us they refute the allegation that unnecessary angiograms were
carried out, and at the time, coronary angiography was an
accepted normal investigation for suspected heart disease throughout
the UK. The Trust is working closely with local GPs to continue
to improve services. Back in Harley Street, it's good
news for Angela. Her scan is clear. If this scheme is anything to go by,
then clearly GPs are likely to go private if they feel their local
NHS services are inefficient. The reforms have been changed so that
private providers can't undercut NHS rates, so they'll have to win
on quality, not price. That seems pretty straight forward.
Yes. But it's still attractive to those like Paul Jenkins who runs
the Harley Street Clinic. Does the opening up of the central
- or the attempt to open up the NHS - does that represent a business
opportunity for you? Yes, I think it does because we have
demonstrated with this project with Bexley that the model works, and
we're very keen to expand it to other, you know, care trust GPs,
commissioners, and in discussions with a number of them. Even Howard
Stoate, who is a fan of GP commissioning, has concerns for how
local hospitals will fare in the brave new world. What happens if a
local hospital can't or won't or is for whatever reason not able to
deliver the service the GPs decide to buy, and they are forced to go
to other providers because there is no alternative? Now, that's the
controversial bit. So will hospitals need to close? And if
they do, who makes the decision? What it means is that may be
significantly fewer people in hospital beds. There may still be
very much, you know, visiting their hospital for the outpatients'
appointment visiting their hospital for diagnostics, visiting their
hospital as a day case. Now, all of those things means hospitals change,
of course it does. It doesn't mean they necessarily close. If it does
need those decisions to be made about hospital closures, who will
make those decisions? But you don't. You don't in the business world.
You don't. You need to decide, you know, how many stores you're going
to have on the basis of somebody sitting there with you in - you
know, head office with a big map moving things around. You do. You
got three Tesco stores within - and one of them is not working. You
don't - you certainly don't build another one, and you certainly
close one. If the people who are commissioning the service want the
service to be there, if the public want the service to be there, if it
is transparent that the service is in demand it doesn't make sense to
shut it down. But the reality is that not all GPs
are happy with what their hospitals are providing, and I feared for
some hospitals. For me it was the first sign that GP reform would
affect the rest of the NHS especially if no-one is managing
from the centre, so how will it affect patients? Like the I -- I
travelled from Bexley to hackney East London, one of the country's
poorest neighbourhoods and home to Dr Deborah Colvin's practise. If
you have money driving your decision, they won't be the best
decisions for the patients. If we agree together as a society, OK.
These are the outcomes we want. Let's get together and work out how
to make them happen, then people will be driven by wanting to do the
best for the patient. Like the heart scan project, the GPs here
have devised a scheme that joins up a lot of agencies really
effectively. It's for patients with diabetes. But unlike the Bexley
doctors, in Hackney, they're keeping it all within the NHS.
beauty of the scheme is that diabetes is a complex illness, and
there are lots of problems, and you need lots of people working
together, and if you can bring everybody together, you can work
out the best path for them because everybody's different. What works
for one person doesn't work for another. Central to the new reforms
is patient choice - the mantra is, "No decision about me without me."
But for Deborah, the choice between private provider and NHS could
If she said I want to see a dietician from this company and a
nurse from that company, it would make my life a nightmare.
Contacting different people, different payment systems, forms,
phone numbers. I would never get everybody together to talk together.
If the service wasn't working for me then, I would need to sit down
with the people that were working with me and then we could discuss
what was going wrong. I wouldn't just necessarily come out and say,
well, I need to change this service. In a sense, the informed choice,
whether we like it or not, it's true for me, has to be made by the
medical expert. I think Debra is really impressive. She's totally
committed to doing the right thing for her patients and totally
committed to doing it within the health service. She's not happy
with outside providers. I've got some sympathy with that. There is a
place for outside providers, but it needs to be very, very carefully
managed. Private health care providers come from a wide and
varied background. Circle are one of them. They run three hospitals
already and plan to open another 25. Ail Parsa, a former Goldman Sachs
investment banker, is their co- founder. Do you think that these
changes will present an opportunity for the private sector to come in
and do things, make things happen? Yes, I do. I think that it's health
care professionals, social entrepreneurs, they will come up
with new ideas, new solutions. Web those ideas and solutions will only
work if patients choose to go there. He passionately believes private
providers will improve the NHS. years ago we used to spend �37
billion in health care. Today we're spending 127 billion in health care.
We tripled the cost of delivery. This country can't afford three
times as much in another ten years. We need to look at different
solutions. The solution being proposed now is that patients will
choose their own treatments from a list of qualified providers, NHS
and private. That makes the NHS lift its game. To me, this is a
total cop-out. Get the system better with management not with the
threat of outside providers. I have absolutely no objection to using
outside providers and I've no objection to their making a profit.
What I hate is the idea of using outside providers as a way of, you
know, making efficiency changes in the health service itself. That's
straightforward cowardlyness. If there are savings to be made within
the health service, it needs to be managed within the health service,
by a central system, which sets out what it wants in a strategic way
and follow it's through. It's cowardly. It's wrong. It doesn't
actually work. It ends up destroying the organisation itself.
I have a strong sense that you're trying to use external competition
to make the internal market or the internal service work better.
really. My experience of the NHS is actually there is more than
sufficient competence, enterprise, innovation in the service. We just
have to let it out. Back in May, when the reforms were
being debated, the anger out there was incredibly powerful. Do you see
this as the beginning of the end of the NHS, do you? I think it's just
going to be a brand, a logo, stuck onto a corporate machine,
disgusting. These measures affect everyone in our society and the
people who are making them and the people who can afford them with
private health care, that's fine for them.
I think the NHS stands for something quite important. It
unites everyone in this country, the NHS. We all have this amazing
access to health care. The NHS has been described as the closest the
British have to a religion. Many here clearly believe what's
proposed is sacrilege. If you're going to change the NHS you need to
do it extraordinarily carefully. And the feeling here is that
actually this is the beginning of the end. People find change
incredibly difficult. Sometimes they have concerns and they want to
know those concerns have been heard and responded to. A lot of that was
about saying, well, you know, it's going to mean privatisation of the
NHS and it won't. But it wasn't about involving the private sector
more. It was actually about getting the best possible services for
patients. The big driver for these changes is savings. With increased
demand and an ageing population, soon the NHS is simply going to
cost too much money. Do you know it's horrifying how much money this
organisation chews threw and ongoing it's just not sustainable.
So it's vital that we make the right changes to make sure that we
do have an NHS around over the coming years. It's just crucial.
Near the top there. That's it. move this, does it hurt? Andrew
Lansley's confident that getting rid of Primary Care Trusts will
bring big savings for the NHS. Where the reforms are yet to be
agreed, it's already happening. Back in Hackney, Dr Deborah
Colvin's local PCT has gone, merged with two others. It's causing chaos.
Things are coming apart. We don't know next month where we're going
to get our IT support from, because half of it's gone, 50% of the PCT
have gone. She took me to her derelict old PCT building. Some of
the team were moved from here. But many have been made redundant.
Horrible, isn't it? Yes. Those teams don't exist any more and all
their memories, all their knowledge of the local area and what patients
need and how things work and Who's Who... All gone. All gone.
It's estimated that 20,000 redundancies will occur, as PCTs
are dissolved at a cost of �1 billion in redundancy payments.
I've been involved in any number of changes in large organisations, but
this is easily the strangest one that I've ever seen. It's already
started. People are being made redundant. Things are changing, but
we don't actually know what the end game is. And there's another worry
about these reforms, in order to run the commissioning process
effectively, GPs are going to have to band together into bigger units.
Does that mean we risk losing something special about our GPs?
Tuck add way in the Lincolnshire Wolds, I meet Ajay Vora, a country
doctor with a thriving practice. Nice to meet you. Welcome to the
practice. Thank you. Essentially a single handed practitioner, but
we're in a rural area, covering approximately 100 square miles. I
work with my wife, who's a nurse practitioner. It's very much a
couple-driven practice. We've been here 20 years. We hopefully have
got to know our patients very well. I'm excited that I might now, forts
first time, have a say in how some of these funds are directly spent.
Tell me the patient we're going to see? It's a lady who is house bound
now. He took me on a home visit to meet one of his patients. How long
is it since you had the fall? when the snow was on the ground.
couple of months. When you hear all this stuff about the NHS not
working well and all the reforms, what does it make you think? Well,
first of all, how fortunate we are to not have the problem. You can
hardly believe that they can ring up to make an appointment and being
told that we can't see you for a week. When we go to our doctor, we
don't get that. Somebody will always see you. It's been nice
seeing you Joyce. Yes, I'm pleased to see you.
Some independent GPs like Ajay also have concerns. They will be asked
to join with local practices to commission as a unit. Where he now
has sole control of his budget, he will find himself part of a large
group having to make joint decisions. I'm told I have to refer
Pat to a certain hospital with a certain consultant because a
contract has been put in place that make it's work better, maybe
financially. Suddenly now, she doesn't know whether I'm saying
that because there's a background motive or because it is the best
for her. Now there's doubt put in a patient's mind. I really think he's
right. There is a danger that the purity of that patient -GP
relationship could be threatened by a financial motive injected into
the decision-making process. What really concerned me was who was
going to manage and coordinate these GP commissioning groups. I
can understand why the power to commission has been centred around
GPs. I think it makes a lot of sense, these commissioning groups.
But you know, who will hold the commissioning groups responsible?
This lack of accountability, which to me, has never been in the NHS,
isn't in the NHS and I see nothing in these reforms that will change
that. There's got to be a set of people in each part of the country
who are responsible. That's for clinical commissioning groups.
There is a line, the NHS commissioning board is responsible
for allocated resources. They're accountable to the public through
the Secretary of State who sets a mandate for the ambitions for the
service as a whole. These reforms affect only England. In Scotland,
they're moving in the opposite direction. I headed 400 miles north
to Glasgow, where they have health boards, instead of PCTs and trusts.
Here hospitals and GPs work together much more closely and
there is a central report ing structure. Lovely to meet you.
Margaret McCartney's practice is in the west of the city. She is
genuinely worried for her colleagues across the border.
have a sense of impending doom. What's happening in England is
horrendous. I do not see any way that patients are going to get a
better deal out of this. I think doctors are going to be moved to
doing more management, accountancy. Their best interests should be
served by the patient in front of them. It's placing doctors in an
untenable situation where the patient in front of them is going
to be thinking, "Is my doctor deciding not to give me this
because there's no evidence for it or because they're not willing to
fund it?" On my journey round the country, I've met believers in
these reforms and been convinced by them that GPs are probably the best
people to handle commissioning. I've also met doubters, deeply
worried about the role of private providers and I share their concern.
And those who simply aren't sure what the reforms will lead to. I
think the stakes here are huge, the very existence of the NHS could de-
- depend on getting this right. Who's managing that big picture?
For me, that's the question that remains. Unless somebody really
does grab this thing at the centre and actually have the courage to
make the decision that's are right, but unpopular, I think it could be
the end of the NHS. This is my view, but the Health
Secretary disagrees, believing the reforms will ensure the NHS is safe
in his hands. With a service the size and
significance of the National Health Service, you've got to take people
with you. You've got 50 million patients who, for whom it's always
going to be an important thing. They've got to know that, where
they hear noise about is the service going to be fragmented, is
it going to be safe in the future? They need to know it's going to be
safe. They need to know that the people who work in it are confident
it will deliver a better service in the future. I think everyone wants
the health service to survive these reforms. If I've taken one thing
from my journey, it's that the British love affair with the NHS is
alive and strong. I just hope that these changes aren't the end of the
affair. Next week on Panorama, remarkable
In this special edition of Panorama, troubleshooter and businessman Sir Gerry Robinson examines the government's plans for the biggest shake-up of the NHS in its history. Sir Gerry travels the country, taking the temperature on support for the reforms and talking to GPs with opposing views. He finds how change has already started with the closure of many Primary Care Trusts, and asks Health Secretary Andrew Lansley if the future of the NHS is at risk should his reforms fail.