Health commissions - there are some 37 in England - are seen by many, inside and outside the health service, as a model for the future. The consensus is that they are better geared to meet the needs of a more primary care-oriented NHS, of community care and in closer partnership with local government.
At their simplest health commissions consist of a marriage of the rump - minus the new trust hospitals - of what were 178 district health authorities (DHAs), traditionally the champions of acute hospital care, with a partner from the 90 Family Health Services Authorities which manage services provided by GPs, dentists, shop pharmacists and opticians. The 'marriage' is like a common law one in that, technically, it is not legal, since there are no provisions under the health reforms for formal merger. Both bodies, however, have responsibilities for purchasing or commissioning health care, through contracts under the marketstyle system from providers - hospitals, community trusts and others.
The Isle of Wight's commission says its greatest achievement in its six-month life for its tiny population of 127,000, with a budget of pounds 70m, has been the launch of an open-access endoscopy service. This means GPs can refer patients for examination direct for suspected cancers, stomach ulcers and other intestinal problems, without going through the usual procedures via a hospital consultant.
Dr Mark Denman-Johnson, secretary of the island's Local Medical Committee, explains: 'You are cutting out layers of bureaucracy to have the investigation which we, the GPs, were well able to determine was necessary. For someone with severe ulcer problems, it means you could avoid a three-month delay. Patients are getting a better service and you may be saving people's lives as a result.'
But the main point about the management of the service, health chiefs point out, is that under the old system when the DHA and FHSA were split into two bodies, a scheme like this might never have got off the ground. The reason is that the pounds 40,000 needed to launch it came from money earmarked for the DHA, which was channelled into a service that actually benefits GPs and their patients under the FHSA.
Peter Mankin, chief executive of the Isle of Wight Health Commission, explains that traditionally in the NHS there has often been tension, even rivalry, between the districts and FHSAs, with the DHAs fighting the corner for secondary, acute care in hospitals. The mere idea of a merger of the two bodies, he continues, creates suspicions: 'People see it as a threat to the FHSA and are worried it will mean an end to primary care, as the DHAs take the money to equip hospital care. In the districts, hospital consultants are worried that they will lose money to primary care. Staff are also worried about their jobs and their status.'
However, through the creation of the commission, he maintains: 'We cut through all those sorts of tensions and say 'We are here to serve the patients.' From the patients' point of view, with a range of needs, they don't give a damn which agency delivers. They just want their services delivered.' He believes patients are not only getting a better service under the commission but that national objectives under the Government's White Paper 'The Health of the Nation', to shift the balance of care towards prevention and primary care, are more likely to be achieved.
Other benefits, Mr Mankin notes, are savings through joint appointments of pounds 20,000, with scope for more streamlining if the law is amended to recognise the 'marriage' of the two bodies, an integrated management structure, and a chance of a more holistic view of the population's needs. Further, there are opportunities for better communication, less duplication and better decision-making when England's first new unitary council is created on the Isle of Wight in April 1995, with 48 councillors, replacing three councils and 103 elected members. Mr Mankin says having one main body for health and one council, in this case with coterminous boundaries, will be crucial in relation to new community care responsibilities. Community care calls for councils and health chiefs to work closer together than ever before. Mr Mankin said: 'We are doing our best to get rid of the bureaucratic boundaries so that there is a seamless service for those on the receiving end.'
Across the water, at Portsmouth and South East Hampshire Health Commission, there is a similar tale of synergy on a larger scale. Here a staff of 60, with a budget of pounds 240m, serve a population of 536,000. This year some pounds 500,000 of DHA money has been put into a primary health care development programme, to encourage a shift from hospital to the GP practice-based services of the future. A single Citizen's Charter was published by the commission for all health services locally, and a single complaints procedure for health and social services launched - an example of health and council co-operation.
Chris West, chief executive, says he hates to think of the paper mountain that would have had to be shifted to achieve these things under the old dual body. Commissions, he suggests, have the potential to help promote better health through 'healthy alliances' in the community, leading' for example, to employment regeneration. He pays tribute to the vision of Wessex Regional Health Authority as the only one of 14 regions to implement a strategy of health commissions region-wide. The region, which achieved notoriety recently for computer deals from which fraud charges have arisen, has caused a different buzz within the NHS for its innovation in the six commissions, including Portsmouth and the Isle of Wight.
Ken Jarrold, Wessex's RHA general manager, says the decision in May 1992 to establish commissions was based on three things: the need for integrated purchasing right across the board from primary to secondary care, recognising that patients who need health care may need it across the spectrum; pooling scarce skills of high-calibre health managers and public health specialists; and seizing the potential of savings on management overheads. He points to Dorset Health Commission's savings of more than pounds 500,000. He sees health commissions as 'a model for the future', and observes a widespread move across the country towards similar, albeit informal arrangements, where FHSAs and DHAs have joint chairmen - even if the new bodies are not actually called commissions. But he insists it is important for every area to adapt the idea to its own local needs, avoiding a prescriptive approach.
The Audit Commission, which has been looking separately at DHAs and FHSAs, is to publish two reports next Wednesday that will also give a strong push to the idea of unified health commissions. Separate DHA and FHSA budgets, they suggest, are likely to hinder the shift of emphasis from secondary to primary care.
At the London School of Economics, Tony Travers, a director of research, suggests a wider view is needed. He advocates some form of rationalisation of the number of tiers in the health service as being 'long overdue'. He says: 'With all those layers of padding between the Secretary of State, Virginia Bottomley, and the public, it is almost inevitable there is duplication, overlap and bureaucratic obfuscation. There are too many layers doing too many things.' He sees the maintenance of dual FHSA and DHA bodies as 'eccentric and a waste of resources'. Moreover: 'The contrast between the new unified local government system and the complex and regularly reformed health service is stark.'
Mrs Bottomley has, in fact, launched a management and structure review of the newly reformed NHS. It has a brief, she told the House of Commons last week, covering 'possible future changes to the configuration of NHS purchasers, including DHA mergers, (and) joint DHA/FHSA working'. Chaired by Kate Jenkins, the senior civil servant behind the radical 1988 'The Next Steps' report, the review team is due to produce its findings in July. 'Next Steps' was a manifesto for devolution in the Civil Service. This time round, perhaps, a 'next steps' for the health service will recognise the potential for health commissions, as a vehicle for devolution and providing better services to patients.
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