Unfinished business on health

Bill Moyes says there should be more foundation hospitals but reforms should also cover primary care trusts and GPs

By John O'Leary

Primary care trusts and GP practices should be the first reform targets of an incoming government, the outgoing executive chair of Monitor has said in an implicit acceptance of Tory health policy.

In an interview for Policy Review magazine, Bill Moyes said Labour’s reform agenda had not had significant impact on or relevance to PCTs in particular. Both they and GPs should be subject to rewards and sanctions in the same way as foundation hospitals.

Mr Moyes stepped down last month as head of the foundation trust regulator after six years of often tempestuous relations with the Department of Health. He remains critical of ministers for their reluctance to cede power over the trusts, in defiance of their own legislation.

There remains work to do for an incoming administration to produce a framework that will encourage more hospitals to apply for foundation status, Mr Moyes believes. But, at a time when health budgets will be squeezed despite promises of protection from both main parties, he argues that PCTs and GP practices must also become more efficient.

Growth of 0.1 per cent would meet the parties’ commitments not to cut NHS budgets, Mr Moyes points out. But, with previous increases running at 6 per cent a year, the likely settlement will be “a million miles away from levels of growth they have had in the past.”

“There have been ideas on how to gauge the performance of GPs,” Mr Moyes says. “An incoming government will need to challenge GPs and make sure there is strong accountability and give them incentives not to waste resource.”

One of the results of previous reforms has been to turn accident and emergency wards into GP surgeries at weekends,” Mr Moyes claims. There should be new incentives and sanctions to ensure that practices offer a more comprehensive service.

The Conservatives have promised reforms that devolve budgets to PCTs and encourage GPs to use their commissioning powers to negotiate less costly services. Mr Moyes has given general support to the plans, which would include the establishment of a commissioning board at the head of the NHS, requiring all NHS hospitals become foundation trusts eventually.

Only half of eligible hospitals have applied to become foundation trusts under Labour – a source of regret and irritation for Mr Moyes, who has accused those opting out of independence of tacitly admitting that their hospitals would not stand up to Monitor scrutiny.

In many cases, including some teaching hospitals, the refusal to embrace foundation status stems from a belief that they will be protected from the impact of unaffordable developments, Mr Moyes believes. “I can only speculate that for some of those hospitals it is a more comfortable position to know that if they get into trouble, they will be bailed out.”

Such protection is unlikely to continue, however, when the squeeze on NHS funding intensifies. “Hospitals that are not foundation trusts ought to start thinking carefully whether they are viable hospitals. They may need to cut costs, bring in more activity or look for other partners to merge with,” Mr Moyes says. In particular, he foresees “huge” rationalisation among London hospitals.

He would not expect a Tory government to force all hospitals to become independent immediately. “Most politicians would be very reluctant to wave a magic wand through legislation. It would require a much more focused effort,” he says.

But Mr Moyes is confident that the system of regulation that Monitor operates would survive a change of administration. “I am less bothered about regulation under the Tories because I think their policies are quite clear. They want economic regulation and quality regulation in some form.”

The system created by Labour has brought strains, however. “I think we’ve all got to recognise that the development of regulation with Monitor has meant and is meaning that lots of problems in hospitals and elsewhere are coming to light. I don’t think that ministers thought carefully about how to handle that situation,” Mr Moyes says. “They didn’t reckon on the fact that the development of Monitor and the Care Quality Commission would mean that quite a lot of bad news would come out. It’s not something that the public have been encouraged to expect. When you are finding faults – quite serious faults – how do you ensure that public confidence isn’t undermined?”

Mr Moyes says there is “unfinished business” in the way in which health service regulation operates. Having given Monitor power over foundation trusts, Parliament almost never called it to account. In six years as chief executive, he made one appearance before the Public Accounts Committee and three before the Health Select Committee.

Instead, the select committee seemed determined to quiz the Health Secretary, even though in his spell at the Department of Health, John Reid had written formally to make clear that the legislation gave him no responsibility for foundation hospitals, so he would not answer questions on them. “We clearly need a rethink of the way Parliament operates in this area,” Mr Moyes says.

He believes that such rethink might come from a Conservative government. “Andrew Lansley is very clear that he does not want the Secretary of State to be involved in the day-to-day operation of hospitals. The Conservative Opposition understand the system and know what they like about it and what might have to change.

“We have the legacy of years of different levels of state bodies simply not developing services in a way that will keep them viable. We should have had many more reorganisations.”

25 February 2010

John O'Leary. Editor, Policy Review Magazine