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Editor’s blog Monday 12 July 2010: The 2010 NHS White Paper ‘Equity and excellence – liberating the NHS’

As an active and wealthy pre-conversion libertine, Saint Francis of Assisi prayed “Oh Lord, make me virtuous - but not yet”.

Saint Francis is the patron saint of the new NHS White Paper, Equity and excellence: liberating the NHS.

It is an unusual mixture of firm strategic signposts and some hard commitments with an almost complete absence of detail. The overall reaction is that this is a Whiter Shade Of Pale Green Paper.

This analysis will grow as the evening wears on. Mainly, I am sticking to reporting in this post - I will note confusions and contradictions separately. This is mainly a summary of key quotes from what it says.

Diary dates
Here are a few dates for your diary:

Tomorrow - five further consultation publications (we were right about that bit)
Summer 2010 (you think this is non-specific? hold your breath) - report of arms’ length bodies review
Autumn 2010 - Health Bill introduced in Parliament –
Late / end 2010 - five more consultations and separation of SHAs’ commissioning and provider oversight functions

From 2011 – introduction of choice for care for long-term conditions and diagnostic testing (and post-dagnosis)
2011 – White Paper on social care reform
By April 2011 – choice of consultant-led team
April 2011 - Shadow NHS Commissioning Board established as a special health authority; arrangements ti support shadow health and wellbeing partnerships (with local government) begin to be put in place; quality accounts expanded to all providers of NHS care; Cancer Drugs Fund established
From April 2011 - choice of treatment and provider in some mental health services; improved outcomes from NHS Outcomes Framework; expand validity, collection and use of PROMs; develop pathway tariffs for use by commissioners
June 2011 - nationally comparable quality accounts information published
By July 2011 – report on funding of long-term care and support
Summer 2011 - hospitals to be open about mistakes
2011 / 12 – GP consortia to be established in shadow form; tariff changes (adult mental health currencies developed; national currencies introduced for critical care; further incentives to reduce avoidable readmissions; best practice tariffs introduced for interbventional radiology, day case surgery for breast surgery, hernia repairs and some orthopaedic surgery)

By April 2012 – NHS Outcomes Framework fully implemented
April 2012 – Majority of reforms come into effect. NHS Commissioning Board fully established; new LA health and wellbeing boards in place; limits on SoS’s ability to micro-manage and intervene; public record of all meetings between the Board and SoS; Public Health Service in place, with ring-fenced budget and local health improvement led by directors of public health in local authoritiers; NICE put on a firmer statutory footing; HealthWatch established; Monitor established as economic regulator
From 2012-13 – International Classification of Disease 10 clinical diagnosis coding system introduced
Autumn 2012 – NHS Commissioning Board makes allocations for 2013/14 direct to GP consortia (calculated on a practice level)
2012 – free choice of GP practice; formal establishment of all GP consortia
2012-13 – SHAs are abolished

April 2013 – GPs hold contracts with providers
From April 2013 – PCTs are abolished
2013-14 – All NHS trusts become, or are part of, foundation trusts – all providers thus subject to Monitor regulation
By 2013-14 – choice of treatment and provider for patient in the vast majority of NHS-funded services; introduction of value-vased approach to the way that drug companies are paid for NHS medicines

By end 2014 – NHS management costs reduced by over 45%

By July 2015 – NICE expected to produce 150 quality standards

What are the things we did not know?
Monitor is going to be hugely, immensely powerful in the new system.
“We will develop Monitor, the current independent regulator of foundation trusts, into an economic regulator from April 2012, with responsibility for all providers of NHS care from April 2013. Providers will have a joint licence overseen by both Monitor and CQC, to maintain essential levels of safety and quality and ensure continuity of essential services.”

“Monitor should have proactive, “ex ante” powers to protect essential services and help open the NHS social market up to competition, as well as being able to take “ex post” enforcement action reactively. Ex ante powers would enable Monitor, for instance, to protect essential assets; require monopoly providers to grant access to their facilities to third parties; or conduct market studies and refer potential structural problems to the Competition Commission for investigation.

“Within the NHS social market, there is also scope for purchasers to act anti-competitively, for example by failing to tender services or discriminating in favour of incumbent providers. Monitor will be able to investigate complaints of anti-competitive purchasing and act as arbiter.

“Monitor’s powers to regulate prices and license providers will only cover publicly-funded health services. However, its powers to apply competition law will extend to both publicly and privately funded healthcare, and to social care.

The independent NHS commissioning board will also be very powerful
This will be “a lean and expert organisation, free from day-to-day political interference, with a commissioning model that draws from best international practice.

'The NHS Commissioning Board ... will not manage providers or be the NHS headquarters.'

"The NHS Commissioning Board will provide leadership for quality improvement through commissioning: through commissioning guidelines, it will help standardise what is known good practice, for example improving discharge from hospital, maximising the number of day care operations, reducing delays prior to operations, and enabling community access to care and treatments. It will play its full part in promoting equality in line with the Equality Act 2010. It will not manage providers or be the NHS headquarters.

“The Board will promote patient and carer involvement and choice, championing the interests of the patient rather than the interests of particular providers. It will involve patients as a matter of course in its business, for example in developing commissioning guidelines.

'To avoid double jeopardy and duplication, it will take over the current CQC responsibility of assessing NHS commissioners and will hold GP consortia to account for their performance and quality.'

"To avoid double jeopardy and duplication, it will take over the current CQC responsibility of assessing NHS commissioners and will hold GP consortia to account for their performance and quality. It will manage some national and regional commissioning. It will allocate and account for NHS resources.

"It will have a role in supporting the Secretary of State and the Public Health Service to ensure that the NHS in England is resilient and able to be mobilised during any emergency it faces, or as part of a national response to threats external to the NHS. It will promote involvement in research and the use of research evidence.

The role of the NHS Commissioning Board

1. Providing national leadership on commissioning for quality improvement:

2. Promoting and extending public and patient involvement and choice:

3. Ensuring the development of GP commissioning consortia:

4. Commissioning certain services that cannot solely be commissioned by consortia, in accordance with Secretary of State designation, including:

5. Allocating and accounting for NHS resources:

GP commissioning consortia will have an accountable officer apiece
There is no mandated number – the much-discussed 500-600 figure does not appear anywhere.

“Consortia … will commission the great majority of NHS services for their patients. They will not be directly responsible for commissioning services that GPs themselves provide, but they will become increasingly influential in driving up the quality of general practice.

"They will not commission the other family health services of dentistry, community pharmacy and primary ophthalmic services. These will be the responsibility of the NHS Commissioning Board, as will national and regional specialised services, although consortia will have influence and involvement.

”The NHS Commissioning Board will calculate practice-level budgets and allocate these directly to consortia. The consortia will hold contracts with providers and may choose to adopt a lead commissioner model, for example in relation to large teaching hospitals.

“GP consortia will include an accountable officer, and the NHS Commissioning Board will be responsible for holding consortia to account for stewardship of NHS resources and for the outcomes they achieve as commissioners. In turn, each consortium will hold its constituent practices to account against these objectives.”

“Every GP practice will be a member of a consortium, as a corollary of holding a registered list of patients. Practices will have flexibility within the new legislative framework to form consortia in ways that they think will secure the best healthcare and health outcomes for their patients and locality.

"We envisage that the NHS Commissioning Board will be under a duty to establish a comprehensive system of GP consortia, and we envisage a reserve power for the NHS Commissioning Board to be able to assign practices to consortia if necessary".

• “GP consortia will need to have a sufficient geographic focus to be able to take responsibility for agreeing and monitoring contracts for locality-based services (such as urgent care services), to have responsibility for commissioning services for people who are not registered with a GP practice, and to commission services jointly with local authorities. The consortia will also need to be of sufficient size to manage financial risk and allow for accurate allocations.
• “GP consortia will be responsible for managing the combined commissioning budgets of their member GP practices, and using these resources to improve healthcare and health outcomes. The Government will discuss with the BMA and the profession how primary medical care contracts can best reflect new complementary responsibilities for individual GP practices, including being a member of a consortium and supporting the consortium in ensuring efficient and effective use of NHS resources.
• “GP consortia will need to have sufficient freedoms to use resources in ways that achieve the best and most cost-efficient outcomes for patients. Monitor and the NHS Commissioning Board will ensure that commissioning decisions are fair and transparent, and will promote competition.
• “GP consortia will have the freedom to decide what commissioning activities they undertake for themselves and for what activities (such as demographic analysis, contract negotiation, performance monitoring and aspects of financial management) they may choose to buy in support from external organisations, including local authorities, private and voluntary sector bodies.
• “We envisage that consortia will receive a maximum management allowance to reflect the costs associated with commissioning, with a premium for achieving high quality outcomes and for financial performance.
• “GP consortia will have a duty to promote equalities and to work in partnership with local authorities, for instance in relation to health and adult social care, early years services, public health, safeguarding, and the wellbeing of local populations.
• “GP consortia will have a duty of public and patient involvement, and will need to engage patients and the public in their neighbourhoods in the commissioning process. Through its local infrastructure, HealthWatch will provide evidence about local communities and their needs and aspirations

PCTs are for the axe – but are vital to transition
“A number of PCTs have made important progress in developing commissioning experience which we will be looking to capitalise on during the transition period. Through the transitional arrangements, we will seek to ensure that existing expertise and capability in primary care trusts (PCTs) is maintained during the transition period where this is the wish of GP consortia.

“Primary care trusts will have an important task in the next two years in supporting practices to prepare for these new arrangements. We want implementation to be driven bottom-up, with GP consortia taking on their new responsibilities as rapidly as possible, and early adopters promoting best practice”.

SHAs likewise will be abolished, in a 'crucial-to-transition' kind of way
“SHAs will separate their commissioning and provider oversight functions. They will support the Board during its preparatory year, and have a critical role during the transition in managing finance and performance.

"It will be for the NHS Commissioning Board to decide what, if any, presence it needs in different parts of the country. SHAs will be abolished as statutory bodies during 2012/13. From 2012 the Board will perform those national functions relevant to its new role that are currently carried out by the Department of Health. It will be subject to clear controls over management costs and consultancy spend.”

The state is getting out of the training business
“Healthcare employers and their staff will agree plans and funding for workforce development and training; their decisions will determine education commissioning plans.

“Education commissioning will be led locally and nationally by the healthcare professions, through Medical Education England for doctors, dentists, healthcare scientists and pharmacists. Similar mechanisms will be put in place for nurses and midwives and the allied health professions. They will work with employers to ensure a multi-disciplinary approach that meets their local needs.

“The professions will have a leading role in deciding the structure and content of training, and quality standards.

“All providers of healthcare services will pay to meet the costs of education and training.”

Bye-bye, national pay bargaining; hello, reduced NHS pension
“Pay decisions should be led by healthcare employers rather than imposed by the Government. In future, all individual employers will have the right, as foundation trusts have now, to determine pay for their own staff.

"However, it is likely that many providers will want to continue to use national contracts as a basis for their local terms and conditions.  … In the longer term, we will work with NHS employers and trade unions to explore appropriate arrangements for setting pay. However, while ministers will retain responsibility for determining overall resources and affordability, we would expect employers to take the lead in providing advice on staffing and cost pressures. Employers would also be responsible for leading negotiations on new employment contracts “.

“We … remain committed to ensuring that pension solutions are found that are fair to the workforce in the health service and fair to the taxpayer”

Constraints for the Health Secretary of the future
“In future, the Secretary of State will be obliged to lay out a short formal mandate for the NHS Commissioning Board. This will be subject to public consultation and Parliamentary scrutiny, including by the Health Select Committee. The mandate is likely to be over a three year period, updated annually. The mandate will set out the totality of what the Government expects from the NHS Commissioning Board on behalf of the taxpayer for that period.

"This will comprise progress against outcomes specified by the Secretary of State, and objectives in relation to its core functions. Should the Government wish, by exception, to impose additional performance requirements on the Board in-year, it will on each occasion be obliged to lay a report in Parliament to explain why.

"The Secretary of State will also lose existing powers to intervene in relation to any specific commissioner other than in discharging defined statutory responsibilities. To ensure transparency, a public record will be made of all meetings between the Board and the Secretary of State.”

Local democracy won’t be in abolished PCTs (natch), but local government
“The Government will transfer PCT health improvement functions to local authorities and abolish PCTs. We expect that PCTs will cease to exist from 2013, in light of the successful establishment of GP consortia. Local Directors of Public Health will be jointly appointed by local authorities and the Public Health Service. Local Directors of Public Health will also have statutory duties in respect of the Public Health Service/

“The Government will strengthen the local democratic legitimacy of the NHS. Building on the power of the local authority to promote local wellbeing, we will establish new statutory arrangements within local authorities – which will be established as "health and wellbeing boards" or within existing strategic partnerships – to take on the function of joining up the commissioning of local NHS services, social care and health improvement.

"These health and wellbeing boards allow local authorities to take a strategic approach and promote integration across health and adult social care, children's services, including safeguarding, and the wider local authority agenda.

“We will simplify and extend the use of powers that enable joint working between the NHS and local authorities. It will be easier for commissioners and providers to adopt partnership arrangements, and adapt them to local circumstances.

“The local authority’s new functions will enable strategic coordination locally. It will not involve day-to-day interventions in NHS services.”

FTs’ private patient income cap is going (but if we say ‘social enterprise' often enough, you might not notice)
“Our ambition is to create the largest and most vibrant social enterprise sector in the world. … As all NHS trusts become foundation trusts, staff will have an opportunity to transform their organisations into employee-led social enterprises that they themselves control, freeing them to use their front-line experience to structure services around what works best for patients “.

“Foundation trusts will not be privatised”

“Within three years, we will support all NHS trusts to become foundation trusts. … in due course, we will repeal the NHS trust legislative model. A new unit in the Department of Health will drive progress and oversee SHAs’ responsibilities in relation to providers. In the event that a few NHS trusts and SHAs fail to agree credible plans, and where the NHS trust is unsustainable, the Secretary of State may as a matter of last resort apply the trust administration regime set out in the Health Act 2009. From April 2013, Monitor will take on the responsibility of regulating all providers of NHS care, irrespective of their status. Financial control will be maintained during the transition, with the Department, Monitor and SHAs taking any necessary steps.”

Money moves differently
“NHS services will continue to be funded by the taxpayer. The Department of Health will receive funding voted by Parliament, and will remain accountable to Parliament and HM Treasury for NHS spend.

“The NHS Commissioning Board will be accountable to the Department for living within an annual NHS revenue limit, and subject to clear financial rules. This arrangement will introduce greater financial transparency between the Government and the NHS. The NHS Commissioning Board will allocate resources to GP consortia on the basis of need.

’The Government will not bail out commissioners who fail‘

“GP consortia will have a high level of freedom; but in return they will be accountable to the NHS Commissioning Board for managing public funds. They will be subject to transparent controls and incentives for financial performance, and will enjoy a clear relationship with their constituent practices. Consortia will be required to take part in risk-pooling arrangements overseen by the NHS Commissioning Board; the Government will not bail out commissioners who fail. Regulations will specify a failure regime for commissioners.

“Commissioners will be free to buy services from any willing provider; and providers will compete to provide services. Providers who wish to provide NHS-funded services must be licensed by Monitor, who will assess financial viability.

“Providers of essential services may be required to take part in risk-pooling arrangements to ensure that, if a provider becomes financially unsustainable, Monitor will be able to step in and keep essential services running, without recourse to the Department of Health. The Government will not provide additional funding for failing providers. Monitor will be able to allow transparent subsidies where these are objectively justified, and agreed by commissioners.”

Top-slice city central: centrally-controlled austerity is the way to freedom
“The Department will require SHAs and PCTs to have an increased focus on maintaining financial control during the transition period, and they will also be supported in this task by Monitor. The Department will not hesitate to increase financial control arrangements during the transition, wherever that is necessary to maintain financial balance; in such instances, central control will be a necessary precursor to subsequent devolution to GP consortia.”

Here’s a bit of a hint about the fate of NHS Connecting For Health
“NHS services will increasingly be empowered to be the customers of a more plural system of IT and other suppliers“

Legislation will include …
Enabling the creation of a Public Health Service, with a lead role on public health evidence and analysis;
• Transferring local health improvement functions to local authorities, with ring-fenced funding and accountability to the Secretary of State for Health;
• Placing the Health and Social Care Information Centre, currently a Special Health Authority, on a firmer statutory footing, with powers over other organisations in relation to information collection;
• Enshrining improvement in healthcare outcomes as the central purpose of the NHS;
• Making the National Institute for Health and Clinical Excellence a non-departmental public body, to define its role and functions, reform its processes, secure its independence, and extend its remit to social care;
• Establishing the independent NHS Commissioning Board, accountable to the Secretary of State, paving the way for the abolition of SHAs. The NHS Commissioning Board will initially be established as a Special Health Authority; the Bill will convert it into an independent non-departmental public body;
• Placing clear limits on the role of the Secretary of State in relation to the NHS Commissioning Board, and local NHS organisations, thereby strengthening the NHS Constitution;
• Giving local authorities new functions to increase the local democratic legitimacy in relation to the local strategies for NHS commissioning, and support integration and partnership working across social care, the NHS and public health;
• Establishing a statutory framework for a comprehensive system of GP consortia, paving the way for the abolition of PCTs;
• Establishing HealthWatch as a statutory part of the Care Quality Commission to champion services users and carers across health and social care, and turning Local Involvement Networks into local HealthWatch;
• Reforming the foundation trust model, removing restrictions and enabling new governance arrangements, increasing transparency in their functions, repealing foundation trust deauthorisation and enabling the abolition of the NHS trust model;
• Strengthening the role of the Care Quality Commission as an effective quality inspectorate; and
• Developing Monitor into the economic regulator for health and social care, including provisions for special administration.
Associated with these changes, reducing the number of arm’s-length bodies in the health sector, and amending their roles and functions.