5 min read

Editor's blog Tuesday 14 June 2011: The next stage of NHS reform - the J-turn, bureaucrats and the CCP

Here are some things we have learned from the latest stage in the reform of NHS reform.


Click here for details of 'Strongman Cameron's J-turn on NHS reform: neo-classical clinical senates (or what did the Romans ever do for us?)', the new issue of subscription-based Health Policy Intelligence.


1. This is a J-turn
The U-turn in politics needs little explanation: it is a total volte face, sending you back the way you came.

What we have seen here is a J-turn. A J-turn means you travel down the long leg of the J, get flicked up a bit to the left, but basically end up (thanks to gravity) very, very close to where you were going anyway before the diversion.

Competition is being rebranded as choice. The competition and economic promotion / regulation won't be done by Monitor, because it will be done by the current NHS Co-operation and Competition Panel, which will now be put on a statutory basis. Choice is a key driver, and clinicians are firmly in charge of bureaucrats.

2. Metaphors are not rationed by the Deputy Prime Minister
Nick Clegg gave us the slightly terrifying image of the NHS as "a living, breathing thing". But he went to town on the Nigel Lawson 'NHS as British national religion' metaphor, using it something like five times.

If the NHS is a religion, then it needs the Enlightenment. What it's getting is the dissolution of the monasteries.

3. Managers are bureaucrats
After a relatively reassuring presentation from the NHS Future Forum yesterday describing "serious concern" about the morale of managers, it was interesting to see the vigorous relish with which PM David Cameron repeatedly called the people who will be essential to making reorganisation of the system and demand management work as "bureaucrats".

That Nice Mr Cameron didn't call management work "empty", though. That had been in his NHS reform speech last week.

A person can learn very little from listening, sometimes.

4. Back to Committee
Michael Crick of BBC Newsnight had been misinformed that the Bill would go into Report stage with no return to Committee. It would have been astonishing if the new changes now proposed to make the Co-operation and Competition Panel statutory had been able to be done in that way. Back to Committee it goes (as we predicted yesterday.)

If we're all very good, we might get the Chair of our dreams.

5. The Co-operation and Competition Panel takes over Monitor
It's not that explicit.

But the attacks on Monitor's leadership yesterday and previously, followed by the news that "We will maintain the existing competition rules for the NHS introduced by the last Government (the Principles and Rules for Co-operation and Competition), and give them a clearer statutory underpinning.

"The body that applies them, the Co-operation and Competition Panel will transfer to Monitor and retain its distinct identity.".

I bet it will retain its distinct identity. Not to mention gain the identity previously intended for Monitor.

6. Lines on maps
First World War generals are welcome to apply for jobs with the NHS Commissioning Board in Leeds: "Clinical commissioning groups will have a duty to promote integrated health and social care around the needs of users. We accept the recommendation of the Future Forum that their boundaries should not normally cross those of local authorities, with any departure needing to be clearly justified.

"Clinical commissioning groups seeking establishment on the basis of boundaries that would cross local authority boundaries, will be expected to demonstrate to the NHS Commissioning Board a clear rationale in terms of benefit to patients – for example, to reflect local patient flows, or to enable groups to take on practices where, overall, this would secure a better service for patients – and provide a clear account of how they would expect better integration between health and social care services to be achieved. The NHS Commissioning Board will need to agree proposed boundaries as part of the establishment process".

7. More central power for the NHS Commissioning Board
Go on, Comrade Sir David: have a bit more power! "Clinical networks and clinical senates will be hosted by the NHS Commissioning Board"

8. AQP - more slowly; for tariff services only
"We will maintain our commitment to extending patients’ choice of 'Any Qualified Provider', but we will do this in a much more phased way, and will delay starting until April 2012. Choice of Any Qualified Provider will be limited to services covered by national or local tariff pricing, to ensure competition is based on quality. We will focus on the services where patients say they want more choice, for example starting with selected community services, rather than seeking blanket coverage. There will be some services, such as A&E and critical care, where Any Qualified Provider will never be practicable or in patients’ interests.".

9. Changes to Monitor
"We will remove Monitor’s powers to “promote” competition as if it were an end in itself. Monitor will be limited to tackling specific abuses and unjustifiable restrictions that demonstrably act against patients’ interests, to ensure a level playing field between providers. Monitor will be required to support the delivery of integrated services for patients where this would improve quality of care for patients or improve efficiency.

· The NHS Commissioning Board, in consultation with Monitor, will set out guidance on how choice and competition should be applied to particular services, guided by the mandate set by Ministers. This includes guidance on how services should be bundled or integrated.

· We will narrow Monitor’s powers over anti-competitive purchasing behaviour so that these are more proportionate and focus on preventing abuses rather than promoting competition.

· We will remove Monitor’s powers to open up competition by requiring a provider to allow access to its facilities to another provider.

· We will maintain the existing competition rules for the NHS introduced by the last Government (the Principles and Rules for Co-operation and Competition), and give them a clearer statutory underpinning. The body that applies them, the Co-operation and Competition Panel will transfer to Monitor and retain its distinct identity.

· We will retain our proposals to give Monitor concurrent powers with the Office of Fair Trading, to ensure that competition rules can be applied by a sector-specific regulator with expertise in healthcare. The Future Forum recommended that this was the best safeguard against competition being applied disproportionately. The Bill does not change EU competition law.

Safeguards against privatisation
· Competition will be on the basis of quality not price. We will create additional safeguards against price competition and 'cherry picking'.

· So that providers cannot 'cherry pick' the profitable, 'easy' cases, services will be covered by a system of prices that accurately reflect clinical complexity, except where this is not practical. Commissioners will be required to follow 'best value' principles when tendering for non-tariff services, rather than simply choosing the lowest price.

· We will outlaw any policy to increase the market share of any particular sector of provider. This will prevent current or future Ministers, the NHS Commissioning Board or Monitor from having a deliberate policy of encouraging the growth of the private sector over existing state providers – or vice versa. What matters is the quality of care, not the ownership model.

· We will require foundation trusts to produce separate accounts for NHS and private-funded services".

10. FT boards meeting in public; duty of candour on mistakes
"We will amend the Bill to require foundation trusts to hold their board meetings in public. We will introduce a 'duty of candour': a new contractual requirement on providers to be open and transparent in admitting mistakes".