1. Introduction

On Monday July 12, Health Secretary Andrew Lansley MP announced the publication of the Coalition Government’s White Paper ‘Equity and Excellence: Liberating the NHS’. The White Paper ‘sets out the Government's long-term vision for the future of the NHS. The vision builds on the core values and principles of the NHS - a comprehensive service, available to all, free at the point of use, based on need, not ability to pay.

The White Paper states that the NHS will:

  • Put patients at the heart of everything the NHS does;
  • Focus on continuously improving those things that really matter to patients - the outcome of their healthcare; and
  • Empower and liberate clinicians to innovate, with the freedom to focus on improving healthcare services’
  1. Overview

The White Paper details the Government’s vision of devolving power from Whitehall to patients and professionals, billed as a ‘radical overhaul’ of the NHS.Two keyreforms involve

(a) GPs being given£80bn of NHS funding and put in charge of commissioning services for patients in their area through the creation of GP consortia across England (although
not detailed in the paper, it is estimated that 500-600 consortia will be created); and

(b) the creation of an independent NHS commissioning board which will oversee GP consortia commissioning. It will allocate and account for NHS resources..

Consortia will start taking on duties from 2012/13 and full financial responsibility from April 2013;GP boundaries will be abolished to allow patients to register with any doctor they want.Every GP will be a member of a 'shadow' consortium by 2011/12.

It is worth noting that not all services will be commissioned by GP consortia, with national and regional specialised services beingcommissioned by the independent NHS commissioning board.

The creation of GP consortia will have implication across the NHS. All hospitals will be forced to adopt the foundation model created by Labour in 2003, while their watchdog, Monitor, will be turned into an economic regulator tasked with promoting competition, price regulation. The role of the Care Quality Commission (CQC) will be strengthened. The new structure will be held accountable to an Independent NHS Board. There will be a greater emphasis on outcomes with the NHS also held accountable to ‘clinically credible and evidence-based’ outcome measures.

The government has declared that the reforms will bring about an "NHS information revolution", where patients would be given access to data about their hospitals and GP services in the hope that their choice of where to go for treatment would drive up standards of care.

3. Summary of key highlights

The key highlights of the document, entitled Equity and Excellence: Liberating the NHS, are listed below:

  • GP consortia will agree local priorities each year, taking account of a new NHS Outcomes Framework.
  • GPs will need to engage patients and the public in the commissioning process.
  • Patients will be able to choose which GP practice they register with regardless of where they live.
  • A new independent NHS Commissioning Board will calculate practice-level budgets and allocate these directly to consortia and will hold practices to account.
  • A new consumer champion, HealthWatch England, will be established to strengthen the voice of patients and the public, under the aegis of the Care Quality Commission, but led by local authorities.
  • CQC will continue to regulate the quality of service provision, whilst Monitor will regulate financial arrangements of all publically funded providers.
  • A National Public Health Service will be set up with jointly with local authorities with a ring-fenced budget and responsibilities covering areas such as obesity and alcohol
  • The current performance regime will be replaced with separate frameworks for public health and social care. The Public Health budget will be ring-fenced.
  • A new NHS Outcomes Framework will provide the direction for the NHS.
  • Patients will be enabled to choose which hospital and consultant-led team they want to be treated by.
  • All NHS trusts will be required to become self-governing foundation trusts with the "aim to create the largest social enterprise sector in the world".
  • The 150 primary care trusts and 10 strategic health authorities will be phased out
  • NHS management costs will be reduced by more than 45% over the next four years.
  • There will be a cut in the numbers of NHS quangos
  • Councils will be given the responsibility to support integration across health and social care.
  • Doctors will be obliged to keep data on their own performance and publish detailed evidence of hospital mortality rates.

4. Background briefing on key chapters.

Chapter 2: Putting patients and public first

The patient is to be put at the centre of the health service, under a Government motto of "no decision about me, without me".

Patients will have greater control over their medical records and will decide who gets to see them. An aim is to make it easier for patients to download their records to share with healthcare organisations of their choice. Doctors and patients will also be able to communicate via email for greater efficiency and convenience.

The Government will enable patients to rate hospitals and clinical departments according to the quality of care they receive. Hospitals will be required to be open about mistakes.

More comprehensive information about treatments, healthy lifestyles and diseases will be released by a wider range of organisations, with consideration given to a 'kite-mark' quality standard.

References in chapter

“An Information revolution” Reference

  • Extended national clinical audit and PROMS2.7
  • Patient access to records2.11

“Increased choice and control”

  • Areas for choice 2.20
  • Registration with any GP2.20

“Patient and Public voice”

  • Establishing local “Health Watch” organisations with CQC 2.24

Chapter 3: Improving healthcare outcomes

The NHS will be accountable to clinically credible and evidence-based outcome measures. Quality standards, developed by NICE, will inform the commissioning of all NHS care and payment systems. Providers will be paid according to their performance.

References in chapter

“NHS Outcomes framework”3.5-3.11

“Developing and implementing quality standards”

  • 150 NICE quality standards 3.12

“Promoting research” 3.16

Incentives for quality improvement

  • Moving to best practice not average price tariff3.17

Chapter 4: Autonomy, accountability and democratic legitimacy

£80bn of NHS funding will be handed to GPs to buy care for patients in their area, with primary care trusts and strategic health authorities to be abolished by 2013. It will mean management costs will be cut by almost half and GPs could subcontract out the work to private companies.

All NHS trusts will become or be part of a foundation trust. Foundation Trust hospitals will be allowed greater freedoms to treat more private patients to boost income and more patients with long-term conditions will be given their own health budgets to buy their care.

A new patient champion organisation called HealthWatch will be established as part of the regulator, the Care Quality Commission. The Care Quality Commission will also have its role strengthened.

The Public health budget will be ring fenced. The Department of Health will focus more on improving public health and less on the day-to-day running of the NHS.

A National Public Health Service will be set up with jointly with local authorities with a ring-fenced budget and responsibilities covering areas such as obesity, smoking and alcohol problems, as well as running vaccination and screening programmes. Regions with unhealthy inhabitants will be given extra cash to reduce inequalities.

References in chapter

“GP Commissioning consortia”4.2- 4.9

“An autonomous NHS Commissioning Board”4.10-4.13

  • Five functions including commissioning GP, dentistry4.11

and pharmacy

“Local democratic legitimacy”4.16-4.19

  • Abolition of PCTs4.16
  • Local authority role – Health and well being boards4.17

“Freeing existing NHS providers”

  • Creating the largest social enterprise sector in the world4.21
  • All trusts become FTs or part of FT4.23
  • Complete separation of existing PCT services by April 20114.24

“Training and education”4.32-34

  • No separate training funding. Will be in consortia/trust

allocation

  • “All providers of healthcare services will pay to meet the costs of education and training. Transparent funding flows for education and training will support the level playing field between providers
  • “Professions will have a leading role in deciding the structure and

content of training and quality standards”

  • “Education commissioning led locally and nationally healthcare

professions through MEE for doctors”

“NHS Pay”4.36

  • Explore appropriate arrangements for settling pay with unions and

employers

  • Expect providers to want to continue to use national contracts

“NHS Pensions”4.37

  • Hutton review of pensions

Chapter 5: Cutting bureaucracy and improving efficiency

The NHS will release £20 billion of efficiency savings by 2014, to be reinvested to support improvements in quality and outcomes. Management costs will be reduced by more that 45%. The number of NHS bodies and NHS functions will be reduced, with the abolition of quangos that ‘do not need to exist’.

References in chapter

“Cutting bureaucracy and administrative costs” Reference

  • 45% management cost reduction over four years 5.3
  • Cull data returns5.7
  • Cut bureaucracy in medical research 5.8
  • Review of all health and social care regulation with the view5.10

to making significant reduction

“Enhanced financial controls”

  • .No bail out of commissioners who fail5.14

“Making savings during the transition”

  • “ The Department will not hesitate to increased financial control 5.18

arrangements during the transition wherever that is necessary to

maintain financial balance ....central control will be necessary

precursor to subsequent devolution”

[NB: The summary chapter references in this Briefing Note are taken from a briefing produced by the Academy of Medical Royal Colleges]

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