Equity and excellence: liberating the NHS. Coalition government s health white paper - published 12 July 2010

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1 Equity and excellence: liberating the NHS Coalition government s health white paper - published 12 July 2010 VSS policy briefing: July 2010

2 CONTENTS INTRODUCTION... 3 THE GOVERNMENT S VISION FOR THE NHS - LIBERATING THE NHS (CHAPTER 1)... 4 PUTTING PATIENTS AND PUBLIC FIRST (CHAPTER 2)... 5 IMPROVING HEALTHCARE OUTCOMES (CHAPTER 3)... 8 AUTONOMY, ACCOUNTABILITY AND DEMOCRATIC LEGITIMACY (CHAPTER 4) CUTTING BUREAUCRACY AND IMPROVING EFFICIENCY (CHAPTER 5) PUBLIC HEALTH AND SOCIAL CARE IMPLEMENTATION OF PROPOSALS (CHAPTER 6)... 16

3 INTRODUCTION This briefing summarises the coalition government s Health White Paper, which sets out an overview of government s plans for reforming the NHS. Key measures in the White Paper include: enshrining the core purpose of the NHS in law as: improvement in healthcare outcomes transferring local responsibility for commissioning NHS services from Primary Care Trusts (PCTs) to consortia of General Practitioners (GPs) establishing the NHS Commissioning Board to allocate NHS funding, hold GP consortia to account and promote patient and carer involvement and choice establishing a framework for local partnership working on the NHS, public health and social care, led by local authorities ( local health and well-being boards ) establishing HealthWatch England, an independent consumer champion sitting within the Care Quality Commission (CQC). Local HealthWatch will replace Local Involvement Networks (LINks). measures aimed at providing greater freedoms to NHS foundation trusts and providers The paper also provides some information on the government s plans for public health and adult social care, on which there will future publications (see section 6 of this briefing). In the White Paper, the Department of Health commits to working with the Department for Education to ensure that these reforms to the NHS and public health support joint working between local health, education and social services to meet the needs of children and families (para 1.17). Further papers providing additional detail on the NHS proposals will be published for consultation from this month onwards. However, the government is also seeking comments on this paper, in particular on planned changes to primary legislation (para 6.8).

4 THE GOVERNMENT S VISION FOR THE NHS - LIBERATING THE NHS (CHAPTER 1) The white paper asserts government s commitment to an NHS that continues to be available for all and free at the point of use, and to upholding the existing NHS Constitution for England 1. However, it sets out a new vision for the NHS, with the aim of achieving excellence as well as equity and liberating the service. The government s vision is of an NHS which: is centred on patients and carers achieves world class levels of quality and outcomes does not tolerate unsafe and substandard care is led by clinicians, gives hospitals and providers the freedom to innovate and includes incentives for adopting best practice is transparent with clear systems of accountability gives citizens a say in how the service is run works across boundaries, including with local authorities and between hospitals and GPs is more efficient and dynamic, with smaller bureaucracy at national, regional and local levels is on a sustainable and stable footing, not subject to political intervention. (para 1.10) The paper goes on to explain how government will seek to realise this vision. 1 Department of Health (2009) NHS Constitution for England dance/dh_093419

5 PUTTING PATIENTS AND PUBLIC FIRST (CHAPTER 2) 1.1 Shared decision-making becoming the norm The government believes that shared decision-making between clinicians and patients will lead to improved health outcomes, higher levels of patient satisfaction, greater adherence to treatment, cost reductions and improved management of long-term conditions. The new NHS Commissioning Board (see section 4.2 below) will be tasked with championing patient and carer involvement (paras ). 1.2 An NHS information revolution The department will publish an information strategy in the autumn 2010, seeking views on how to implement reforms in this area. Proposals will include: providing the public with more, good quality information to enable them to make choices about their healthcare and hold services to account. giving the public access to information on: conditions, treatments, lifestyle choices and looking after their and their families health. publishing nationally comparable data on the safety and effectiveness of services and on patient experience, as well as assessments of commissioners performance making staff feedback about the quality of patient care publicly available. requiring hospitals to be open with patients about mistakes made. expanding the validity, collection and use of patient experience and feedback data (including the use of real-time feedback). providing access to data via the NHS Choices website, while also encouraging third parties to provide information to support patient choice. providing assistance to those who do not access the Internet or who require additional support. enabling patients to be able to communicate with their clinicians online. giving patients control over their health records, starting with those held by their GP.

6 revising quality accounts 2 and extending it to all providers of NHS care in 2011 (subject to evaluation). putting the Health and Social Care Information Centre and its functions on a firmer statutory footing through the forthcoming Health Bill, giving it lead responsibility for data collection and quality assurance, working with the CQC and Monitor. making providers subject to contractual obligations around data accuracy and timeliness, based on standards developed by the NHS Commissioning Board. a review of data collection in order to reduce any burden. (paras ) 1.3 Increased patient choice and control The paper states that, by no later than , having a choice of treatment and provider will be a reality for patients in the vast majority of NHS-funded services. Later this year, government will consult on how to give patients choice over treatment, and the NHS Commissioning Board will be responsible for developing and implementing patient choice guarantees. However, the white paper gives an indication of the government s intentions: The current choice of any provider offer will be extended, and, where appropriate, there will be a presumption that this means the choice of any willing provider (i.e. any provider willing to provide that service) By 2011, patients will have a choice of named consultant-led team (for elective care where clinically appropriate) Patients will be given more information on relevant research studies and more opportunities to take part Patients will have right to choose to register with any GP, rather than being restricted by catchment area 2 Quality Accounts are annual reports to the public from organisations which provide NHS services on the quality of the services they deliver.

7 Government will develop a 24/7 urgent care service with a single telephone number in every area of England Choice in maternity care will be extended From 2011, government will begin to introduce: choice of treatment and provider in some mental health services; choice for diagnostic testing and post-diagnosis; and choice in care for long-term conditions A national choice offer around end-of-life care will be introduced In 2012, government will use the results of the evaluation of personal health budgets to inform wider roll-out (paras ) 1.4 Patient and public voice The white paper sets out government s plans to establish HealthWatch England and local HealthWatch as a means to better promote patient and public voice. HealthWatch England will: be established through the Health Bill be an independent consumer champion sitting within the CQC provide leadership, advice and support to local HealthWatch bodies; advise the Health and Social Care Information Centre on what information patients needs to help them make choices about their care; advise the NHS Commissioning Board, Monitor and the Secretary of State have powers to flag up poor services to the CQC for investigation in some cases, be commissioned directly by local authorities to provide patient advocacy services (as an alternative to local HealthWatch). Local HealthWatch will: replace Local Involvement Networks (LINks) ensure that patient and public feedback is central to local commissioning; be commissioned by the local authority to provide advocacy and support to patients to help them make choices and complaints; take part in local authorities new partnership functions

8 (see section 4.4 below); provide information to Health Watch England, including reporting concerns about providers like HealthWatch England, be able to recommend poor services to CQC for investigation be accountable to local authorities. IMPROVING HEALTHCARE OUTCOMES (CHAPTER 3) The primary purpose of all NHS-funded care will be to improve quality and healthcare outcomes. This will be enshrined in law, the NHS Constitution and model contracts for providers. This chapter sets out the government s plans for performance management and quality improvement. 1.5 Performance management the NHS Outcomes Framework and quality standards The Secretary of State will establish a new performance management regime, with three separate frameworks setting out national objectives for the NHS, for public health and for social care The NHS Outcomes Framework will include a set of national outcome goals, against which the NHS Commissioning Board will be held to account. It will cover three domains of quality: effectiveness (measured by clinical outcomes and patient experience); safety; and broader patient experience The framework will be translated into a commissioning outcomes framework for the GP consortia responsible for commissioning NHS services locally (see section 4.1 below) The NHS Commissioning Board will be responsible for developing a set of indicators by which to measure progress in relation to the national framework. These indicators will reflect National Institute for Health and Clinical Excellence (NICE) quality standards. By July 2015, NICE will produce 150 quality standards on the main pathways of care, including 5-10 quality statement and associated measures 3 3 The first three of which were published in June.

9 The Health Bill will include measures to: make NICE a nondepartmental public body, clarify its functions in law, and extend its remit to cover social care Locally, GP commissioning consortia and providers will agree local priorities for each year, taking into account the NHS Outcomes Framework, and commissioners will draw on the NICE quality standards when agreeing contracts and financial incentives. Government expects that this will provide national consistency. The first framework will be subject to consultation and made available later this year. NHS organisations will be able to use the framework from April 2011, but it will be fully implemented from April (paras ) 1.6 Payment systems providing incentives for quality improvement In the future, the NHS Commissioning Board will be responsible for the structure of payment systems, and Monitor, the economic regulator, will be responsible for pricing. Until then, the government will begin to design and put into place a system whereby payment follows the patient and reflects performance. This will include: developing currencies 4 for child and adolescent services [Note: it is unclear in the paper whether this is referring to all child and adolescent services or only those relating to mental health) developing payment systems to support the commissioning of talking therapies in 2011/12, mandating currencies for neonatal critical care reviewing payment systems for end-of-life care speeding up the development of currencies and tariffs 5 for community services in , introducing further incentives to encourage more joined up working between hospitals and social care post-discharge linking quality measures in national clinical audits to payments 4 Defined units of healthcare (e.g. outpatient appointment) 5 The prices of defined units of healthcare)

10 speeding up the development of best-practice tariffs, taking into account the costs of excellent (rather than average) care enabling commissioners to pay a quality increment for excellent care, and to impose a contractual penalty for poor care. (paras ) AUTONOMY, ACCOUNTABILITY AND DEMOCRATIC LEGITIMACY (CHAPTER 4) This chapter sets out government s intention to: transfer responsibility for commissioning NHS services from PCTs to consortia of GPs; establish an autonomous NHS Commissioning Board to oversee local commissioning; create a new relationship between the NHS and government; reform local governance around health and well-being; give greater freedom to NHS providers; and improve economic regulation and inspection. 1.7 GP commissioning consortia The government plans to publish further details of its proposals for GP commissioning soon. However, the white paper provides an overview of its plans. In the forthcoming Health Bill, government will legislate to establish GP commissioning consortia, which will have responsibility for commissioning local NHS services. They will take on the commissioning functions of PCTs As well as carrying out commissioning activities themselves, they will be able to buy in the support of others including local authorities and private and voluntary sector organisations. The consortia will be under duties to: work in partnership with local authorities; promote equalities; and involve the public and patients. Every GP practice will have to be a member of a consortium, however there will be flexibility as to how consortia are formed The GP consortia will not be directly responsible for commissioning services provided by GPs themselves; nor will they commission services that are the responsibility of the NHS Commissioning Board (see section 4.2 below)

11 The NHS Commissioning Board is likely to be under a legal duty to establish a system of GP consortia and to assign practices to consortia where necessary. The NHS Commissioning Board will calculate and allocate practicelevel commissioning budgets, and the consortia will be responsible for managing the combined commissioning budgets of their member practices. The NHS Commissioning Board will hold consortia to account, and in turn the consortia will hold each of its practices to account. Government s plans for the geographical coverage of consortia remains unclear, however they will need to be able to: commission locality-based services, provide for unregistered patients in a given area, and commission in partnership with local authorities. The consortia will receive evidence about their local communities health needs through the HealthWatch arrangements. The consortia will be introduced in shadow form during , will officially take on commissioning responsibilities in and will take on full financial responsibility from April (paras ) 1.8 The NHS Commissioning Board The government will establish in statute an NHS Commissioning Board, which will have five key functions: 1. Providing national leadership on NHS commissioning: setting commissioning guidelines; designing model contracts; setting NHS commissioning and procurement quality standards; designing a payments structure and other financial incentives (prices will be set by Monitor see section 4.6); hosting some clinical commissioning networks; publishing commissioner performance information; and tackling inequalities in health outcomes 2. Promoting patient and carer involvement and choice: including patient involvement in decision-making and managing their own care, personalisation, choice and personal health budgets 3. Ensuring the development of GP commissioning consortia: putting in place the system of consortia and then holding them to account for health outcomes and financial performance

12 4. Commissioning certain services: as directed by the Secretary of State, to include dentistry, community pharmacy and primary ophthalmic services, national and regional specialised services and maternity services 5. Allocating and accounting for NHS resources: allocations to GP consortia; managing overall NHS commissioner revenue limit; and promoting productivity through better commissioning. The Board will be established in shadow form in April 2011, will be converted into a statutory body in the Health Bill and will be fully established in April Strategic Health Authorities (SHAs) will be abolished as statutory bodies during , but they will support the Board during its shadow year. (para ) 1.9 The relationship between the NHS and government The forthcoming Health Bill will include provisions limiting central government intervention in the NHS. The role of the Secretary of State in relation to the NHS will be to: set a formal three-year mandate for the NHS Commissioning Board and holding it to account. The mandate will be subject to public consultation and Parliamentary scrutiny, and will be updated annually act as arbiter of last resort where disputes arise between NHS commissioners and local authorities establish the legislative and policy framework report annually to Parliament on overall performance of the NHS, as well as on public health and social care systems. (paras ) 1.10 Local governance and partnerships The government will establish new statutory arrangements to ensure that the commissioning of local NHS services, health improvement and social care is joined up. This will be through health and well-being boards or existing partnership structures. The new arrangements will be in place by April 2012 (introduced in shadow form from April 2011)

13 Local authorities will take on Health and Overview Scrutiny Committees responsibilities in relation to: promoting integration and partnership working between the NHS, social care, public health and other local services; leading joint strategic needs assessments; and building partnership for service change and priorities. NHS commissioners and directors of public health (see section 6 below), children s services and adult social services will also be under partnership working duties. (paras ) 1.11 Giving NHS providers greater freedom The government s plans for freeing up NHS providers reflects its ambition to create the largest and most vibrant social enterprise sector in the world (p.36). Within three years, all NHS trusts will become a NHS foundation trust (or a member of such a trust). They will be given greater freedoms, but will not be privatised. Before bringing forward any legislative changes, government will consult on options, which are likely to include: allowing foundation trust staff to turn their organisation into an employee-led social enterprise ensuring foundation trusts are regulated in the same way as private and voluntary sector providers enabling trusts to merge easily abolishing the cap on income from other sources allowing foundation trusts to alter their governance structures according to local need A new Department of Health unit will take this work forward, while also taking on Strategic Health Authorities provider oversight duties. The government will seek, as soon as possible, to move to a system of any willing provider with the aim of lifting barriers to entering the market for new providers. (paras ) 1.12 Economic regulation and inspection The CQC will be responsible for: licensing NHS providers (jointly with Monitor); and carrying out a targeted and risk-based programme of provider inspection, responding to information from HealthWatch, GP consortia, the NHS Commissioning Board and patient feedback. From April

14 2012, Monitor will be the economic regulator for the health and social care sectors: promoting competition (in both public and private healthcare and in social care) regulating prices (publicly-funded healthcare only) supporting the NHS Commissioning Board in ensuring continuity of services, including through licensing (publicly-funded healthcare only) Government will consult on its proposals for economic regulation before making legislative change. (paras ) CUTTING BUREAUCRACY AND IMPROVING EFFICIENCY (CHAPTER 5) The paper confirms government s commitment to increase NHS spending in real terms in each year of this Parliament, but efficiency savings will have to be made. The government believes that plans set out in this white paper will contribute significantly to making savings within the NHS, achieving greater productivity and enhanced financial control. Additional measures mentioned in this chapter include: A review of all health and social care regulations, with a view to making significant reductions. A review of the Department of Health s arm s-length bodies with abolition and streamlining where necessary (to be published shortly). A review of data provided by NHS organisations, later this year, with consultation on proposals before implementation A reduction in medical research bureaucracy No additional funding from government for failing providers, however Monitor will be able to step in to keep services running where required. Continuation of the Quality, Innovation, Productivity and Prevention (QIPP) initiative (looking at efficiencies and service redesign) with a stronger focus on general practice leadership.

15 (paras ) PUBLIC HEALTH AND SOCIAL CARE The reforms to the NHS in the white paper will result in changes to the functions of the Department of Health, reducing its role in overseeing the service. In the future, the department will focus more on: improving public health, tackling health inequalities and reforming adult social care. Government will set out details of its reforms to public health later this year, however the white paper provides some indication of its intentions: creation of a new Public Health Service (through the forthcoming Health Bill), integrating and streamlining existing health improvement and protection bodies and functions responsibility for local health improvement to transfer from PCTs to local authorities, overseen by a local Director of Public Health (jointly appointed with the Public Health Service). PCTs will therefore be abolished by Department of Health to create a ring-fenced public health budget, allocated according to need and including a new health premium to reduce health inequalities. PCTs remaining functions around health improvement (public health) will be transferred to local authorities. These reforms would come into force in April (paras and 4.16) The department will also: develop a vision for adult social care (including reforming and consolidating the legal framework underpinning adult social care); establish a commission on the funding of long-term care and support (to report within a year); and publish a white paper on these issues in (paras )

16 IMPLEMENTATION OF PROPOSALS (CHAPTER 6) This chapter emphasises government s intention to consult widely on these proposals, and, from this month, it will publish detailed consultations on: Implementation of the NHS Commissioning Board and GP consortia Achieving local democratic legitimacy in health (local governance and partnership) Freeing providers and economic regulation The NHS Outcomes Framework An NHS information strategy Moving to provider-led education and training (paras ) This chapter also provides a single list of measures requiring legislation, along with a timetable for implementation (paras 6.7 and 6.11). Zoë Renton Senior Policy Officer, NCB July 2010

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