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Policy responses and statements
- Name of organisation:
- Department of Health
- Name of policy document:
- White Paper - Equity and Excellence: Liberating
the NHS
- Deadline for response:
- 5 October 2010
Background: Our strategy for the NHS: an executive summary
- The Government upholds the values and principles of the NHS:
of a comprehensive service, available to all, free at the point of
use and based on clinical need, not the ability to pay.
- We will increase health spending in real terms in each year of
this Parliament.
- Our goal is an NHS which achieves results that are amongst the
best in the world.
Putting patients and public first
- We will put patients at the heart of the NHS, through an information
revolution and greater choice and control:
- Shared decision-making
will become the norm: no decision about me without me.
- Patients will have access to the information they want,
to make choices about their care. They will have increased control
over their own care records.
- Patients will have choice of any provider, choice of consultant-led
team, choice of GP practice and choice of treatment. We will
extend choice in maternity through new maternity networks.
- The Government will enable patients to rate hospitals and
clinical departments according to the quality of care they receive,
and we will require hospitals to be open about mistakes and always
tell patients if something has gone wrong.
- The system will focus on personalised care that reflects
individuals’ health
and care needs, supports carers and encourages strong joint arrangements
and local partnerships.
- We will strengthen the collective voice of patients and
the public through arrangements led by local authorities, and
at national level, through a powerful new consumer champion,
HealthWatch England, located in the Care Quality Commission.
- We will seek to ensure that everyone, whatever their need
or background, benefits from these arrangements.
Improving healthcare outcomes
- To achieve our ambition for world-class healthcare outcomes,
the service must be focused on outcomes and the quality standards
that deliver them. The Government’s objectives are to reduce
mortality and morbidity, increase safety, and improve patient experience
and outcomes for all:
- The NHS will be held to account against clinically credible
and evidence-based outcome measures, not process targets. We
will remove targets with no clinical justification.
- A culture of open information, active responsibility and
challenge will ensure that patient safety is put above all else,
and that failings such as those in Mid-Staffordshire cannot go
undetected.
- Quality standards, developed by NICE, will inform the commissioning
of all NHS care and payment systems. Inspection will be against
essential quality standards.
- We will pay drug companies according to the value of new
medicines, to promote innovation, ensure better access for patients
to effective drugs and improve value for money. As an interim
measure, we are creating a new Cancer Drug Fund, which will operate
from April 2011; this fund will support patients to get the drugs
their doctors recommend.
- Money will follow the patient through transparent, comprehensive
and stable payment systems across the NHS to promote high quality
care, drive efficiency, and support patient choice.
- Providers will be paid according to their performance.
Payment should reflect outcomes, not just activity, and provide
an incentive for better quality.
Autonomy, accountability and democratic legitimacy
- The Government’s reforms will empower professionals
and providers, giving them more autonomy and, in return, making
them more accountable for the results they achieve, accountable
to patients through choice and accountable to the public at local
level:
- The forthcoming Health Bill will give the NHS greater
freedoms and help prevent political micromanagement.
- The Government will devolve power and responsibility
for commissioning services to the healthcare professionals
closest to patients: GPs and their practice teams working in
consortia.
- To strengthen democratic legitimacy at local level, local
authorities will promote the joining up of local NHS services,
social care and health improvement.
- We will establish an independent and accountable NHS
Commissioning Board. The Board will lead on the achievement
of health outcomes, allocate and account for NHS resources,
lead on quality improvement and promoting patient involvement
and choice. The Board will have an explicit duty to promote
equality and tackle inequalities in access to healthcare. We
will limit the powers of Ministers over day-to-day NHS decisions.
- We aim to create the largest social enterprise sector
in the world by increasing the freedoms of foundation trusts
and giving NHS staff the opportunity to have a greater say
in the future of their organisations, including as employee-led
social enterprises. All NHS trusts will become or be part of
a foundation trust.
- Monitor will become an economic regulator, to promote
effective and efficient providers of health and care, to promote
competition, regulate prices and safeguard the continuity of
services.
- We will strengthen the role of the Care Quality Commission
as an effective quality inspectorate across both health and
social care.
- We will ring-fence the public health budget, allocated
to reflect relative population health outcomes, with a new
health premium to promote action to reduce health inequalities.
Cutting bureaucracy and improving efficiency
- The NHS will need to achieve unprecedented efficiency gains,
with savings reinvested in front-line services, to meet the current
financial challenge and the future costs of demographic and technological
change:
- The NHS will release up to £20 billion of efficiency
savings by 2014, which will be reinvested to support improvements
in quality and outcomes.
- The Government will reduce NHS management costs by more
than 45% over the next four years, freeing up further resources
for front-line care.
- We will radically delayer and simplify the number of NHS
bodies, and radically reduce the Department of Health’s own NHS
functions. We will abolish quangos that do not need to exist
and streamline the functions of those that do.
Conclusion: making it happen
- We will maintain constancy of purpose. This White Paper1 is the
long-term plan for the NHS in this Parliamentary term and beyond.
We will give the NS a coherent, stable, enduring framework for quality
and service improvement. The debate on health should no longer be
about structures and processes, but about priorities and progress
in health improvement for all.
- This is a challenging and far-reaching set of reforms, which
will drive cultural changes in the NHS. We are setting out plans
for managing change, including the transitional roles of strategic
health authorities and primary care trusts. Implementation will happen
bottom-up.
Many of the commitments made in this White Paper require primary legislation
and are subject to Parliamentary approval.
COMMENTS ON
DEPARTMENT OF HEALTH
WHITE PAPER - EQUITY AND EXCELLENCE: LIBERATING THE NHS
Background
- The Royal College of Physicians of Edinburgh is pleased to comment
on the White Paper and will also contribute to the related consultations
on:
- Transparency in outcomes – a framework for the
NHS
- Commissioning for patients
General Comments
-
The College understands and accepts the need for radical change
given the demands on the NHS at a time of financial hardship and
is committed to working with government and other stakeholders
to deliver effective change for the benefit of patients and staff. The
vision and many of the high level policy objectives are very welcome
with a return to clinical focus and local operational control, clear
patient input and “joined up” healthcare. The
emphasis on clinical outcomes is also very welcome.
-
However there are real worries about implementation, the pace
and scale of change, the limitation of current information systems
and the lack of piloting. The College is also particularly
concerned about the effectiveness of commissioning across England
if accountable to a single national Commissioning Board, the reality
of expected budgets savings, how the transition will be managed
at a time of financial hardship and the protection of post graduate
medical training.
-
Comments are offered under the following headings:
- Commissioning
- The opportunity to deliver efficiency savings
- Quality and Outcomes
- Other points
Commissioning
-
The governance arrangements for the new GP commissioning consortia
are unclear. Will these new organisations be established by
statute with participating GPs appointed to “boards” that
will be held to account for their publicly funded commissioning budget
independently of their contractual relationship with the NHS Commissioning
Board for primary care services? Will the government ensure
that any surpluses are ring fenced for NHS services?
-
The College believes that consultants are excluded from the commissioning
model with this role given to GP consortia and where specialist
expertise may be limited. This risks the development of inappropriate
contracts for secondary care services and could create barriers
between clinicians working in primary and secondary care.
-
The White Paper acknowledges that GP consortia will require external
expertise to undertake their new commissioning responsibilities
and this includes the option of buying in support from the private
sector. Thus
in time private commissioning organisations based in GP consortia
could be influencing the commissioning of publicly funded secondary
care services. Will appropriate safeguards be in place to
protect the quality of patient care?
-
The College also fears that the proposed model of GP commissioning
creates a conflict of interest whereby GPs may elect to move services
from secondary to primary care. This is particularly evident
for long term conditions where the future locus of patient care is
far from certain and not necessarily based on quality parameters. It
is imperative that such decisions are taken objectively and with
the benefit of patient experience and specialist knowledge.
-
The position regarding the design and commissioning of emergency
and out of hours care is very unclear within a locality and it is
imperative that consultants are engaged in this process, given the
potential for emergency care to impact on elective services.
-
The viability of highly specialised and/or low volume services
is uncertain if competition remains a key plank of policy and Foundation
Trusts seek to avoid high risk areas, e.g. paediatric cardiac surgery.
-
There
is a risk of fractured services and inefficiencies through multiple
small scale commissioning consortia, reversing the recent trend
for the smaller PCTs to merge to create effective commissioning
units. Efficient commissioning will be complicated further
by different funding streams from NHS Commissioning Board and the
new “health premium” that will be within the control
of the Public Health Service embedded within local authorities.
-
It
is unclear how local authorities will develop to provide essential
public health expertise, including the management of health screening
and outbreaks of infectious diseases and how national co-ordination
will be delivered. This is of particular importance given the
announcements to abolish the Health Protection Agency and the National
Patient Safety Agency and the uncertainty over how their functions
will be retained in alternative structures. The College awaits
the detail on the proposed new Public Health Service. The
proposals for creating “health and well-being boards” are
unclear in terms of their authority over the commissioning choices
of GP consortia.
-
The College notes the intention to use competition to
drive up quality and cost effectiveness but there are no clear
plans to protect local services for patients if/when Foundation
Trusts or commissioning consortia fail. Financial penalties
for poor quality may stimulate improvements in patient care but
will local populations accept the closure of local services?
-
The College notes
the intention to protect health inequalities and preserve equity
of access. However local commissioning
of services must risk “postcode services” – will
the NHS remain “national” in terms of access
to services for patients?
The Opportunity to Deliver Efficiency Savings
-
The expected savings resulting from the abolition of the SHA and
PCTs will be required to support the increased management costs
of an unknown number of smaller GP commissioning consortia. In
addition there will be (unspecified) set up costs to establish the
new structures during the transition period. This questions
whether the reduction of up to 45% of management and administrative
costs is realistic. The College is also concerned that some
tasks currently provided by support staff may fall on clinical teams
with consequent loss of direct clinical care time. The actual
level of savings is unknown and something of a leap of faith.
-
The
concept of collective risk within a managed population-based healthcare
system protects services that are highly specialised and expensive
and ensures equity of access for patients. A strategic
view of how such services will be delivered is essential, at a regional
if not national level, and it is unclear how this will be delivered
with the abolition of SHAs. This role appears to be given
to the new and inexperienced “health and well being boards” within
local authorities and their staffing needs are unclear.
-
The expansion
of the concept of complete freedom of choice for patients is worrying
in a cash limited system and the evidence base supporting this
policy imperative is far from clear. Anecdotally
patients want access to high quality services delivered locally rather
than complete freedom of movement. Indeed the College believes
that the laudable aim of patient focus and choice may drive up
costs rather than generate savings; plurality of provision may
be wasteful at a time when the NHS seeks efficiency savings.
Quality and Outcomes
-
Payment by outcome rather than input is largely welcome but there
are significant concerns about how outcomes will be measured that
reflect fairly on the quality of care delivered and the impact
of patient preferences (e.g. where patients reject clinical advice). Clinical
information systems are being asked to provide individual clinical
data for revalidation and team based/service data for contract purposes – it
is unclear that both are sustainable.
-
NICE quality standards are welcomed in principle but the first
3 such examples have been related to process rather than outcome
and require significant data capture effort given the limitations
of current information systems. The proposed replacement
for the 4 hour wait in A and E target illustrates the increase
in data monitoring and the administrative challenge in capturing
the required information should not be underestimated, particularly
if administrative teams are culled.
-
The development of NICE quality standards as the “must do” targets
sits uneasily against the intention to remove “top down” regulation
and allow local freedom to choose. The College is concerned
about the coverage of all disease/injury groups within the proposed
150 sets of standards for NICE and whether the rare or “Cinderella” specialities
may miss out.
-
Removal of process targets is welcome with the caveat
that this should be selective, retaining those that drive up the
quality of patient care, e.g. the 4 hour target in A & E where
the 100% compliance requirement rather than the target itself causes
the distortion of clinical priority.
-
The College supports strongly
the expansion of audit, including Patient Reported Outcome Measures
(PROMS) but is concerned that the investment required in terms of
staff and information systems may have been underestimated (see para.
19 above).
Other points
-
The White Paper gives providers greater autonomy in workforce
planning and training matters, albeit that the input of the professions
is acknowledged and a role retained for Medical Education England
(MEE). It
is uncertain where the postgraduate Deaneries, recently moved into
the SHAs, will now be placed. GP consortia will have some responsibility
for the oversight of provider-based training, but their relationship
with Deaneries and MEE is unclear. Post graduate medical
training has undergone significant change in the past 3 years and
the College calls for stability and reassurance that providers
will retain their training responsibilities, given the importance
of medical training to quality and patient safety.
-
Patient expectations may be raised
unrealistically by the high level policy statements within the
White Paper, e.g. the creation of a new Cancer drug budget. As
the population ages this will become more challenging and the White
Paper is largely silent on how this new approach can be made to
work for the increasingly frail and those with cognitive impairment.
-
The pace
of change is extremely worrying with the proposed dismantling of
existing structures within 2 years and with no evidence that effective
commissioning via GP consortia can be established in time to take
over these roles. How will quality be monitored for patient
safety and effectiveness during this transition period?
Copies of this response are available from:
Lesley Lockhart,
Royal College of Physicians of Edinburgh,
9 Queen Street,
Edinburgh,
EH2 1JQ.
Tel: 0131 225 7324 ext 608
Fax: 0131 220 3939
[30 September 2010]
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