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NHS White Paper Equity and Excellence Liberating the NHS

The LibCon coalition government, on the 12th July 2010, released the next stage review of the NHS under the newly appointed Secretary of State, Andrew Lansley.

This paper sets out the agenda for the next 5 years and seeks views on policies within it. Three additional papers have been released, along with this paper, to provide supporting documentation. These include an analytical review, impact assessment and reform plan. All comments on this paper need to be received by the 5th October 2010.


The government argues that health care reform needs to be pushed through as the NHS faces great challenges with financial pressures, an aging population and greater patient expectations. There are 6 chapters in this paper. The most salient points are mentioned below:


Chapter 1: Liberating the NHS
Chapter 2: Putting patients and the public first
Chapter 3: Improving health care outcomes
Chapter 4: Autonomy, accountability and democratic legitimacy
Chapter 5: Cutting bureaucracy and improving efficiency
Chapter 6: Conclusion: Making it happen



Chapter 1: Liberating the NHS:


The vision is of an NHS based on its founding notion of “Free to all, at the point of use and based on need, not the ability to pay”. The NHS will promote equality with greater independence, centred on patients, and lead by clinicians in the driving seat. The results of this new NHS will be internationally respected. Lord Darzi’s NHS constitution is to be kept.

A new focus on public health with the creation of a new public health service delivered by local authorities (not PCTs) with a ring fenced budget.




Chapter 2: Putting patients and the public first

Patients are empowered to make decisions and give them the best information to make decisions. Lord Darzi’s 3 point focus on the information that reflects the quality of care is to be retained. This includes information on care based on:

1) Safety
2) Effectiveness
3) Experience

This will start an “information revolution” including patient experiences (patient reported outcome measures) which will be publically available. The use of quality accounts from 2011 will be encouraged.
This will result in increased choice and control by patients on their healthcare whilst providing data for NHS trusts to benchmark against each other. Patients will be able to choose a consultant for elective procedures. Patients can even choose their GP (with an open list).

A new organisation called “Healthwatch England” will be formed. It will work within the Care Quality Commission (CQC), is accountable to local authorities and can propose that poor services are investigated by the CQC.




Chapter 3: Improving health care outcomes

Detailing how quality outcomes can be improved so patient’s experiences are safer, efficient and pleasant. This build on Lord Darzi’s next stage review document by using:

a) The NHS Outcomes Framework: This framework is due to start in April 2011 and the outcome goals will be decided by a national consultation process. The goals will need to be met (and will be also be accountable) by the NHS Commissioning Board. The outcomes will reflect NICE standards and other international benchmarks. NICE has already published 3 standards (in this proposed library) on stroke, dementia and DVT prevention/management. This library is expected to reach 150 published quality standards in the next 36 months.

b) Providing incentives to improve quality: Whilst NICE and the NHS commissioning board will strive to set the desirable standards of quality of care, this document also outlines incentives for change to occur in view of these standards. The tariff system will be slightly modified so that a best practice tariff will be formed which will reward higher quality care (rather than a standard tariff payment). The scope of the Commissioning for Quality and Innovation payment framework (CQUIN) system will be broadened. The formation of a contractual penalty (financial) for poor levels of care is to be introduced.




Chapter 4: Autonomy, accountability and democratic legitimacy

The accountability for the commissioning of services and budgets is given to groups of GP patients.

GP Commissioning consortia: The devolution of power from SHA's and PCT’s will occur with consortia of GPs, at a local level, taking responsibility to budgets and service commissioning. This will, however, exclude GP services, dentistry, and primary ophthalmic and maternity services. GP practices will be allocated (if required) by the NHS commission board to facilitate this process. These consortia will decide who and what services to commission (from both NHS and private/alternative providers). A handover period will be required from the PCT to the GP consortia. It is hoped that full financial control will be with the new consortia by April 2013.

Autonomous NHS Commissioning Board:

This will be responsible for holding GP consortia accountable and assessing these commissioners. It will be free from political interference. This will be formed in April 2011 as a statutory body by the forthcoming health bill and go live a year later. After this point, strategic health authorities will be abolished. The commissioning board will need to work closely with the local authority and local healthwatch, as the PCT structure is to be abolished, hence, saving administration costs and handing control over to a more locally based system.

Freeing Existing NHS Providers:

All NHS trusts are to become Foundation Trusts within 3 years. This will encourage a more locally based, and run, employee and patient led level of care.
The CQC will act as an overall assessor of quality of health care services by providing licenses to operate and also providing inspectors to investigate areas of concern. Monitor will be taking over an as the economic regulator from April 2010 for NHS services to ensure competition works efficiently in the commissioning process and to set/regulate the pricing structure of NHS services.

Valuing NHS Staff:

The recommendations of the Boorman Review into NHS staff wellbeing will be implemented. Employers will be given more autonomy and accountability as well as pay for training/CPED and developing their workforce. Further proposals for general consultation on this are expected.

NHS pay however will fall in line with the announced budget freeze for 2 years for public sector pay restraint (only those earning over £21,000/yr). It is proposed that Lord John Hutton will chair a review of the affordability and sustainability of public sector pensions.



Chapter 5: Cutting Bureaucracy and Improving Efficiency

The largest reduction in NHS administrative costs in history will be introduced with 45% of the NHS management cost being reduced in the next 4 years. This will be achieved by abolishing the SHA and PCT structure, forming GP consortia and slash the number of NHS “quangos” otherwise known as arm length bodies (e.g. NPSA, MRHA).

Enhanced financial controls:

The NHS will still be funded by general taxation. The Department of Health will regulate the NHS commissioning board that will, in turn, regulate GP consortia. A competitive market system is created where commissioners can purchase services from any provider. NHS providers must be licensed by Monitor so that its financial viability can be assessed. The government will not bail out commissioners who fail or indeed failing providers, however Monitor will have some limited funds to keep some services running. The pooling of risk between providers is to be encouraged. Efficiency savings of £20 billion over the next 4 years have already started.




Chapter 6: Conclusion: Making It Happen

A new health bill will be released in the autumn of 2010 and will include the following principle reforms:

  • Creation of a better public health service
  • Giving local authorities more input into local health services
  • Forming new health care outcomes
  • Empowering NICE to deliver 150 standards of clinical quality
  • Establishing GP consortia
  • Establishing a new arm of the CQC called the “Healthwatch”
  • Abolishing PCTs and SHAs
  • Reforming the Foundation Trust model
  • Giving more regulation to the CQC
  • Giving financial regulation/control for NHS providers to Monitor
  • Reducing the number of quangos
  • £20 billion in efficiency savings over 4 years via a QIPP initiative (Quality, Innovation, Productivity and Prevention)

What do the BMA think about this Paper and its proposals?

Lord Darzi’s themes of increased patient choice, the focus on quality have been continued in this White Paper. The paper sets out radical structural reform at almost every level. There is significant devolution of power from Whitehall to an independent NHS commissioning board, monitor, CQC and NICE.

Local authorities will add some democracy to the process at the local level. The continuation of a competitive market could favour the private providers in the future for NHS services. The move towards local based pay negotiations and training of staff could be abused by cash-strapped trusts.




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