Health Command Paper: ‘Liberating the NHS: legislative Framework
and Next Steps’
The Command Paper entitled ‘Liberating the NHS: legislative Framework and Next
Steps’ is the formal response to the White Paper consultation and sets out the
framework for creating an NHS that focuses on three things;
• putting patients at the heart of the NHS
• focusing on improving outcomes instead of hitting targets
• freeing professionals from bureaucracy and central control.
Four Key policies for Liberal Democrats:
Extend councils’ formal scrutiny powers to cover all NHS funded services:
• Our strong desire to increase local democratic legitimacy and scrutiny,
and to create a level playing field, have led the Government to decide to
take the important step of significantly extending the powers relating to
the scrutiny functions of local authorities.
• The Government will now extend the powers of local authorities to
enable effective scrutiny of any provider of any NHS funded service.
• They will include the ability to require any NHS-funded providers or
commissioners to attend scrutiny meetings, or to provide information, thus
substantially increasing local democratic scrutiny.
• Scrutiny will be able to follow the pound to ensure that local authorities
are able to scrutinise any provider, irrespective of whether they are from
the public, voluntary or private sector.
Enhanced health role for Local Authorities
• Local authorities will lead on improving the strategic coordination of
commissioning across NHS, social care, and related childrens’ and public
health services.
• Health and Wellbeing boards will bring together the key NHS, public health
and social care leaders in each local authority area to work in partnership.
This will be a statutory requirement for all upper tier authorities.
• The core purpose of the new Health and Wellbeing Boards is to join up
commissioning across the NHS, social care, public health and other services.
There must be a minimum of at least one local elected representative on the
Health and Wellbeing Board.
• Joint Strategic Needs Assessment will provide an objective analysis of local
current and future health needs for adults and children. There will be a
statutory duty for it to be undertaken by local authorities and GP consortia
through Health and Wellbeing Boards and a new legal obligation on NHS and
local authority commissioners to have regard for the JSNA in exercising their
relevant commissioning functions.
• Will place GP consortia and local authorities under a new statutory duty to
develop health and wellbeing strategies together through the Health and
Wellbeing Boards.
• The strategy will provide the overarching framework within which
commissioning plans for the NHS, social care, public health and other services
the Health and Wellbeing Board agrees are relevant and developed.
Creating local consumer champions:
• We have recognised the good work of many LINks (local involvement
networks), but some patient needs-like support to make choices-are not
necessarily being met.
• These needs will be met by local Health Watch organisations, which led by
Health Watch England, will take on additional functions to LINks to serve as
an independent consumer champion within the Care Quality Commission.
• Health Watch will act as a local consumer champion for patients and will
ensure that local patients are heard on a national level. Local authorities
will tailor each local Health Watch according to the range of support
services already provided to reflect local needs.
• Local Health Watch will be to scrutinise local care services by escalating
concerns about the quality of health and care services to CQC.
• Health Watch England will agree standards against which local Health Watch
organisations and local authorities can benchmark performance and spread
good practice.
Any Willing Provider
• Everyone should have choice and control over their care and treatment, and
choice of any willing provider, wherever relevant. This option was denied to
patients under Labour’s “preferred provider” model.
• In the autumn of 2009, the then Health Secretary, Andy Burnham, said in a
speech that “the NHS is our preferred provider”. This represented a U-turn
to long-standing Department of Health policy, and a contradiction of a pledge
in the Labour Government’s last manifesto.
• If we want the best services for NHS patients, at the best price for taxpayers,
we simply cannot afford to exclude the quality, innovation and efficiency
that the third sector and private providers can bring to the table.
• One such example excluded under Labour’s “preferred provider” model was
the drugs charity Addaction. Their ‘Breaking the Cycle’ programme has been
enormously successful and the resultant savings to the state are enormous.
• Seven months of Breaking the Cycle support for one family costs £1,700.
Within eight months, that is likely to have saved the state £20,000. Within
two years, it is likely to have saved £148,000. Over the long term, the effects
on two generations of that one family could save the state £880,000.
• The Command Paper reaffirms the Government’s commitment to allowing
patients to choose any healthcare provider for the majority of NHS-funded
services.
• Providers will need to deliver care at NHS standards and within the price
the NHS is willing to pay
• The Liberal Democrat Manifesto refers to “Any Willing Provider” by
committing to provide “freedom to commission services for example staff
co-operatives, on the basis of a level playing field.
• Providers will need to deliver care at NHS standards and within the price the
NHS is willing to pay, bringing an end to the practice under Labour of
private providers overcharging the NHS for services.
Key messages:
1. Reform is not an option; it is a necessity: If we are to make patient outcomes
truly world-class and respond to rising demand, we must reform the NHS so that it
can focus its resources on patients and quality.
• Labour are making the case for standing still based on the premise: that if
it ain’t broke, why fix it. But Labour are defending a failed status quo.
• Under Labour, NHS spending rose to European levels but it was so tied
up in red tape it was unable to deliver European levels of quality health
care.
• If the status quo is right, why are a staggering 23% of cancer patients
only diagnosed when they turn up as emergencies? If the NHS was
performing at the level of the best in Europe 10,000 lives could be saved
every year. Why is it that a patient in this country is twice as likely to die
from a heart attack as a patient in France?
2. Putting the NHS on a sustainable financial footing: Our reforms will help put
the NHS on a sustainable financial footing through reduced bureaucracy,
increased accountability and stronger incentives for quality and efficiency.
• In 2009, Labour signed up to Sir David Nicholson’s figure of £15-
20billion savings over the next four years. But they still haven’t offered
any serious or coherent plan of reform to achieve it.
• Andy Burnham, as Shadow Secretary of State for Health; “It is
irresponsible to increase NHS spending in real terms within the overall
financial envelope.”
• Our reforms will cut outdated and costly administrative structures, saving
£1billion by 2014/15 which we will reinvest in frontline patient services.
3. An NHS based on the principles of freedom, fairness and local decision
accountability:
• We will reject Labour’s tick box mentality and instead give freedom to
professionals to shape services around their patients and focus on improving
health outcomes.
• We will give responsibility to clinicians so that those designing health
services understand how to do so based on what their local communities tell
them.
• Diane Abbott, Shadow Health Minister, 2/11/10 “I concede that inequality
widened under the previous (Labour) Government”. We will create a fairer
system, driving out health inequalities so that all patients have equitable
access to services.
• We are placing patients at the centre of the NHS. Our reforms will mean
patients are given more information and choice about their care-in future
‘there will be no decisions about me without me’.
Detailed messages:
• The NHS Commissioning Board will have a duty to promote the
involvement patients and carers in decisions about the provision of their health
services, and should include in their support to consortia, guidance on public and
patient involvement.
• NHS Commissioning Board and GP consortia will help patients to make
choices about their healthcare and utilise the personal health budgets pilot
programme.
• The Health and Social Care Information Centre will collect data to support the
NHS and will have the power to collect data needed from NHS organisations to
support patient choice and information.
• It is crucial that people know how to make complaints about health services,
and that information about the complaints raised is used to improve services-that
is why we will be strengthening the Ombudsman’s power to allow information
to be shared more widely in investigating concerns.
• To increase transparency, all GP consortia will publish a constitution
against which patients can hold them to account.
• In addition, we will create an Accountable Officer role which will oversee
compliance of their consortia with its financial duties, promote continuous
improvements in the quality of services it commissions and provide good value
for money.
• We will establish a health and wellbeing board in every local authority so
that commissioning across the NHS, social care, related children’s and public
health services are integrated and co-ordinated to achieve better health
outcomes for their populations
• Competition will give patients more choice in their healthcare and is a key
driver in improving the quality of services they receive. Monitor, the economic
regulator, will be given more powers to promote competition where appropriate
in healthcare and, at a later date, for adult social care.
• Taking into account the level of response, commissioning of maternity
services will now sit with GP consortia, but with a strong role for the Board to
promote quality improvement and extending choice for pregnant women.
• An NHS Commissioning Board will be created in shadow form during
2011/12. PCTs will support the development of GP consortia; and SHAs will need
to support every NHS trust to become a Foundation Trust within the next three
years.
• In helping all trusts to become Foundation Trusts, we are allowing a longer
transition period to ensure that a stronger, more transparent approach can be
tested before implementation;
1. our programme of GP pathfinders will create a clearer, more phased
approach to the introduction of GP commissioning;
2. we are accelerating the introduction of health and wellbeing boards
through a new programme of early implementers; and
3. we are phasing the timetable for giving local authorities
responsibility for commissioning NHS complaints advocacy services.
Q&A:
You said no more top down restructuring and political meddling with the NHS.
You have broken the promise you made in the Coalition Agreement.
This is not a top-down reorganisation: we have set out no central plans for how the
NHS should be changed: instead, we are allowing GPs and local communities to take
these decisions. Reform is required precisely so that we can create a system in which
professionals and patients are empowered to take decisions and politicians are no
longer able to micromanage the NHS.
Why change – Commonwealth Fund says the NHS is one of the best health care
systems in the world
Reform isn't an option, it's a necessity. With ever increasing demands on our NHS, we
must deliver efficiency and quality improvements if we want to sustain and improve
services for patients.
We are proud of the NHS and its achievements, especially in terms of equitable
access. But we should not mistake equity in access for excellence in outcomes. The
UK lags behind many international healthcare systems on survival rates - for example
for diseases such as cancer or stroke – and a recent OECD report found that if the
NHS were to perform as efficiently as the best performing health systems, we could
increase life expectancy in the UK by 3 years.
Patients deserve the best that we can give them. Our plans to reform the NHS will put
patients at the heart of the system, and focus the NHS on achieving outcomes that are
among the best in the world.
No compelling evidence that reforms will result in better or more cost-effective
care. Plans are untried and untested and are based on ideology rather than
evidence.
The reforms build on many previously tried-and-tested models: GP fundholding in the
early 1990s; total purchasing in the mid-1990s; and practice-based commissioning in
the mid-2000s. The experience of these systems gives us a wealth of evidence on
which our reforms are based.
Why create new structures? Why not build and improve on what you already
have?
These reforms build on existing structures. For example - GP consortia build on
existing practice-based commissioning arrangements and clusters; economic
regulation builds on Monitor; and the functions of the NHS Commissioning Board
already exist within the Department of Health and the NHS. What we are doing is
creating a sustainable framework and stripping out avoidable layers of management.
Devolving power to professionals and patients means we can remove SHAs and
PCTs.
What will the reforms cost? How much will be saved by these reforms?
There will be one-off costs, which we will set out shortly, but savings will recur year
on year. Reducing the costs of administration across the health system by one third in
real terms will save £1.9bn per year by 2014/15. These savings will be used to support
front-line NHS services.
Waiting times are already rising. These reforms will undo what has been
achieved in the NHS. They represent a massive risk to patient care.
We need a culture of continuous improvement in the NHS. That means ensuring
patients get timely and appropriate access to the care they need. Our reforms will
deliver this through the publication of waiting times, patient choice, standards in
contracts and competition between services.
But patients deserve more than just timely access to care. That's why we are
realigning the NHS to focus on patient outcomes, so patients will get optimum care at
each stage of their care pathway, not just for one part of it.
Median waiting times for patients on consultant-led referral to treatment pathways
remain low. Clinical priority must be the main determinant for when a patient is
treated and no-one should experience undue delay at any stage of their treatment.
What about the claims made in the Civitas report (published today) that
scrapping primary care trusts all in one go will damage patient care?
We recognise the scale of the challenge and we have adapted our transition plans
following consultation, creating a clearer more phased approach to the introduction of
GP commissioning by setting up a programme of GP consortia pathfinders. This will
give the new organisations nearly three years to secure capability.
This is completely the wrong time for reform. In the current financial climate the
NHS should be dedicated to making sound efficiencies and improving patient
care rather than undergoing costly reforms.
The financial climate is a reason to accelerate reform, rather than not reform at all.
The reforms will help put the NHS on a sustainable financial footing through reduced
bureaucracy, increased accountability and strong incentives for quality and efficiency.
The money saved will be used to improve the quality of NHS services for patients.
How will the NHS deliver £20 billion efficiency savings during a period of
massive upheaval?
The scale of the efficiency challenge is such that it can only be met by system-wide
reform. Plans to manage QIPP, and plans to manage transition, are in practice one and
the same thing. The reforms will help put the NHS on a sustainable financial footing
through reduced bureaucracy, increased accountability and stronger incentives for
quality and efficiency.
Failed to honour the pledge to provide real terms increases each year to health
funding
The Spending Review delivered on the coalition commitment to grow health spending
in real terms. Inflation forecasts will change, but our commitment to sustain and to
improve NHS services is constant. The NHS budget has not changed and includes
funding for social care and reablement — honouring the commitment to protect the
most vulnerable in our society. Even under that forecast, overall funding will increase
by more than 10 per cent in cash terms over the Spending Review period.
Is the Nuffield Trust correct when it says that the NHS is actually not getting an
increase in spend due to the extra billion that is going to social care?
No; the Nuffield Trust is wrong. The NHS is getting an increase over the next four
years.
The health select committee says the the Govt's planned cuts will test the NHS's
limits
The Government is committed to the NHS - to sustain and to improve services in the
face of a tough economic climate. But even with this commitment, in order to meet
demand and improve the quality of services, the NHS needs to make up to £20 billion
of efficiency savings by 2015. Reform isn't an option, it's a necessity in order to
sustain and improve our NHS. We have been clear that the NHS must cut back on
bureaucracy, not on frontline care.
What about the health select committee’s comments on social care – the
committee’s report suggests that councils will be unable to avoid reducing levels
of care?
The Spending Review confirmed the Coalition Government's commitment to social
care. Next April an additional £1.3 billion of funding will be made available, rising to
£2 billion in 2014/15. This funding is on top of the Department of Health's existing
social care grants, which will rise in line with inflation. This additional investment
will make it possible to protect people's access to care, without tightening eligibility.
Councils and NHS partners will need to work harder to improve efficiency and
achieve improved value for money.
Giving commissioning to GPs will result in a two-tier health service / postcode
lottery; treatment availability will depend on where you live.
We are creating greater flexibility for services to be shaped by local needs and the
choices of patients, rather than central diktats from Whitehall.
Both the NHS Commissioning Board and GP consortia will be under a statutory
obligation to reduce inequalities in healthcare provision and will be held to account
through the Outcomes Framework and a Commissioning Outcomes Framework for
the outcomes they achieve. Where there is evidence that consortia are failing to fulfil
their functions the Commissioning Board will have the power to intervene.
What about job losses?
The NHS must make up to £20bn of efficiency savings by 2014, through reducing
bureaucracy and working differently.
While it is for local Trusts to determine their specific workforce needs, we have made
it clear that efficiency savings must not impact adversely on patient care. Every penny
saved — including a one third cut in the cost of administration across the health
system — must be reinvested in support of front line services and improving quality.
SHAs are developing their own workforce plans and will be updating these in the
light of the Operating Framework, PCT allocations and tariff details for 2011/12.
This is privatisation of the NHS
We are clear that we are not changing the fundamental basis on which the NHS is
funded – out of general taxation. In addition, there is no question of ‘privatising’ the
assets of the NHS: the taxpayer investment in the NHS will be secure, and we will not
issue shares in it.
We have no ideological preference for private sector provision over the NHS – in
marked contrast to the previous Government, which set a target for the number of
NHS procedures it wanted to see undertaken by the private sector. In addition, the
reforms we are implementing will prohibit the possibility of any preferential
payments to private sector providers, and ensure that the private sector does not make
any undue profits from delivering NHS services. Our policy of ‘Any Willing
Provider’ will facilitate patient choice and allow for a range of providers to offer
healthcare, which is most likely to bring about innovation and greater responsiveness
to patients in community services.
Local democratic legitimacy is a toothless sham – LAs have no power
These proposals are about real strategic influence, not over-ruling each other’s
decisions. Picking up on the consultation responses, it is right that Health and
Wellbeing boards do not have a right of veto over plans, as that would undermine GP
autonomy, and give local authorities the ability to make NHS commissioning
decisions that could commit additional expenditure from GP consortia, without local
authorities having to take responsibility for that expenditure. Each member of the
health and wellbeing board has separate accountabilities, but a shared responsibility to
the local community.
