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A paper exercise

Liberating the NHS, the government’s blueprint for health care in the UK, published in the immediate aftermath of the July issue of Medtech Business – and just as we headed into our summer recess. The White Paper has been hailed as the most radical reorganisation of the NHS in its history. Chris Ross goes on a whistle-stop tour of the White Paper.

The world of UK health is currently in consultation mode. The full gamut of healthcare stakeholders – health professionals, academics, industry and patients – are currently reviewing proposals outlined in the coalition government’s ‘radical’ White Paper, Equity and Excellence: Liberating the NHS. To date, five consultation documents have been published; Commissioning for Patients, Local Democratic Legitimacy in Health, The Review of Arm’s-Length Bodies, Transparency in outcomes: a framework for the NHS and Regulating Healthcare Providers. The government says it will publish a response to the consultations prior to the introduction of the Health Bill later this year. In reality, consultation is widely regarded as a paper exercise: plans to implement the proposals are already underway. So what are the most salient points of the government’s proposals?

Reorganisation, consortia and commissioning

The headline act of the White Paper has, of course, been the abolition of Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs), and the resultant introduction of GP commissioning. Consortia of GPs will be given the responsibility for buying care from local hospitals and other providers as the balance of purchasing power shifts from central management to the GP surgery. The consortia will control upwards of 70% of the NHS budget – approximately £80 billion. The remainder of commissioning will be done by a new NHS Commissioning Board.

The NHS Commissioning Board will be ‘a lean and expert organisation, free from day-to-day political interference, with a commissioning model that draws from best international practice.’ The White Paper states that the Board will: “support GP consortia in their commissioning decisions and provide leadership for quality improvement through commissioning: through commissioning guidelines it will help standardise what is known good practice, for example improving discharge from hospital, maximising the number of day care operations, reducing delays prior to operations and enabling community access to care and treatments. It will not manage providers or be the NHS headquarters.”

The government’s indicative timetable for GP consortia is as follows:

• a comprehensive system of GP consortia in place in shadow form during 2011/12, taking on increased delegated responsibility from PCTs;

• following passage of the Health Bill, consortia to take on responsibility for commissioning in 2012/13;

• the NHS Commissioning Board to make allocations for 2013/14 directly to GP consortia in late 2012; and

• GP consortia to take full financial responsibility from April 2013.

The abolition of PCTs, which will take place ‘from 2013’, is seen as a major policy u-turn for the new government, having ruled out top-down NHS reorganisations in the coalition programme for government back in May. However, Health Secretary Andrew Lansley said the about turn was simply because his other reforms had left nothing for PCTs to do. “If we don’t have a job for primary care trusts to do, it doesn’t make sense to be paying thousands of people to do it,” he said. The policy is expected to result in tens of thousands of redundancies, with the cost of NHS management aiming for a 45% reduction over the next four years.

Foundation Trusts

All NHS Trusts are to become Foundation Trusts within three years. The White Paper says this will create the largest and most vibrant social enterprise sector in the world. “The intention is to free foundation trusts from constraints they are under, in line with their original conception, so they can innovate to improve care for patients. It will not be an option for organisations to remain as an NHS Trust, rather than become or be part of a foundation trust. The NHS Trust legislative model will be repealed in due course, while SHAs will be abolished by 2012 – and their responsibilities in relation to providers will be undertaken by a new unit within the Department of Health. From April 2013, responsibility for regulating all providers of NHS care will be passed to Monitor.

Accountability and outcomes

The government aims to make the NHS more accountable to patients who, it says, will be at the heart of everything it does. As such, the White Paper promises patients will have more choice and control, which will be supported by easier access to the information they need about the best GPs and hospitals. The ‘information revolution’ promised by Lansley has spawned a new slogan to sum up the approach to patients: ‘no decisions about me, without me.’ To help deliver this, a new body, HealthWatch, will be set up to compile data on performance, while GP boundaries will be abolished to allow patients to register with any doctor they want.

Information generated by patients will be critical to the process, and will include much wider use of tools such as Patient-Reported Outcome Measures (PROMS), patient experience data and real-time feedback. The use of PROMS and other outcome measures will be expanded across the NHS, while the DH will extend national clinical audit to support clinicians across a wider range of treatments and conditions.

The government says the central aim of its programme of reform, and indeed of the NHS, is the drive to improve health outcomes. Progress on outcomes will, it says, be supported by quality standards. These will be developed for the NHS Commissioning Board by NICE, who will develop authoritative standards setting out each part of the patient pathway, and indicators for each step. NICE will rapidly expand its existing work programme to create a comprehensive library of standards for all the main pathways of care. The first three on stroke, dementia and prevention of VTE were published in June. A further nine areas for Quality Standards was unveiled last month (see p3). NICE expects to produce 150 standards within the next five years and, to support quality standards, will advise the National Institute for Health Research on research priorities. The role of NICE will also be expanded to develop quality standards for social care.

The consultation document Transparency in Outcomes proposes a new framework for NHS targets, with the emphasis on outcomes achieved for patients rather than processes measured within the NHS. It is expected that the new NHS operating framework will be in place by April 2011

Best-practice tariffs and CQUIN

The White Paper notes the absence of an effective payment system within the NHS, which it says restricts the ability of commissioners and providers to improve outcomes, increase efficiency and deliver patient choice. Responsibility for the future structure of payment systems will belong to the NHS Commissioning Board and the economic regulator will be responsible for pricing. The DH plans to refine the basis of current tariffs and to accelerate the development of best-practice tariffs, introducing an increasing number each year so that providers are paid according to the costs of ‘excellent care’ rather than average care. Best-practice tariffs for interventional radiology, day-case surgery for breast surgery, hernia repairs and some orthopaedic surgery will be introduced in 2011/12. Alongside this, the DH will also extend the scope and value of the Commissioning for Quality and Innovation (CQUIN) payment framework.

The ABHI response

The White Paper signals a number of fundamental changes to the NHS. It is crucial that industry is represented to government by a strong single voice. Work has begun at ABHI to consult members and ensure our response highlights any concerns industry may have but is also able to demonstrate how industry can support the NHS to continue to deliver healthcare more efficiently, through making concrete proposals in support of the policy outlined in the White Paper.

The Health White Paper outlined a number of measures that are expected to have an impact on how industry interacts with the NHS.

Key points of industry interest include-

•   Establishment of GP consortia to commission services

•   Establishment of NHS Commissioning Board to produce commissioning guidelines and removing Secretary of state from day-to-day running of NHS. 

•   Monitor to become economic regulator 

•   PCTs and SHAs to be abolished 

•   Change of direction for the performance regime which will be replaced ‘with separate frameworks for outcomes that set direction for the NHS’

•   Government ‘will rapidly accelerate the development of best-practice tariffs’

The White Paper answers some important questions about the future of Payment by Results, whilst raising new ones. There is recognition that the absence of an effective payment system in parts of the NHS is getting in the way of improving outcomes and efficiency and enhancing patient choice. The intention is to design and implement a more comprehensive, transparent and sustainable structure so that money follows the patient and reflects quality. The new NHS Commissioning Board will design the structure of the tariff and other financial incentives, whilst Monitor will set tariff levels. This single change may make the NHS tariff look more like its global equivalents than it has hitherto.

On the issue of best practice tariffs the paper outlines plans for the Government to ‘rapidly accelerate the development of best-practice tariffs, introducing an increasing number each year, so that providers are paid according to the costs of excellent care’. This could have significant implications for healthcare providers if they are less efficient than the very best performers, as costs of NHS and technology inputs may not be fully covered by tariff. Best practice tariffs will be introduced for interventional radiology, day-case surgery for breast surgery, hernia repairs and some orthopaedic surgery by 2011/12. As previously anticipated, the scope and value of the Commissioning for Quality & Innovation (CQUIN) payment framework will be further extended.

The consultation is open until October and ABHI has already begun to draft industry’s response. In order to ensure that ABHI provides a comprehensive response representing all of industry we will be holding a number of workshops and meetings up and down the country to ensure that members get the chance to participate. Anyone wishing to discuss the White Paper and ABHI’s response should get in touch with Dan Jones (Daniel.jones@abhi.org.uk) 0207 960 4360.

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