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A statute of liberty

 Liberating the NHS, the Government’s blueprint for healthcare in the UK, proposes an unprecedented and radical reorganisation for the NHS. Still ‘free at the point of use’, the White Paper remains true to the core principles of the NHS. But its desire to provide patients with the freedom of choice and, crucially, GPs with the freedom to commission services, suggests some challenging times lie ahead. In these turbulent economic times, not all that is good can be free. Chris Ross takes an early glance at the White Paper.

Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) are to be scrapped and hospitals encouraged to move out of the NHS to create a ‘vibrant’ industry of social enterprises, as part of radical proposals to restructure the NHS in England.

The new White Paper, Equity and Excellence: Liberating the NHS, outlines how power will be devolved from Whitehall to patients and professionals – and gives GPs freedom to take charge of much of the budget.

GP consortia

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 majority of commissioning will be undertaken by GP-led consortia – with the rest being 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.”

Subject to consultation, the Government’s indicative timetable for GP consortia is to be 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.

· 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. “Inevitably, as a result of the record debt, the NHS will employ fewer staff at the end of this Parliament,” said Lansley. “That’s a hard truth which any government would have to recognise.” The NHS is charged with finding efficiency savings of £20 billion during the same period in which it hopes to drive through the reforms.

Foundation trusts

The White Paper says that all NHS Trusts will become Foundation Trusts within three years. This, it says, 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.

Patient choice

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.

The Paper says: “We want the principle of ‘shared decision-making’ to become the norm: no decision about me, without me. International evidence shows that involving patients in their care and treatments improves their health outcomes, boosts their satisfaction with services received, and increases not just their knowledge and understanding of their health status but also their adherence to a chosen treatment. It can also bring significant reductions in cost, as highlighted in the Wanless Report, and in evidence from various programmes to improve the management of long-term conditions.”

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 audits to support clinicians across a wider range of treatments and conditions.

NICE and quality standards

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. 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 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.

Value-based pricing

Reforms to the way in which drug companies are paid for NHS medicines are also on the way, with proposals to move to a system of value-based pricing when the current scheme expires. “This will help ensure better access for patients to effective drugs and innovative treatments on the NHS, and secure value for money for NHS spending on medicines,” the White Paper states. As an interim measure, the DH is creating a new Cancer Drug Fund, which will operate from 2011. “This fund will help patients get the cancer drugs their doctors recommend.”

ABPI response

The ABPI has welcomed the proposals, in particular the extended remit of NICE which, it says, will help it move beyond a narrow focus on the cost-effectiveness of medicines. Dr Richard Barker, Director-General at the ABPI, said: “We warmly welcome the Government placing outcomes at the heart of health policy, a move we have long advocated. We must ensure that the new era of commissioning builds in the intelligent prevention, early diagnosis and timely treatment necessary to halt the burden of chronic disease that threatens the financial future of the NHS. The NHS spends more on unplanned hospital admissions for chronic disease sufferers than it does on medicines that, if used appropriately, could prevent them.”

The move towards a more clinically-led NHS is also supported. “We are also pleased that the White Paper signals a move towards greater doctor and patient influence over clinical decisions. We agree with Government that it is important to set quality standards for the new era of GP-led commissioning and we welcome the involvement of NICE in this process. The ABPI believes that this expansion of NICE’s remit to promote clinical best practice is a higher priority for the future of the NHS than the overly narrow cost-effectiveness calculations on new medicines it currently conducts. The new Government also proposes to introduce a Cancer Drugs Fund and to review how better to reflect value in the pricing of NHS medicines. We look forward to working with the Government to develop these proposals further whilst maintaining the stability of the current PPRS agreement.”

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