Ten challenging questions about the White Paper

The coalition government's health White Paper is expected to be published shortly. 'Equity and Excellence: liberating the NHS' will contain far-reaching proposals to increase choice and competition, strengthen the commissioning of health care, give NHS providers more autonomy, and establish an independent commissioning board.

We believe the White Paper will need to answer some difficult questions if it is to offer a credible plan for the future.

1) How will patients be supported to take greater responsibility and to exercise informed choices?

The coalition government has signalled its intention to put patients at the centre of the NHS and to start an information revolution by publishing more information about quality and outcomes. While patients want to be more involved in decisions about their care and to be supported to make informed choices, professionals are often too busy to do this, do not see this as their role, and believe that patients want them to make decisions for them. How will professionals be motivated and supported to put patients first and involve patients more in decisions? Will patients and professionals be able to make use of the information to drive improvements in care?

2) How will provider competition work in future and what will be the role of the proposed economic regulator?

A mix of competition and co-operation is needed to support the goals of improved health outcomes and enhanced patient experience. Will ministers follow through the logic of competition and allow unsuccessful providers to fail? How will co-operation be supported, for example, to ensure that the providers of unscheduled care work together to reduce duplication and inefficiency? What will be the role of the economic regulator and how will it work with the Care Quality Commission?

3) How will difficult decisions about service reconfigurations and hospital closures be taken in future?

Major changes such as those being implemented in London to address the oversupply of acute hospital beds and duplication of specialist services have taken many years and elaborate processes of public consultation to get to the point of implementation. The impetus for changing services is even greater given the financial context. How will commissioners tackle complex issues like the reconfiguration of tertiary and acute hospital services and how will the views of patients, the public and clinicians be taken into account without them blocking decisions that need to be taken on financial and quality grounds?

4) Will the right incentives and support be in place to ensure enough GPs are motivated to lead the development of GP commissioning and have the competence to do so?

The NHS White Paper will place great emphasis on the devolution of budgets to groups of GPs to enable them to commission care. Previous experience in the NHS has shown that while some GPs are likely to be enthusiastic about this opportunity, many will not be. Will the incentives be strong enough to engage a critical mass of GPs and will they have the leadership and other skills required?

5) How will GP commissioners be held to account for their stewardship of public resources for health care?

If most of the NHS budget is devolved to GP commissioners, it will be essential to be clear who are the 'accountable officers' for the resources they control. The proposed independent commissioning board (see below) will not be able to hold to account 500-600 GP commissioning groups, and there will need to be a body sufficiently close to these groups in a position to ensure appropriate and effective use of resources. Who will take on this role? What will be the consequences of failure, and who will ensure continuity of care for registered populations?

6) Who will commission primary medical care and ensure that GPs as providers of care deliver good value for money?

GPs provide primary medical care services under the terms of contracts negotiated nationally and locally, and currently their performance in relation to these contracts is assessed by PCTs. We know that issues such as how well those with long-term conditions are supported by their GPs or the availability of out-of-hours care are not only important to patients but also have a crucial role in reducing avoidable and costly emergency admissions to hospital. Who will take on this responsibility in future? Will consortia of GPs be responsible for the performance of other practices and if so what leverage will they have?

7) What will happen to NHS providers?

The health White Paper will need to have a coherent plan for all NHS providers to become foundation trusts. It will also need to offer greater autonomy to high-performing foundation trusts and active encouragement of social enterprise and mutual models. Greater integration of providers should be encouraged where this offers benefits for patients. Will there be a clear vision for the future of NHS providers and how this will be delivered?

8) What will be the future role of PCTs and local authorities?

The coalition agreement signalled that the boards of PCTs will include people who are directly elected as well as members drawn from local authorities. This will help to strengthen local accountability as long as PCTs have a significant role in future. If most commissioning is devolved to GPs, what will be the role of PCTs, and how will they work with local authorities to ensure that cuts in social care do not impact adversely on patients and users?

9) How will the independent commissioning board relate to the Department of Health on the one hand and the NHS on the other?

Distancing ministers from the day-to-day running of the NHS is welcome in principle but how will it work in practice? In the face of any significant clinical failure and result in loss of public confidence in services or organisations, what mechanisms will ensure that politicians remain removed from operational intervention? In the absence of targets, can the board ensure quality is maintained through commissioning standards without reverting to the command and control of past years?

10) How will the government ensure that leaders remain focused on finding £15-20 billion under the QIPP programme while at the same time making far-reaching changes to the organisation of the NHS?

The NHS faces the biggest challenge in its history in delivering financial savings under the QIPP programme. Work on the programme could be derailed by the organisational changes contained in the NHS White Paper and by the loss of experienced leaders as management costs are cut. What transition arrangements will be made to avoid this and to ensure delivery of both QIPP and the White Paper?

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#152 Andrew Craig
Moore Adamson Craig Partnership LLP

Great questions Chris. Here's no 11 for you: what about LINks and Healthwatch? Synergy or conflict?

#153 Catherine Lander
Speech and Language Therapist

As GPs will be both Commissioners and Providers, they could have a conflict of interest. How will this be regulated and monitored? Many services delivered to people with low incidence difficulties are small and specialist. To commission such services will need both awareness and cooperation among the commisioning bodies. I am very concerned that services will be broken up, seamless services will be an impossible dream,and many services will dissappear. It will be the poorer families who lose most as usual.

#154 george paton
psychiatric nurse

The rhetoric being given out by both the govt. and the right wing media appears to be nothing less than an all-out assault on the founding principles behind the founding of the NHS.
We are going backwards towards the fear that existed prior to the creation of the NHS.
If GP's, who essentially run their practices as a small business choose to agree to this proposal, the NHS is likely to become more unequal in the distribution of outcomes, and less like the vision outlined at it's creation

#155 Richard McCallum
Head of Oral Health
NHS Nottinghamshire County

What are the skills of GPs and how can they be harnessed to do their primary task of providing medical care?
What will happen to other primary care services that are not medical e.g. dentistry, pharmacies and optical services. yet again the model seems to be the medical model and ignores the wider public health agenda in the direct commissioning of services for the population rather than the care plan for individual patients. The latter has a direct GP input, does the former?

#156 Dr Paul Worthington
NHS Project Manager

Good questions; obviously the ones in relation to accountabilities and skills/incentives are critical. However, the issue that almost all commentators are missing (Prof ham being an exception) is the absolute need for a strategic focus. It's absolutely clear that difficult service reshaping decisions have to be taken and acted on; that won't be driven by just a focus on a multiplicity of individual market exchanges. It needs a strong strategic focus and lead, and it needs to harness a range of interests. That includes patients and communities being engaged, and not just about choosing where to go for an op or out-patient appointment.

Similarly, where and how does the parnterrship agenda sit - along with the greater integration that's suppose to be drving efficiency in the public sector ?

#157 Anon

As of today and based on everything Mr Lansley has said so far I do not believe he has answers to the majority of these questions. I think in many cases his best answer will be to say that arrangements should be made locally.

#158 simon knighton

We just can't face the demands of an ageing population and ever increasingly costly health innovations if we carry on in the current way. I an definitely not on the right wing of anything, but we would do a lot better to see how we can make the current opportunity work to redesign services - starting from the people they are intended for. There are a lot of us around who can help and physicians helping enable good decision making by patients in an environment in which all feel supported is more than a possible outcome.
If we want more than a "sickness" service in the future we must ensure that some of the good innovatory ideas that are around now are not lost as commissioning and management structures go into their inevitable tailspin.

#159 Rhion Jones
Programme Director
The Co0nsultation Institute

Inherent in several of the questions is uncertainty about the future of public and patient involvement in the NHS. This suffered over 10 years of reorganisation and nothing is as destabilising for the processes of consultation than for the 'consultor' to lack credibility. Will informed stakeholders and the public generally participate in services redesign and other essential tasks if it isn't sure that those who commission the consultation will be around 3 weeks or 3 months later to act upon this input? It is possible that GPs may prove to be excellent at listening to LINKs, or local authorities or other voices. But are we sure ?

#160 Anon
IT Architect

The questions are great and I would love the answers to these for the current organisation. Do you feel all is well with PCT/SHA structures now and these changes are not needed, my experience is that PCT/SHA have one common trait... don't share anything 'it's too complicated'. I would like to see this work as it creates a 'Face' that you can go to and raise issues/problems ... THE GP

#161 Stephen Henderson

I would have thought bureaucrats were paid less to fill in forms, push-pens, dot-i's, etc.. than GPs?

#162 belinda greathurst
data entray
alliance healthcare

what would it mean for the patients and is it only to deal mental health they are not quilified in pshycitry so there must be linked up with them

#163 Josh Potter

There are so many questions that could be asked about this and Chris Ham's list is a good summary. I worry most about this fragmenting services and leading to major disparities in the quality and range of services available to patients. I hope Lansley comes up with some good minimum standards that all areas will be expected to achieve.

Having said that, having clinician led commissioning is a no brainer. I would like to see however, public health teams and senior clinicians in the acute, mental health and community sectors initimately involved as well. GPs do have a unique view of the system as gate keepers but they are by no means the only people qualified to make these sorts of judgements.

#164 Judy Viitanen
Healthcare Communications Consultant

I totally agree with the comments expressed by Richard McCallum: a total focus on a medical model to revolutionise NHS services could risk diluting the great potential and benefits of other primary care services - community pharmacy, optical services, etc - and their valuable role in public health. Lansley and the Government need to factor in safeguards to ensure GPs are competent and appropriately incentivised to commission health services!

#165 Tim Warren

Did GP Fundholding work in the past?
What did we learn from that experience?
How are the proposed plans different to GP Fundholding?

#166 Audrey Lawrence
Independent Analyst

An excellent summary of the key issues. It's just disappointing to see yet another upheaval based on selective, scant evidence. Any benefits will certainly not be short-term and I'm sure the management consultants are already rubbing their hands in anticipation.

#168 Anne Tofts

And the governance challenges will be interesting. A greater role for Local Authority scrutiny? A commissioning board for each new Cluster? Or a performance management and governance role for the new National Commissioning Board?

#169 Anon
Emergency Planning Manager

Casius Petronius in AD66 comes to mind......

“We trained very hard, but it seemed that every time we were beginning to form up into teams, we would be reorganised. I was to learn later in life that we tend to meet any new situation by reorganising and a wonderful method it can be for creating the illusion of progress, while producing confusion, inefficiency and demoralisation”

Or perhaps this is just a ruse to set up a system destined to fail from the onset and use it as the justification to renegotiate GP Contracts

#171 Ann Hepworth

A useful set of questions Chris and many more that still need answers. I understand the desire for clarity and appreciate the complexity of the change we are about to make, but wouldn't it be great to sieze the direction we have been given and make the most of it rather than spend time and energy picking at the policy?

#172 karen samuel-smith

What assurances will be in place for patients who don't have a voice now? There is a risk that commissioning decisions and service provision will be biased to diseases of affluence, with no thought for the needs of the less educated, more deprived, less empowered patients.
Who is going to buffer the commissioning consortia with neutral, evidence-based data against the onslaught of marketing activity from the pharmaceutical industry?

#174 Dr Rick Fisher

Excellent points, Chris. What really concerns me is the control gps may have over community nurses,who traditionally have acted as advocates for patients. More importantly, where will the necessary incentives for promoting public health initiatives come from. We have already seen derogaatory remarks being made about Jamie Oliver's rather succesful exercise that reinforced previous governement policy on nutrition.

#182 DBarlow

Forgive me but did I miss something - in which, or whose manifesto was this NHS reform programme set out? I thought we lived in a democracy where impending change of this nature to such a critical service would be discussed pre -election? or was it scribbles found on the on the back of an envelope from the 1980s?

#185 LPointon
Community Nurse

Great Questions! Accountability and governance is key.
What about the groups of vunerable adults that do not go to a GP or indeed have a GP, many voluntary sector organisations have been commissioned by PCT's to fill this gap and support service users. How will this continue if GP's are commissioners?
Also in a recent survey by the organisation Rethink, 60% of GP's do not want to commission Mental Health services, where will Mental Health commissioning sit in the government's plan?
The White paper in my view is directed at a very expensive medical model of care and does that fit all services, providers and patients/ service users.

#186 lhaslam
Student Nurse

How are local authorities going to manage health promotion in a more efficient and dynamic way than PCTs and where will the innovation come from in designing local services for hard to reach groups? Surley There will have to be a lot of shuffling of positions from PCTs to LAs in order to achieve the staus quo let alone service improvements. I can only foresee increased inequalities.

#200 CMC
Occupational Therappist

Really good questions and I agree that Lansley is unlikely to be able to answer them. Doesn't this essentially just create a plethora of smaller bodies that will be harder to coordinate, create infinitely more bureacracy, overlap and confusion?
I fear the policy delegates the politically difficult decisions unfairly to the hands of those not equipped with sufficient knowledge and information to make them. Vulnerable people will go unheard as the more evocative issues such as cancer care gain greater attention.
Will effective admission prevention, quality of life promotion and rehabilitation provided by allied health professionals be sustained?
This is an ill-considered, dangerous punt that risks drastically affecting the most vulnerable in our society.

#207 Pam Lewis
Hospital Pharmacist

My understanding was that one of the reasons the PCTs were created was to reduce the number of administrative staff involved in commissioning under the utterly disasterous(personal view) GP fundholding system. Each of these consortia is going to require staff with indepth knowledge of finance etc so surely this will simply multiply the number of these posts required?

#216 dominic birtwistle

A few points :

- where are GP's going to get time to do all this managing. Most put in a lot of hours already.Are they going to cut back on their clinical work, employ the same managers from redundant PCT's to run these consortia or put in more time themselves and increase risk of burnout and thereby compromise their own patient care ?

- Most , if not all , of the problems in the NHS come from historical and current power battles and status issues between the different professions, Whatever benefits or not of proposed changes , one definite outcome is going to be a huge increase in the power of GP's
(which is why they're so keen on the proposals) which is going to be hugely regressive in trying to break down power struggles in the NHS as a whole.

-Most important of all , no-one really seems to have done a really valid analysis of what the problem is in the first place. Lack of clarity about a problem ensures that whatever solution you're applying means its going to be pot luck whether it works or not. This seems so obvious , yet as with the NHS IT saga , there's no clarity about what the problem is in the first place.There's just a sort of blind faith that 'the solution' will work. There's an old saying that 80 or 90 percent of solving a problem lies in clearly defining what that problem is in the first place !!

#233 Jane Galbraith
University College London

How will the limited NHS funds be allocated to GP consortia and Local Authorities? That is an overlooked question.

Currently formulae for the allocation of funds to PCTs are unjustified and may contribute to deficits and uneven healthcare provision. How much harder to develop fair funding formulae for hundreds of GP consortia in a time of financial constraint. Will GP consortia go bankrupt?

#365 Annie Hunningher
Locum consultant
UCH, London

How will the current government changes; Liberating the NHS, influence the future staffing of anaesthetic departments? How does the paper iron out health inequalities? How does this compare with other countries health models?

#569 Confused mental...

I do receive some services due to mental health problems attributed to a diagnosis of bipolar disorder. I also used to work within the caring professions. I have tried hard to understand how all this will work in practice and hava asked numerous questions at my local level from the care professionals. I am told IT is already happening but trying to get an idea of what IT is has been virtually impossible .I dont think this is due to the professionals being unhelpful either but, what is more worrying is that they also appear to be as confused as me. I am a tryer and have been to many dialogue groups which involved service users and managers but am still left confused and also worried because this lack of transparency and clarity will most probably mean a lot of talk about NOTHING in real care terms for the most vulnerable.

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