NHS 2010–2015: from good to great – our analysis

The NHS 2010–2015: from good to great is the first NHS-wide vision from the government since the publication of High Quality Care for All in 2008.

The timing and content of this White Paper is a reflection of how much has changed since the publication of Lord Darzi’s ‘once in a lifetime’ review. As was made clear in the Pre-Budget Report, the NHS is facing very limited or possibly no growth in resources from 2011 and a cap on wage increases while having to meet the needs of growing numbers of older people and new technologies.

The government has already identified the need for the NHS to generate up to £20 billion of savings and productivity gains. This will prove highly challenging, as rates of productivity have been declining by an average of 1 per cent each year over the past few years. This publication is designed to reconcile the earlier visions for NHS improvement with the new realities of financial slowdown.

It is also designed to address the government’s underlying fear that patient care will suffer as a result of the financial challenge, as has happened in the past. As the report notes, ‘patients should not bear the price of change’. Many of the decisions about savings will have to be made at a local level. This represents a considerable challenge for the government if it wishes to control the direction of change in the NHS at the same time as preserving local autonomy.

Most of the document refers to work already announced or in progress across a range of activities, from increasing access to GPs, enhancing patient choice and improving the care of people with chronic conditions. It is organised under three main headings: initiatives relating to patients and the public, initiatives affecting staff, and proposals to ensure that the system can deliver these objectives.

Patients and the public

Prevention is a major theme. There are several references to the 2006 White Paper, Our Health Our Care, Our Say. That White Paper set out a vision for better health promotion and better care of people with long-term conditions, delivered in the community as part of a drive to move care away from acute hospitals. This has been an enduring theme of health policy for at least two decades. As the recent Audit Commission report suggested, this shift of activity away from the acute sector into the community is not happening quickly enough. The prospect of a financial squeeze has sharpened the need to deliver this shift to improve productivity as well as for patients’ convenience.

There are few new commitments in this document, but it hints at several new initiatives – such as pushing breastfeeding hard as an effective way of preventing hospital admissions for infants – and promises to identify high-impact changes ‘to transform the care’ of people with COPD, heart failure, diabetes, cancer and dementia. Although details are sparse, the emphasis appears to be on identifying best practice at a national level and applying it ‘systematically’ across the NHS. This needs to be handled sensitively if it is not to contradict the bottom-up, clinically led initiatives fostered by the Next Stage review process.

Many of the initiatives under ‘people-centred’ care are already under way. There is some clarification of recent announcements, such as the promise made by the Secretary of State for health in September that hospital income will be linked to patient experience and satisfaction in future. This will begin in 2010. Although the proportion of payment that will be linked is not specified for next year, ‘up to 10 per cent of trusts’ income’ could be affected within a few years. The initiative is designed to give providers a strong incentive to measure and improve the experiences of their patients. However, there is still some uncertainty about how effective this might be. Routine patient experience surveys are still limited in scope – sampling 800 patients a year, with a 60 per cent response rate – a less-than-robust basis on which to allocate significant proportion of hospital income.

This could be helped by the proposal for more in-depth measurement of patient experience at a service level within each hospital, but the costs of this exercise are not to be underestimated and could prove challenging beyond 2011, especially if trusts are faced with trade-offs between investment in frontline services and in collecting patients’ experiences.

NHS organisations

The main initiative affecting hospital providers is the announcement of a ‘maximum uplift of 0%’ for the next four years. This is designed to force hospitals to take a hard look at their costs: those with above average costs could lose money. There is a risk that some hospitals might drop services altogether if they are losing money or else they will have to continue to cross-subsidize inefficient services.

On its own, this initiative will not liberate cash for commissioners, as efficient hospitals can still increase income by performing more procedures. There is a broad ambition to adapt the tariff in order to incentivise the shift away from hospital care, but no details beyond establishing that there will need to be some way of ‘limiting payments providers receive when activity exceeds planned levels’. There are already mechanisms in place in the acute contract for PCTs to limit the level of unplanned elective care, suggesting that this might be used to tackle emergency admissions.  

Clearly the focus for the NHS must also be on demand management. There are proposals that PCTs and practices are given better information on referrals and admissions and patients who need operations are given more support ‘to decide whether they want an operation or not’.

There are strong signals that the government would like to see more integration between hospitals, primary care and community care. This kind of integration has been happening on a small scale locally. In future, foundation trusts will be encouraged to provide acute and community services and primary medical services in new areas, if PCTs are keen to commission from them.

The status of the NHS as the ‘preferred provider', first announced by the Secretary of State in September, is also re-emphasised here (but re-titled ‘NHS first’) with more specific guidance promised in January. 

There is a recognition that the process of making these changes at local level has not been easy but sometimes ‘fractious and divisive’. There is a promise to look again at the ‘reconfiguration process’ to see whether it can be simplified and how best to involve patients and the public.

Staff

The promise to ‘significantly’ reduce management costs in SHAs and PCTs by 30 per cent in the next four years could have significant implications for staff. It is likely these savings will have to come through reductions in staff numbers. It is accompanied by the recommendation that very senior management receive no pay increase in 2010/11.

Pay increases for other NHS staff from 2011 have been capped at 1 per cent – announced in the Pre-Budget Report (compared with a 2.25 per cent increase next year). The government is exploring the costs and benefits of offering local or regional employment guarantees in exchange for pay restraint. Whether this can be delivered locally remains unclear.  

Summary

NHS 2010–2015: from good to great attempts to set out a strong vision for the NHS to keep investing in prevention as finances become tighter and tighter. Whether prevention is crowded out will in part depend on the targets and objectives set out in next year’s Operating Framework. But it will also hinge on the strength of the levers – such as financial incentives – that are available to commissioners and the ability of commissioners to use them effectively.

References

Audit Commission (2009). More for Less: Are productivity and efficiency improving in the NHS? Health Briefing.

Brown G (2009). ‘Check against delivery’. Speech at Labour Party Annual Conference, 29 September.

Burnham A (2009). Speech at breakfast debate organised by The King’s Fund, 17 September.

Department of Health (2009). The NHS Constitution: A consultation on new patient rights. London: Department of Health.

Department of Health (2008). Using the Commissioning for Quality and Innovation (CQUIN) Payment Framework: For the NHS in England 2009/10. London: Department of Health.