Equity and Excellence: will the White Paper achieve all it sets out to?

If the proposals set out in yesterday's NHS White Paper 'Equity and Excellence: liberating the NHS' are implemented in full, the changes will have far-reaching and significant consequences for the NHS. The result will be a health care system, unique internationally, that gives groups of general practitioners unprecedented control over public funding. But will the proposals actually be realised in the way the Secretary of State hopes?

The health White Paper is littered with references to consultations. Many detailed questions remain to be answered in further documentation, which is expected to follow. Some of the proposals will need legislative change. The parliamentary process under the coalition government is as yet untested. The Bill is likely to be subject to close scrutiny both within the House of Commons and by the Lords. Some aspects will require renegotiation of contracts with trade unions. At a time when public sector pay is likely to be frozen these negotiations could be protracted. Andrew Lansley is said to be a man in a hurry, yet these issues suggest implementation could be slow.

There is a real danger that the financial squeeze on the NHS, which will start to show within 12 months, could derail implementation of the White Paper. Many providers will become financially challenged, making their ability to go it alone as a social enterprise organisation difficult if not impossible. And any appetite that does exist among GPs to take on commissioning (with support from other organisations, including the private sector) is likely to be dampened by the challenges of having to deliver huge productivity savings.

The other factor likely to make implementation more challenging is that the reform proposals themselves dismantle the very apparatus used in the past to get things done in the NHS – targets and performance management by strategic health authorities and primary care trusts. A reliance on choice and competition and the motivations of professionals and clinicians to drive the changes is a gamble. Our research on patient choice has shown that after several years, it was still having only a limited impact on providers.

If the proposals are to succeed, the government needs to engage and motivate clinicians and managers to work effectively together. They ultimately will lead change across local health economies and deliver improvements in quality and productivity. It is unlikely that managers, who face potential redundancy, and clinicians, who are being given new responsibilities without any increase in pay, will feel 'liberated' by the government's plans. Instead, the government runs the real risk that these structural and organisational changes will distract from the real task of clinically led service change.

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#170 Steve Mink

The best analysis of the White Paper I have read so far.

#173 Dr Paul Worthington

Excellent analysis. The repeated emphasis on the key role of choice is misplaced; all the evidence indicates it's not a major issue for patients, nor has it ever been a major driver for change. besides, the choice agenda the White Paper talks about is largely related to elective care, and touches only marginally on primary and community services. Moreover, it has little bearing on unscheduled care, and it's arguably the rehsaping of services in this area that is the key objective in tackling the financial and clinical challeneges we're facing.

#175 kelvin karim

An excellent summary. I agree wholeheartedly that managers and clinicians will not feel motivated to deliver the Coalition's objectives. In addition, they do not have a mandate to dismantle our NHS!

#176 Dr Hilary McDermott

I agree with your analysis. Much of the crucial detail that will make all the difference between success and disaster is still awaited. It is anti dogmatic, but I seriously doubt if the emphasis on very open competition at so many levels can deliver the appropriate joined up services and savings that we all need. There really needs to be co-operation not competition to deliver what patients repeatedly say they want - seamless quality services close to home.

#177 Nuraja

As a doctor affected by the lack of resources, I fail to see what can be achieved by suddenly implementing radical changes which will divert much energy, money and increase paperwork at this time when very penny shoukld be used to patient care?
How can any governement be allowed to make sweeping changes without a NHSwide and countrywide clear consultation? We are asked to run an evidence based practice without any evidence based decision making from the whitehall. Why have we lost the will and power to say NO?!

#178 Dr C Potter

Clearly major changes to the present, clumsy, ignorance-lead organisation are necessary. I just hope we can get it right this time.

The Federation of GP Commissioners

I agree with Anna whole heartedly.There is lot of scaremongering going on by various bodies that if we donot subscribe to Federation we are doomed.Why did this situationarise -the reason is the failure of PBC even though there was money but the beauraucracy won.Now there is no money and half the professionals fed up its too late.Even the petitions to D H or SHA are not actioned-personally i am positively negative anout the whole issue-let the natural coalition happen and then we will progress

#180 Georgina Parkes

If there are going to be real monetary cuts then I do not believe another radical change to the NHS is the way to save money but is a way to waste further resources. Why should we pay for more expensive management consultants and consultations? It would be nice if we were allowed to get on with our jobs without major structural changes for at least 5 years- that would be a good initiative. Each successive government looks on the NHS as something to change large scale as a vote winner. It is such a massive organisation that individual clincians if they have the drive and the ability, improve services locally much more than any government initiatives. Besides most large scale changes barely get implemented before the next one comes along. I do my job despite government initiatives.

#184 Christpher P

An excellent analysis of the White Paper.
Given the unprecedented commissioning changes indicated by the White Paper - and the closer alignment of a more streamlined health service with Local Authorities; with drive to reduce duplication and bureaucracy, an additional question is whether reform of Local Authorities will be on the horizon too, given the mix of Unitary Authorities, District Councils and County Councils etc.. How the health and social care agenda, as well as other services, link at the right level and translate across these boundaries safely and effectively will be key to ensuring improved outcomes for individuals and the population, whilst maintaining local accountability.

#195 Dee Speers

As is the current situation, will the data of evidence be fundamentally flawed by passive regulation and an untenable complaints process?
Integrity is telling yourself the truth....honesty is telling the truth to others.

#196 Dee Speers
5 years in NHS complaints!

The Parliamentary Health Service Ombudsman (PHSO) only reviews less than 2% of complaints brought to her, thus leaving over 98% of complaints unresolved. PHSO has never investigated a 'reconsidered complaint' (which can take up to a year of reconsideration)and yet this complaints process costs us in excess of £34m per annum....."FOR WHAT!"

My local LINKs manager states "We are currently wading through the White Paper consultation documents and trying to figure out a way of making them accessible to the general public. My fear is that no “normal person” will have the time, will nor inclination to respond to the consultation documents and even if they do I wonder how much of what is going to happen nationally will be decided by the powers that be?" IS THIS LOCAL NEEDS BEING IDENTIFIED?

As I see things, it appears the current aim of complaints is to frustrate and delay, in fact it seems common practice especially in the most contentious cases…e.g. Ian Tomlinson death investigation delay meant that an assault case timed out. My sons case is taking too long so that the Human Rights opportunity (that the solicitor was prepared to fight for free) timed out after a year.

Therefore, I believe, the purpose of investigations is to frustrate and delay so as to defend the perpetrators as a far as possible. Whilst such a tactic does nothing to improve the performance of the State, it saves it from too much reputational damage (undeservedly!).

We need to break out of the cycle and remove the protection. There will be a short term hit on the reputation of the State, but the driver to improve State performance will at least then be there. Improved performance would then restore the reputation of the State long-term.

Will the NHS Complaints process now be independently reviewed?

#258 Laurie Trott
Equalities Consultant

Anna,s analysis is well thought through and precise. I we look at the proposals in more detail we see, for example the notion of patients having the choice of provider and choice of treatment. In the final analysis these decisions will have enormous fininacial implications, For instance if patients regularly choose the most expensive treatment option for a particular complaint, then will this be continued to be offered, or simply 'left off' the option list? More importantly, to understand the implications of treatment choices in some cases, requires substantial knowledge and understanding - will this lead to the public reverting in most cases to say 'You do what is best for me, Doc' Finally, the the paper proposes that it will 'seek to ensure that everyone, whatever thier needs or background, benefits from these arrangements'. In order to achieve this, there will, in my view, need to be substantial investment in work with many sections fo the community for whom barriers exist to accessing health care in the U.K.. This is manifest when one analyses the proportions of the people from some minority groups who access services, compared to the general population.

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