Ten challenging questions about the White Paper

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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?

Comments

Andrew Craig

Position
partner,
Organisation
Moore Adamson Craig Partnership LLP
Comment date
09 July 2010
Great questions Chris. Here's no 11 for you: what about LINks and Healthwatch? Synergy or conflict?

Catherine Lander

Position
Speech and Language Therapist,
Comment date
09 July 2010
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.

george paton

Position
psychiatric nurse,
Comment date
09 July 2010
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

Richard McCallum

Position
Head of Oral Health,
Organisation
NHS Nottinghamshire County
Comment date
09 July 2010
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?

Dr Paul Worthington

Position
NHS Project Manager,
Comment date
09 July 2010
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 ?

Anon

Comment date
10 July 2010
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.

simon knighton

Position
ce,
Organisation
eppcic
Comment date
10 July 2010
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.

Rhion Jones

Position
Programme Director,
Organisation
The Co0nsultation Institute
Comment date
11 July 2010
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 ?

Anon

Position
IT Architect,
Comment date
12 July 2010
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

Stephen Henderson

Comment date
12 July 2010
Hmmm...
I would have thought bureaucrats were paid less to fill in forms, push-pens, dot-i's, etc.. than GPs?

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