Reforming the NHS: changes to the Health and Social Care Bill

The explicit duty on the Secretary of State to provide or secure the provision of a comprehensive health service removed.

Widespread powers for the Secretary of State to intervene if national bodies fail to perform their functions.

No specific requirements about how consortia should be governed.

Duties on GP commissioning consortia and the NHS Commissioning Board to involve patients in commissioning decisions.

The Secretary of State's duty to promote a comprehensive health service restored. Secretary of State will be ultimately accountable for securing the provision of services – this duty will be exercised through the NHS Commissioning Board and other bodies.

Secretary of State now able to intervene only if institutional failures are 'significant'. New requirement on NHS Commissioning Board and clinical commissioning groups to promote the NHS Constitution.

Clinical commissioning groups required to have a governing body that must adhere to Nolan Principles. Two lay members must be included to champion public and patient involvement and lead on governance.

Governing bodies must meet in public, with minutes of meetings and details of contracts to be published.

How will the rights contained within the NHS Constitution be guaranteed?

How will the Prime Minister's pledge to keep waiting times low be measured and enforced?

Will the pathfinder scheme for commissioning consortia be properly evaluated and lessons learned to inform the roll-out of clinical commissioning groups?

Will the more prescriptive approach now set out in the Bill lead to over-centralisation and discourage locally led innovation?

Choice to be extended beyond elective care to most NHS-funded services by 2013/14.

Duties on the NHS Commissioning Board and commissioning consortia to promote patient choice and involve patients and their carers in decisions about their care.

Patients to be able to choose their GP, regardless of where they live.

A 'choice mandate' to be included in the NHS Commissioning Board's mandate from the Secretary of State.

Duties to involve patients and their carers in decisions about their care strengthened to better reflect the 'no decision about me without me' principle.

Personal health budgets to be extended through a mandate to the NHS Commissioning Board, with a right to a personal budget to be introduced over time.

How will the government make a reality of shared decision-making in clinical practice?

How will the NHS Commissioning Board be held accountable for delivering on the 'choice mandate'?

How will decisions be made about extending personal budgets to more conditions?

60 per cent of NHS budget to be transferred to GP commissioning consortia to commission the majority of local health services.

Commissioning consortia required to obtain advice from health professionals but wider clinical involvement in commissioning process limited.

All commissioning consortia to be in place and operational by April 2013. GP practices to be members of GP commissioning consortia as a condition of their ability to practise.

No requirement for commissioning consortia and local authority boundaries to align.

Primary care and specialist services to be commissioned by the NHS Commissioning Board.

Part of GP practice payments to be linked to quality premium based on performance of GP commissioning consortia.

GP commissioning consortia re-named clinical commissioning groups, reflecting requirements for wider clinical involvement in commissioning.

Clinical commissioning groups required to obtain advice from a wider range of health professionals and will be supported by clinical networks and new clinical senates. Governing bodies must include a nurse and a hospital specialist

Clinical commissioning groups to be established either in full or in shadow form by April 2013, but take on their new responsibilities only when they are 'ready and willing'. All practices still need to be members of a clinical commissioning group by this date.

Requirement that the boundaries of clinical commissioning groups should not normally cross those of local authorities, with any departure needing to be clearly justified.

Quality premium revised to focus on quality and outcomes and may take account of progress in reducing inequalities in health.

Will the multiple lines of accountability and requirements to consult immobilise clinical commissioning groups?

Will clinical senates and networks be locally based sources of advice and support to clinical commissioning groups or outposts of the NHS Commissioning Board?

Will momentum be maintained or will the changes discourage enthusiastic GPs from leading reform at a local level?

Who will be responsible for driving major reconfigurations of hospital services?

Will the NHS Commissioning Board adopt a top down or locally led approach to quality improvement in primary care?

How will conflicts of interests be managed for GPs as provider and commissioners of services?

Any willing provider' will be able to provide NHS-funded services.

Providers to be permitted to offer services at less than the mandatory tariff price.

Any willing provider now called 'any qualified provider' and will be phased in gradually from April 2012.

Amendments made to outlaw price competition.

Amendments to outlaw any policy to increase or maintain the market share of any particular sector of provider.

How will the any qualified provider policy work, will commissioners be able to commission whole pathways of care and how much flexibility will there be for them locally?

Under fixed prices, how will commissioners extract value for money from providers?

Will small voluntary sector providers be able to compete with larger providers?

Duties on the NHS Commissioning Board and health and wellbeing boards to promote integration of health and social care.

Integration now at the heart of the reforms, in line with the pledge made by the Prime Minister

New duties on Monitor, the NHS Commissioning Board and clinical commissioning groups to promote integration of health services.

Stronger duties on health and wellbeing boards and clinical commissioning groups to promote integration between health and social care.

Will wider changes be made to health policy (eg, the tariff) to support the development of integrated care and will health professionals be able to overcome historic divisions to deliver it?

Will the outcomes frameworks for the NHS, public health and social care be revised to reflect the new emphasis on integration?

Health and wellbeing boards to be established in upper-tier local authorities and to be responsible for developing joint strategic needs assessments and a joint health and wellbeing strategy.

Scrutiny powers of local authorities to be restricted; they would be able to use their power of referral to the Secretary of State only for significant changes to designated services.

Health and wellbeing boards to have a stronger role in promoting joint commissioning and can act as lead commissioner for some services.

Health and wellbeing boards to play a stronger role in the development of commissioning plans and will be able to refer plans back to the NHS Commissioning Board or commissioning groups if they are not satisfied with them.

Health and wellbeing boards will have a formal role in the authorisation of clinical commissioning groups and will lead on local public involvement.

Restrictions on scrutiny powers of local authorities lifted.  Consideration to be given to the feasibility of the NHS Future Forum's recommendation to develop citizens’ 'right to challenge' poor services and lack of choice.

Legal powers for lead commissioning and pooled budgets have existed for more than 10 years but few local authorities have used them – is a more prescriptive approach needed?

Monitor to become the new sector-specific economic regulator for health, with concurrent powers with the Office of Fair Trading.

Monitor's primary duty to protect the interests of patients. This is to be achieved by promoting competition 'where appropriate' and regulation 'where necessary'.

Monitor also responsible for setting prices (with the NHS Commissioning Board), ensuring continuity of essential services (with commissioning consortia) and licensing providers (with the Care Quality Commission).

Monitor remains the sector-specific regulator. The Co-operation and Competition Panel will be absorbed within it and their rules will be given statutory force.

Monitor's duty to promote competition removed, with a number of changes to focus its powers on preventing anti-competitive behaviour.

How will Monitor, the Care Quality Commission and the NHS Commissioning Board work together to ensure that their decisions do not conflict with each other?

Should Monitor's role be extended to include prudential oversight of the financial viability of health and social care providers with a significant market share of publicly-funded services?

All NHS trusts to become foundation trusts by 2014 (NHS Trust Development Authority to assist with the transition).

Controls on mergers and acquisitions relaxed to facilitate takeovers of failing NHS trusts.

Providers unable to compete will be allowed to fail. Monitor to have powers to ensure continuity of services at a local level by 'designating' them.

Private patient income cap on foundation trusts to be lifted.

The 2014 deadline for all NHS trusts to become foundation trusts has been relaxed, although the majority will still be expected to meet this deadline.

Monitor's oversight of foundation trusts will be extended to 2016 to allow time to build capability of governors.

Foundation trusts will be required to hold board meetings in public.

All providers are to be placed under a 'duty of candour' requiring them to be open and transparent in admitting mistakes.

Amendments to be brought forward at a later stage to revise the failure regime.

Foundation trusts will be required to produce separate accounts for their NHS and privately funded activities.

How can NHS trusts be helped to achieve foundation trust status in the current financial context?

Will necessary decisions be taken to reduce and in some cases close services?

What will happen to NHS trusts that are not able to achieve foundation trust status by 2014?

What will the new failure regime look like?

National leadership on public health to be provided by Public Health England, a new body to be located within the Department of Health.

Responsibility for public health to be transferred to local authorities, who will receive a ring-fenced public health budget.

Duties on the Secretary of State, NHS Commissioning Board and commissioning consortia to have regard to the need to reduce health inequalities.

Public Health England now to be an executive agency of the Department of Health.

Explicit recognition that public health professionals should be involved in the commissioning process.

New duties on Monitor, the NHS Commissioning Board and clinical commissioning groups to promote integration of health services emphasise reducing health inequalities.

Explicit duty on clinical commissioning groups to commission services for unregistered patients.

With Public Health England becoming an executive agency, will there be a strong enough voice on public health within government?

Will there be sufficient public health capacity to fulfil its various responsibilities?

Are the duties to reduce health inequalities strong enough to leverage the full potential of the NHS as a major contributor to the economy and employer, as well as a provider of services?

Will local authorities prioritise reducing health inequalities if they are not under a duty to do so?

How will the government use non-legislative levers and incentives to translate the duties in the Bill into practical action to reduce health inequalities?

Is the duty on commissioning groups to commission services for unregistered patients strong enough to ensure GPs prioritise public health?

Strategic health authorities to be abolished from April 2012 and primary care trusts by April 2013.

NHS Commissioning Board to be operational from April 2012.

These changes to be implemented alongside a 45 per cent cut in management costs.

The deadline for abolishing primary care trusts has been retained; PCT clusters will become local outposts of the NHS Commissioning Board with responsibility for overseeing commissioning groups from April 2013.

The deadline for the abolition of strategic health authorities has been extended to April 2013. In the meantime, they will retain responsibility for NHS finances and be slimmed down into a small number of clusters.

The NHS Commissioning Board will not take on its full responsibilities until April 2013.

The government's response to the NHS Future Forum emphasises the importance of good management and leadership.

Will the number of changes being made to the structure of the health system result in confusion and additional bureaucracy?

Will the NHS Commissioning Board be the 'lean and expert' body described in the NHS White Paper?

Will there be sufficient management capacity to manage the transition?

Will the structural reforms undermine efforts to find the £20 billion in productivity improvements needed to maintain quality and avoid significant cuts to services?