Ten things you need to know about the NHS reforms

At last we have it: a defence of the coalition’s NHS reforms that is worthy of the name. It came courtesy of David Cameron, speaking on BBC Breakfast earlier, and you can watch it in the video above. Suffice to say, the Prime Minister dwelt on the endemic waste and excessive bureaucracy of the current system, yet he also found room to explain why choice matters, and why it won’t leave patients stranded.

But, even then, the performance wasn’t perfect. Cameron may have thought he was being disarmingly honest by admitting that his brother-in-law’s fellow hospital consultants have qualms about the proposals, but one suspects it has served only to arm his opponents. Downing Street spokesmen have since put out hurried explanations that the PM was trying to “humanise” the issue.  

Much of it comes down to the reforms themselves: they do not lend themselves to snappy summary, not least becauase many of them are organisational. For welfare, it’s “making work pay”. For education, it’s “putting parents and teachers in control of schools”. For health … well, here’s our ten-point summary of the government’s prospectus, to hopefully fill in some of the gaps:

1) GP commissioning. By the government’s account, “key decisions affecting patient care should be made by healthcare professionals in partnership with patients and the wider public, rather than by managerial organisations.” To that end, they plan to establish a network of “GP commissioning consortia” by 2013, bringing an end to Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs). Under this system, GPs will be members of a consortium which controls budgets and commissions services. But the government is keen to stress that, “individual GPs or GP practices will not have to take commissioning and financial decisions on their own. The majority of GPs will continue focusing on providing primary care.” GP consortia will be accountable to the new independent “NHS Commissioning Board”. They will be under a statutory obligation to seek to reduce inequalities in access to healthcare”. How this works in practice, though, is another matter entirely.

2) Outcomes, not targets. The government’s White Paper calls for “a move away from centrally-driven process targets which get in the way of patient care; and a relentless focus on outcomes and the quality standards that deliver them”. While it stresses that processes and structures are vitally important, “they do not need to be micro-managed by central government, nor to be treated as an end in themselves, rather than the means of meeting the objectives”. And the objectives that the system will judged against? The White Paper lists five broad-brush “domains” that will be used to measure the success, or otherwise, of the NHS:

i) Preventing people from dying prematurely.
ii) Enhancing the quality of life for people with long-term conditions.
iii) Helping people to recover from episodes of ill health or following injury.
iv) Ensuring people have a positive experience of care.
v) Treating and caring for people in a safe environment and protecting them from avoidable harm.

3) The Secretary of State’s role. The role of the Health Secretary will be much more limited under the new system, but he “will remain responsible for the design of the system, the legislative framework and overall strategic coordination”. The various healthcare organisations will be required to work in partnership and, where they fail to do so, the Health Secretary will “have a new ability to write formally and publicly to the organisation in question.” Where “the breach in the duty of partnership is significant, is sustained and is having a detrimental effect on the NHS,” he will be able to impose constraints on the organisation. The bill also sets out the Health Secretary’s role in promoting public health, including providing “services or facilities designed to promote healthy living” and “financial incentives to encourage individuals to adopt healthier lifestyles”. That’s all the Nudge stuff coming through.

4) Local authorities’ role. The government wants local authorities to have “an enhanced role in supporting the delivery of health and social care service”. By April 2013, all upper tier local authorities will have to set up a “health and wellbeing board”, consisting of councillors, NHS, public health figures and patient representatives. Local government will also be responsible for “bringing together the NHS, social care, public health and children’s services” to perform a “joint strategic needs assessment” (JSNA) and create a “joint health and wellbeing strategy” (JHWS) to address local needs. NHS and local authority commissioners will be legally obliged to consult the JSNA and JHWS when preparing their services.

5) Watchdog for patients. We already have bodies to champion local views on healthcare. They’re called – in typical public sector speak – Local Involvement Networks (LINks). But now the government wants them to “evolve” in local Healthwatch, “supported and led by Healthwatch England as an independent consumer champion”. These organisations, consisting of local individuals and community groups, will ensure “public involvement in the commissioning, provision and scrutiny of local care services”. Healthwatch will also “provide advice and information to enable people to make choices about health and social care”.

6) Stronger Foundations. Taking yet another leaf out of Alan Milburn’s  book, the government wants to “liberate NHS providers” such as hospitals and ambulance services. In practice, this means that they will encourage all NHS trusts to become Foundation Trusts (FTs). And those FTs will be made even more independent from the state, thanks to being able to “rely less on external oversight from Monitor, in its current role as regulator of foundation trusts, and more on their own internal governance.” The bill also removes the cap on the income that FTs can make from private patients, which the White Paper calls “both arbitrary and unfair in its effects” (and which does not apply to NHS trusts).

7) “Fair, stable and transparent” regulation. The government will strengthen the Care Quality Commission’s (CQC) role in ensuring “essential levels of safety and quality” from providers. Its scope will be extended to primary care providers, such as GPs, and its responsibility for assessing NHS commissioners will be transferred to the NHS Commissioning Board, to allow CQC to focus on regulating providers. The non-departmental body Monitor will become an economic regulator for providers, and will carry out three core functions: promoting competition; regulating prices; and securing continuity of supply where there is no alternative provider.

8) Cutting admin costs. The government plans to cut extraneous administration costs by: removing layers of management (such as PCTs); culling the number of arms-length bodies from 18 to 8 by 2013-14; cutting out duplication of services; and removing some functions from the national level entirely. In this way, it hopes to save £1.9 billion a year by 2014/15.

9) Culture change. The government has coined a dreary couplet to describe what patients should expect from the NHS: “no decision about me, without me.” Aside from the specific bodies mentioned above, this will require a “culture change,” it is said, in the relationship between healthcare professionals and patients. This will be driven “through leadership and action across the health community”.

10) The importance of personal budgets. Personal budgets have operated in social care – with some success – for a while now. So why not extend them throughout the health service? This, at least, seems to be what the government is thinking. According to them, personal health budgets will be managed in one of three ways: a “notional budget, ” where the NHS holds the money for the patient and buys the services on their behalf; a “third party arrangement,” in which an independent organisation holds the money; or a “direct payment,” where money is transferred directly to the patient to buy their own services. The White Paper makes it clear that the current pilot scheme (which will conclude in October 2012) is of “high priority” to the government, and commits it to extending personal health budgets nationally if it is successful.