The Coalition Government’s White Paper on health sector reform (“Equity and Excellence: Liberating the NHS”), published on 12 July 2010, sets out an ambitious programme for the implementation of major structural changes to the NHS. The Secretary of State for Health, Andrew Lansley, describes the NHS of the future as one which is built on the Government’s core beliefs of “freedom, fairness and responsibility”; themes which feature in the current NHS but which look set to become more pronounced in the coming years. While the health sector is still trying to get to grips with the implications of such wide-ranging reforms, early indications are that there have been mixed responses from both within the NHS and the independent sector. The scope for opportunities to improve the way in which public health services are provided is recognised by the industry but there is still a lot of work to be done to define the practical application of such opportunities and in particular, who will have the power necessary to bring about changes on the ground in an efficient, balanced and cost-effective manner.
The White Paper attempts to hide the obvious complexities of introducing major structural changes to the NHS by focusing on a number of key “selling points”, designed, no doubt, to win over the public and those closest to the frontline delivery of patient care. The reforms are based around the following themes:
- Patients at the heart of the NHS;
- A focus on clinical outcomes instead of process targets;
- A reduction in bureaucracy and top-down control;
- The empowerment of health professionals – ownership and accountability in the hands of frontline staff; and
- The promotion of better public health and reform of the social care system.
Patient led NHS
There is no doubt that the Coalition Government is determined to drive the future of the NHS by reference to the needs and the choices of the patient. There are plans to extend patient choice through increasing choice of provider, introducing choice of named consultant, permitting patients to register with any GP and expanding choice into maternity services, mental health, long-term care, end-of-life care and diagnostic testing. There is also a greater focus on patient responsibility and empowering those in need of care to make their own decisions about how they use the NHS. Patients are to be given better control over their own health records and improved access to information about GPs and hospitals (including performance data) to help inform decisions about their health. Personal budget pilots are also to be encouraged, particularly for those with long-term care needs where there may be a crossover between health and social care budgets.
Better Health Outcomes
The former government’s approach to performance managing the NHS is widely criticised, particularly by those in frontline clinical roles who believe that the best health outcomes are achieved by ensuring that management is clinically led rather than target led. The proposals for reform include scrapping all process-based targets and introducing national outcome measures based on quality standards set by NICE. The existing Payment by Results system will also be revised and extended to cover community services, mental health and end-of-life care.
Revolutionise NHS accountability – “de-layering” the NHS
Perhaps the most fundamental change in NHS structure is the abolition of Strategic Health Authorities and Primary Care Trusts. Instead, an NHS Commissioning Board will be established and, controversially, GP commissioning consortia will take responsibility for most of the current commissioning role of PCTs (full responsibility from April 2013). Further liberalisation of the NHS will come through the conversion of all NHS Trusts to Foundation Trusts and, potentially, greater freedoms for Foundation Trusts in the management of their own affairs. Regulatory changes are also proposed involving greater powers for Monitor to act as an economic regulator for the whole of the NHS as well as an enhanced scope of responsibility for the Care Quality Commission.
Promotion of Public Health
A much greater focus on improving public health as a preventative measure will come with the creation of the “Public Health Service” and an enhanced role for local authorities in setting public health agendas and educating and incentivising local communities to take responsibility for improving their own health. There is also an emphasis on jointworking between local authorities and the NHS to improve public health outcomes at a local level.
Reform of Social Care
A shake-up in the funding of the social care system is expected with a further White Paper on Social Care Reform to be published in October 2011. In addition to giving greater independence and choice for users of the social care system, the use of personal budgets is intended to be implemented on a national scale following evaluation of the results of initial pilots.
The proposed structural and policy changes in the White Paper will not be welcomed by everyone, but for those who are prepared to look for the opportunities inherent in the proposed new NHS world, the outlook for the future could be positive. For example:
- Opportunities for GPs to shape local healthcare provision – While there are plenty of sceptics, entrepreneurial GPs will grasp the opportunity with both hands. One of the biggest obstacles will be ensuring that commissioning consortia have the requisite expertise and resources to make the new arrangements work. While existing expertise within PCTs/SHAs should not be lost when those bodies are dissolved, there is scope for new talent to support the creation and ongoing operation and management of new GP consortia, including perhaps, through joint ventures with the independent sector.
- Opportunities for the independent sector – The increased focus on patient choice and outcome related measures of performance may well open up the market even further and improve the independent sector’s chances of winning work. This view is supported, at least in theory, by the move to give Monitor increased powers as economic regulator of the industry, with the tools to aid the development of a level playing field for those involved in health services provision.
- Potential for growth in social enterprise sector – The Coalition Government is very keen to transfer power into the hands of employee led social enterprises, thereby promoting change at a local level by those who are closest to the frontline delivery of services to the community. There are undoubtedly challenges to the creation of social enterprises, but for those employee groups with the skills, determination and entrepreneurial spirit to “go it alone”, the path to creating social enterprises may not be hindered by as many obstacles as we have seen in recent years. There are also opportunities for the independent sector to partner with new social enterprises to bring about change perhaps faster and more effectively than might otherwise be the case.
- Potential for hospital trusts to benefit from greater autonomy – The conversion of all NHS Trusts to Foundation Trusts is, for many, a positive step forward and may lead to a much more commercially focused NHS with hospital trusts who are willing to pursue new and innovative ventures with social enterprises and the independent sector.
- Potential for a more joined-up provision of health and social care – The concept of plurality of service provision across the health and social care arena is not new but was slow to progress under the previous government’s initiatives. How the NHS and local authorities will structure closer joint working remains to be seen but there is plenty of scope for the independent sector to influence their approach. Models such as NHS LIFT and the Scottish HUB may well prove to be useful structures for the roll-out of new initiatives.
While the White Paper focuses on the high level reasons and objectives behind the proposals, there have been a steady stream of publications since July setting out details of how the proposals will be implemented and more are expected. Consultations on discrete aspects of the reforms have already been published, giving interested parties an opportunity to comment on the proposals and influence the way they are implemented. No doubt, top on the agenda for the independent sector (along side the future of the NHS tariff) will be to seek clarification of the Government’s proposals for addressing NHS pension provision and the impact this has on the “level playing field” for independent sector providers tendering for opportunities in the NHS. This was a difficult issue for the previous government and is only briefly referred to in the White Paper.
The far-reaching proposals in the White Paper are a bold move for a Coalition Government still in its infancy. Whilst there have been other significant structural changes in the NHS over the last decade, the reforms outlined in the White Paper (in particular, the “de-layering” of NHS management and the empowerment of frontline clinical staff) seem driven by a genuine focus on improving health outcomes and creating a patient-led service. This is in keeping with other initiatives in the Coalition Government’s agenda - not least, Cameron’s “Big Society” which also focuses on empowering communities and the people within them.
As the proposals in the White Paper unfold in more detail, the independent sector should work along side the NHS and local authorities to influence the direction of travel, ensuring that the ideas and concerns of all key players in the health sector (public, private and third sector) are accommodated and that each of them is given the opportunity to influence the future of the NHS.