3. Revolutionise NHS accountability
by Department of Health on 12 July 2010 | 23 commentsCreate a long-term sustainable framework of institutions with greater autonomy for doctors and nurses, and greater accountability to patients and the public, focused on outcomes
Actions: Improve commissioning and resource allocation | GP commissioning | Reduce bureaucracy | Set providers free | Strengthen local democratic legitimacy | Increase local say over reconfigurations| Develop Monitor into an economic regulator
3.1 Improve the effectiveness of commissioning and resource allocation
i. Publish commissioning proposals in White Paper – (Start Jul 2010)
ii. Establish NHS Commissioning Board in shadow form – (Start Apr 2011)
iii. Complete abolition of Strategic Health Authorities – (Start Apr 2013)
iv. NHS Commissioning Board fully established – (Start Apr 2012)
v. NHS Commissioning Board makes allocations to GP consortia for 2013/14 – (Start Autumn 2012)
3.2 Enhance commissioning to give GPs greater autonomy
i. Launch engagement on proposals for GP commissioning consortia – (Start Jul 2010)
ii. Begin to establish GP commissioning consortia in shadow form – (Start Apr 2011)
iii. Formally establish GP commissioning consortia – (Start Apr 2012)
iv. GP consortia take full responsibility for commissioning – (Start Apr 2013)
3.3 Reduce bureaucracy
i. Publish review of Arm’s Length Bodies – (Start Summer 2010)
ii. Legislate to abolish unnecessary Arm’s Length Bodies – (Start Oct 2010 – end Nov 2011)
iii. Incorporate health protection functions into the Public Health Service – (Start Apr 2012)
iv. Abolition of Primary Care Trusts once NHS Commissioning Board and GP commissioning are in place – (Start Apr 2013)
3.4 Set providers free and reduce political interference
i. Publish proposals in White Paper to reform Foundation Trust governance – (Start Jul 2010)
ii. Establish “turn-around team” for NHS Trust transition to Foundation Trust status – (Start Sep 2010)
iii. Complete transition to Foundation Trust status – (Start 2013/14)
3.5 Strengthen local democratic legitimacy by creating a greater role for local government in health and well-being
i. Publish proposals in White Paper for consultation – (StartJul 2010)
ii. Begin implementation of proposals – (Start Apr 2011)
iii. Full implementation of proposals – (Start Apr 2013)
3.6 Increase local say over reconfigurations
i. Local authorities have the right to challenge health organisations over the closure of local services, and refer cases for national arbitration – (Start Jun 2010)
ii. Stop the centrally-dictated closure of A&E and maternity wards, so that people have better access to local services – (Start Jun 2010)
3.7 Develop Monitor into an economic regulator that will oversee regulation to ensure access, choice, competition and price-setting for health and social care
i. Publish proposals for developing Monitor into an economic regulator – (Start Jul 2010)
ii. Include provisions in Health Bill for Monitor to become an economic regulator – (Start Nov 2010)
iii. Launch Monitor as an economic regulator – (Start Apr 2012)
iv. Monitor regulates all providers – (Start 2013/14)
On 21 July 2010 Chris said:
GP commissioning will not revolutionise NHS accountability, it’s merely a rearrangement of deck-chairs.
The managers currently working at PCTs will simply transfer to the new GP consortia (possibly as private consultants), albeit GPs will probably demand a commensurate pay rise thanks to their new expanded ‘role’.
However, there are health policy experts pushing for truly radical reform. Forward looking members of the the Department of Health would do well to hear them out.
Real, ‘revolutionary’ structural reform of the NHS means radically changing the shape of the organisation.
It means changing it from the 3rd biggest employer in the world, management behemoth and simultaneous postcode lottery into an organisation that truly reflects its founding principles.
http://www.reform.co.uk/Research/ResearchArticles/tabid/82/smid/378/ArticleID/1/reftab/79/t/Making%20the%20NHS%20the%20best%20insurance%20policy%20in%20the%20world/Default.aspx
On 22 July 2010 ms said:
I am all for having seamless medical care. However I do recognise that the NHS has many flaws (no large organisation is!) but to scrap accountability and monitoring aspect of Medicines Management is not the answer. What I would challenge is if the Government is looking for value for money, look at the work that Pharmacists within the Medicines Management teams have done in their respective patches, that is where you will find the expertise to guide GPs in commissioning of evidence based medicines and cost effectivness. Giving a broad statement that GPs will be working with other HCPs is not a get out quick clause but will also give the larger majority of GPs the sense of what is happening and what has been achieved in their localities.
On 22 July 2010 Quentin Cornish said:
Four comments only:
1) It’s time for politicians to leave the NHS alone – and that includes the current “coalition” bunch. Every reorganisation deflects attention from the real job of the NHS, which is not – in my view, as an NHS employee of 30 years’ standing – to be the plaything of idealogues but to provide a universal and excellent health service. I think it is true that all the good ideas I have seen in the NHS have come from within it (or from other countries’ health systems); all the bad ones have come from politicians. This White Paper is an addition to the latter group.
2) How does giving all the commissioning money (and therefore a huge lumo of power) to just one group of professionals (i.e. GPs) help anything? I know GPs present themselves as the ones who know what local need is, but this is just their propaganda: if anyone really wanted the staff with the best on-the-ground knowledge of health need to control commissioning, they’d pick community nurses and CPNs, not GPs. GPs are incredibly varied in their competence, interests, motivation and skill-levels (they range from the venal to the expert) and none of them is, crucially, accountable to the rest of the NHS or the public. Letting them commission services for substance misuse or severe mental illness is just bizarre. Plus GP Fundholding was a complete disaster, as even this White Paper recognises. Of course, doctors are generally of the same social class as Conservative politicians, and so the old master-servant relationships in health were always likely to be strengthened under this government.
3) If an A&E department is small or under-used and does not have the throughflow to maintain staff expertise in major accidents and illnesses then it is by definition dangerous and should be downgraded or closed. Local public opinion is irrelevant to this – people may have opinions but they are very unlikely to be based on meaningful knowledge. Populist politics here is playing with lives.
4) NHS managers didn’t come about by accident: there are many things in NHS services that need the skills of a manager and a managerial overview that clinicians cannot bring. Clinicians are most needed to treat and care for patients, odd though that may seem, and we currently often run our hospitals with too few expert nurses and doctors as it is. “Doctors and nurses” (that old politicans’ duo) and other clinical staff should not be running Trusts but caring for their patients. Politicians do not understand this.
On 23 July 2010 Jon said:
There is a widespread view among clinicians that there exists a need to free clinical services (both primary and specialist) from the dead hand of PCT and SHA bureaucracy. The demise of these structures is surely to be welcomed. However, it would be a missed opportunity if this reorganisation led merely to a shuffling of the deckchairs. It is high time that most of them were folded away for good, although it will take considerable courage to free the NHS from wasteful scourages such as “mandatory training” (when irrelevent to specific staff needs), along with the plethora of pointless non-clinically relevant posts. It is hard to see the economic justification of often highly paid jobs in areas such as social marketing or carbon officers, to give several examples, or to understand the futile duplication of functions such as clinical governance and audit across local bureacracies within the same organisation. These reforms are a wonderful opportunity to divest the NHS of centralised bureaucracy.
On 27 July 2010 Paul said:
Quention Cornish makes the most cogent point about this. I agree wholeheartedly with points 1&2 and can see merit in points 3&4.
Some of our GPs are wonderful and would make an excellent job of commissioning. Some are truly awful and will make a complete hash of it.
Perhaps the coalition can advise how they will detect (presumably by means of interviewing, appraisals, cognitive assessments, psychometrics, tasks during interview, sending on courses to McKinsey) which is which? If they’d like a list from my area I’d be happy to provide one.
On 27 July 2010 Paul said:
3.6 Increase local say over reconfigurations
i. Local authorities have the right to challenge health organisations over the closure of local services, and refer cases for national arbitration – (Start Jun 2010)
This one particularly intrigued me. As my LA has consistently prevaricated (along with the PCT) about allocating more funding to my team (and other teams) I wonder how the coalition thinks this will be achieved and what they think the result is.
I’m not clear that there is anyone in the LA that has a particularly good understanding of what is needed in the local health population. I have spent a lot of time trying to tell them what is required re my own area of expertise but it has fallen on deaf ears. The PCT has a slightly better understanding but only slightly.
On 29 July 2010 Peter said:
I would have thought that when GPs were training for their future, they had the desire to become clinicians, not commissioners. If the GP Consortia comes into being, how many GPs will an area lose and how many of the current PCT commissioners will just move into a new role with the consortia??
Isn’t this just a political dogma coming in under the guise of cost cutting/ money saving at the cost of health to the man in the street?
On 29 July 2010 Dianne said:
I agree with Quentin’s comments too. Each time the NHS reorganises a great deal of time and money is wasted.
Whoever commissions the services, there will be some who get it right and some will get it wrong whether they are mangers or GPs. But if we keep restructuring we keep losing the lessons learnt by those mistakes.
On 02 August 2010 jagb said:
The model of a centralised commissioning board does not ensure quality of service and value for money. Neither does putting public money in the hands of private sub contractors to the NHS who have a conflict of interest. Who will undertake clinical governance of the services they commission? Other GPs?
On 03 August 2010 YS said:
I totally agree with the comments and all the points made by Quentin Cornish. I have a clinical background (nursing) and moved into commissioning (I still continue to practice clinically) as I strongly felt that I can make a difference and really influence the local health agenda using my clinical knowledge and understanding, my local knowledge and understanding and having the strategic view – whatever the view maybe of this government but with the all the reforms PCTs have gone though over the last 6 years alot of things were also achieved – certainly locally we had started to tip the balance towards improving outcomes for people (reducing teenage coneptions, improving uptake of vaccinations, improving access to primary care, improving access to out of hours care, reducing waitng times and starting to drive up quality within secondary care provision. this seems to have been discounted by this government with their sweeping statements.
Unfortunately locally handing commissioning lead to GPs will be a real backward step – locally majority of our GP practices are single handed practices and they are single handed for a reason – these GPs do not like to work in partnership with other GPs and professionals – how they will manage to come together in consortia to commission services will be the scary part – all the positive work that has been done to date will be undone and unfortunately postcode lottery will start to creep in again.
The final point I would like to make is that all this re-organisation will actually cost more not reduce costs – it does not take genius to work this one out!!
On 03 August 2010 Susan said:
I welcome any actions that will improve the quality of care for all patients. I support the move to abolish PCT’s and SHA mainly because of the proliferation managers with support mangers, support managers assistance etc etc. Unfortunately there is no evidence to support the move to give commissioning power to GP’s. Whilst I am sure there are some able GP’s as with any group there are also those who do not have the ability or knowledge that is required. We need to move away from the medical model of care and look toward a multidisciplinary focus – in short , how can putting more power in the hands of the medical staff improve care, when it hasn’t worked in the past?
On 05 August 2010 Jerry said:
I am fearful that GP commissioning will decrease health equality. When the patient knows that their doctor holds the purse-strings it will be very hard for that doctor to tell the patient they can’t have the treatment they want. Therefore it will be the people who shout loudest who will get the best treatment. As usual it will be groups such as the elderly and people with mental health problems who come off second best.
On 10 August 2010 VS said:
Two points – as a GP, I am wondering who is going to be blamed when the money runs out in a few months/years and we are seen by the public to be holding the purse strings – clever move by the politicians I would say.
Secondly, it was my understanding that both PCTs and PBC groups were developed with the idea of encouraging greater clinician involvement in managing health care. Both work moderately well for our local health care – but the number of GPs involved is very small – most of us simply do not want to give up our clinical time to move into commissioning, something that few GPs are likely to feel confident or skilled in. What evidence is there(in this current evidence based age) that these proposals will attract any greater interest and involvement from GPs?
On 12 August 2010 Eric Sharp said:
As the decision has long ago been made that the NHS will be a ‘marketised’ service, the first and most obvious economy has already been lost. Provider trusts have to employ managers with the sole purpose of bidding for contracts, and commissioning organisations owe their whole existence to the market model. To offset these losses, the commissioning processes need to be lean, efficient and stable, and the commissioners need to have sufficient understanding of what they are purchasing to define the contract, and sufficient skill and power to drive a hard bargain. PCTs had just about got big enough and established enough to challenge the major provider trusts. Although these provider trusts are generally internally motivated to do things very well, they aren’t always so good at doing the right thing, so the commissioners specifications are really useful. GP conglomerates will go through the same evolutionary process as PCTs because effective commissioning processes have an inescapable logic, which defies government dictats. The GP organisations will become truly efficient as commissioners about three years after going live. That’s in six years time. GPs are astute, community minded and with a good overview of the health care needs of their patients. Unfortunately they can’t compensate for errors of judgement in policy, so it will be a long slow road.
On 13 August 2010 Watson Low said:
When the next Stafford Hospital happens who will the Government be blaming? Or to put it another way, while you are tinkering with your new toys who is addressing the real problems of the Health Service?
On 13 August 2010 Healthy Thoughts « Sustained Fort said:
[...] August 13, 2010 This is a comment I entered on the Department of Health “Have your Say” website: [...]
On 13 August 2010 Peter Nash said:
I am fed up having just received a second THE GP PATIENT SURVEY questionnaire, managed by Ipsos MORI and paid for by the Dept. of Health. I completed the first, promptly, and wonder what the costs are of sending duplicate requests presumably as “they” are unable to properly cope with recording the initial returns.
On 21 August 2010 John Swiffin said:
After a 3 year term as a public governor on a Foundation Trust, I am not at all persuaded that there is any need at all for a group of 30+ Governors, nor indeed a costly chair and part time directors.There is no scope to dicuss local issues because of ther vast pile of endless papers/studies/reports/affiliated group reports.
Non of which seem to add little to the end result of quality patient care.
When I asked to clarify a point about dirty wards I was told that the Cleaners are bought in and not directly under the control of the hospital. That says it all really.
Far to many managers,and far to many political appointments are all being paid very highly. I have papers supporting this.
I came off because I do not wish to waste time and public money pretending that NHS Trust Hospital Governors have any real use.
Have a serious think about it..Please
On 27 August 2010 R said:
Why don’t you use this opportunity to get rid of duplication in Government. The Digital Information Policy team in the DH Informatics department just rehash guidance from the Information Commissioner and add no value to it in the process. The Information Governance Toolkit duplicates information collected by other regulators. The rest of the public sector has no such function.
On 06 September 2010 AA said:
I find it amazing that there are those that object to clinicians having a greater role in commissioning services with proclamations that their only role is to treat patients. Most other countries seem to have no problem involving clincians to help lead delivery of healthcare.
I am not a GP but the basic issue is that GPs are the most likely to hear from patients whether things are working or not. A non-clinical manager will never receive that feedback directly. The suggestion that CPNs and community nurses would be better is also ridiculous as these two groups have very focussed roles, the majority of patients will never see a CPN and it’s rare for a patient under the age of 60 to have much interaction with a community nurse. They both have very important but targetted roles – they are not generalists. The truth is that the GP is the one person that is exposed to the vast majority of patient groups. Of course that doesn’t mean that other healthcare professionals shouldn’t be involved and I certainly think that there would be merit in having nurse, physiotherapist, pharmacist, CPN, etc. representation on the consortia but one has to acknowledge that GPs (like them or not) are the lynchpin of the NHS. Over 80% of all healthcare in this country is delivered by them.
My biggest reservations with regard to these proposals are:
1. They will not be properly funded and therefore doomed to fail from the outset. One has to recognise that any change like this will initially cost more before the true savings come in.
2. There seems to be little oppurtunity for input from secondary care doctors and nurses which is a shame as just as GPs are directly responsible to patients in the community, hospital doctors and nurses are directly responsible to hospital patients.
I personally would like to see a situation where GP consortia commission care from secondary care clinicians to a create a more joined up system. Then the role of management on both sides would simply be facilitating those discussions, provide the figures to back up the plans and advise on implementation. GPs talking only to hospital managers I’m afraid may not achieve the goals that this Government want to acomplish. Clinicans need to be actively engaged on both sides of the fence so that we can get rid of the fence altogether and end up with truly integrated care which is what will really benefit our ageing population.
On 07 September 2010 stuart clegg said:
How will the Government handle the obvious conflict of interest GPs will face in their dual role as commissioners and providers? How can patients be sure that when a GP refers them to a service run by someone else in their Practice, in preference to a Consultant-led service, they are not influenced by the additional profit that will accrue to their own Practice, rather than purely clinical motives? Will there be any mechanism for the public to have access to such activity patterns and by which Consultants who suspect this is happening (perhaps by noticing that patients are being referred to them later than is clinically acceptable) can have their concerns investigated?
On 08 September 2010 steve said:
Despite the usual call to reduce NHS bureaucracy, NHS managers are better placed to manage NHS hospitals if it means clinicians can get on with delivering health improvement outcomes. I’d suggest a radical look at the manager/clinician ration – start by asking what resources a hospital needs to provide maximum healthcare with minimum overheads and aim to restructure around that.
Regarding GPs holding funds – some GPs are better at being Doctors and others are better at managing their Practices – I’d hate to turn a good Doctor into a poor Doctor because he’s burdened by budget management. There’s no easy answer, but we consumers of health care services should get a say in how and who gets to choose how the resources are used.
On 10 September 2010 Anita said:
As a clinician and a manager working for a PCT with over 30 years experience of change within the NHS I feel a sense of deja vue. Change within the NHS is analogous – this is because the NHS is a political punchbag where all parties want to demonstrate their political values and leave thier mark. I feel to some large extent that the aims and objectives that support the White Paper are designed to attract public support by over simplication and scapegoating. The changes it states it is aiming for still requires services to be of high quality, still wants them to be commissioned and to have a competation in place- how will this happen well with few managers to do it?I am worried that this change will leave the NHS so asset stripped (of knowledge) that it will be unable to function and this could lead to a situation where privatisation is allowed to find fertile soil to grow through necessity to fill the exposed gaps (and this may push the costs up and be out of control). In my area the services that are of interest to private companies are those that are relatively straight forward to provide and which are profitable. How will GPs be held to account for their actions locally- including issues relating to ‘conflict of interest’ ?