Your views: Accountability and patients

How can we make the NHS properly accountable to the public, and make sure that patient involvement is at the heart of its decision making?

We are interested in your views on this area, including:

  • How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?
  • How can we best ensure that the NHS commissioning budget, held by the new NHS Commissioning Board, is allocated transparently and used with proper accountability to the public at local level, and Parliament at a national leave?
  • Are we doing enough to make sure the NHS at local level has the freedom it needs to take locally-based decisions?

This page was closed to comments on 31 May, the last day of the listening exercise. All comments have been fed back to the NHS Future Forum to consider.

The Forum will submit its report to the Prime Minister, Deputy Prime Minister and the Health Secretary in June. The government will consider the Forum’s findings and then publish its official response

In Conversations, NHS Future Forum, NHS listening exercise | Tagged ,

421 Responses to Your views: Accountability and patients

  1. ruth butterfield says:

    i think GPs alone do not provide the best way of commissioning, as a health professional i have worked with a variety of GPs and some are very intune with the needs of their client group and are open to explore the interventions and treatments that can be offered. unfortunately there are also many GPs who have a much narrower view and will stick to their preferred interventions which do not always give the patient the best choice of options

    in a similar way to GP fund holding several years ago the commissioning should be the responsibility of a wider group of professionals and i dont just mean a token nurse….other groups should be included eg OT and physio

    • Deborah Milburn says:

      I agree with Ruth. The much vaunted Future forum has no allied health professionals on it. How can services be commissioned to deliver the comprehensive service that patients are promised if that is the case?

      Recovery from ill health is not just a case of swallowing some medication or having an operation. People often require ongoing rehabilitation or, in the case of mental health, years of support from multidisciplinary teams. There is no recognition of these facts from the government or the department of health in these discussions about reform. I can’t see private providors wanting much to do with mental health or chronic physical stuff.

    • I completely agree with Ruth Butterfield.
      My question and concern :where is the difference between physio and Radiographer they all care for patients,they are part of clinicians,they are part of the MDT so why not use that name’clinician’
      The plan is to nurse and look after patients in their own homes:would GPs’ visit patient home to ensure that that home is fit for purpose before sending patient home to be nursed?Who will do that assessment for the GP if not the
      clinicians that would include nurses,infection prevention control ,district nurse,health promotion nurse dietician and so on.

    • S Mollison says:

      It is clear to me that my own GPs do not even operate their own surgery in a way that is clearly in my best interest. For example, their appointments system is not bad for ensuring access to a doctor for patients who are acutely sick but terrible for ensuring good access for working patients with chronic conditions or health concerns. Prevention and public health are not served – presumably because these things pay their practice less well.

    • Michael Swarbrick says:

      The only way to ensure public accountability and patient choice is to keep control of the NHS entirely within the public sector. Already the possibility of more private involvement has caused some quite questionable activity as people set up “consultancies” so that they can benefit from the dismantling of the NHS. This must be happening at a very high level because complaints get no response.
      Michael Swarbrick

    • Abigail Morrison says:

      I agree. As an Occupational Therapist working in a large acute trust, I worry about the security of our positions, when GP’s have the power to commision services. Partly as I feel most GP’s do not have a full understanding of our role, and the difference we can make. At the moment it feels like we are in constant battle to justify what we do. Perhaps more multi-disciplinary education within GP practices needs to take place?

    • Jean Lymath says:

      I agree totally and would push it further to suggest there has to be a holistic overall approach from GP’s to ensure that the approach for diagnosis and recovery includes nutrition, reflexology, eastern acupuncturists, counselling etc. I cannot see that this will improve with GP’s commisioning NHS services, in fact it will probably get much worse.

    • Siobhan says:

      I am a GP and I totally agree with this statement.

    • Catherine Lander says:

      While I have every respect for GPs, I have concerns about GPs deciding on the range of services for a community. A GP is a deliverer of services and will therefore be in a position where they may have a conflict of interest. GPs are often a signposting service and once they have referred someone on they may have no more contact with that person or family, and do not know the extent of the service provided or delivered. I work with children and GPs have told me that children are 5% of their workload, and I am concerned that this area will be a low priority for many of them. GPs may not be aware of the services families may be accessing.
      I work as a Speech and Language Therapist, and SLTs have always had an open referral system whereby people can self refer, and a small percentage do. When we get referrals from Health Visitors and occasionally GPs, while letters and reports are sent, the referrer may never see the child again and will have little knowledge as to the type or extent of input they receive. I have asked GPs if they read these reports and letters, and they tell me that they do not have time to go through all the letters they receive, and if it is a report rather than a request for their input, they do not have the time to read them, nor are really interested as it does not impact on their work. They have plenty to do dealing with those who come into their surgeries. Many care pathways are led by AHPs and so it is critical to bring their knowledge to the decision making table. AHPs are often the first contact a patient has with the health or social care service. Chronic illness and disability is not managed by doctors but by other health professionals. the NHS is bigger than Drs and Nurses.

    • Bruce Poole says:

      I agree Ruth, however I would also like to see that the commissioning of primary prevention work is undertaken by as wide a stakeholder group as possible and the commissioning bodies having a mandatory obligation to engage with the Directors of Public Health on the wider determinants of health

    • Kate Patience says:

      I absolutely agree. GPs will need to be aware of a vast number of services including small specialities that are easy to overlook, or don’t have the knowledge and skills to make decisions about (e.g. cancer services). With an emphasis on health and wellbeing and long term conditions there needs to be a lot more engagement with Allied Health Professionals and community staff to ensure that the needs of the local community are met effectively and efficiently. If these services are not represented well enough this may have a huge impact on patient outcomes, and patients will be less likely to take more responsibility for their own health, which the white paper calls for.

    • Helen says:

      I think local health services need clinical expertise to lead and commission, however, I think giving it to GPs is a mistake as this will not give a balanced view. There is also the issue of Gp’s fundamentally running their own businesses which I think is counter to being publicly accountable. Will their not have to be a whole raft of beauracracy created around making sure GP’s are not favouring their own commercial interests? Please ensure other clinicians and managers with clinical expertise get to lead the way so that we get balance.

    • Tristan Harvey says:

      I agree with Ruth. At the end of the day I think public confidence in GPs is pretty low so why are we trusting them alone with such a large proportion of commissioning responsibility?? The idea of GP consortiums is totally un proportional in respect to the people relying on their commission.

    • tim says:

      profit profit profit ….what do gps know about managing….accountability based on what profit skewed outcomes i really hope not

    • Wendy Patterson says:

      Accountability is an important issue but not the most important issue for patients. Patients want to see GPs, Consultants and other clincial professionals who are focussed on providing them with the best possible care. They do not want their GPs to have to consider costs, budgets, targets, etc. when deciding on their treatment. Let managers manage, and doctors look after patients. The tension between clincial staff and managers is necessary and ensures a healthy balance between the need to keep the whole organisation on track providing fair and equal treatment and the needs of individual patients as decided by dedicated clincians.

    • Cathy Holden says:

      How can we make the NHS properly accountable to the public, and make sure that patient involvement is at the heart of its decision making?

      In what way is the NHS not already properly accountable to the public? (Don’t understand the question).

      Surely patient involvement has always been at the heart of its decision making.

      ■How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?

      I don’t think you can. It’s not fair to pretend that patients can be involved in commissioning services, when most of us have not undergone the seven years of training that we would need to be able to understand the criteria for chosing one service over another. Not only that, but at the very moment when you want us to make life and death decisions about our own health, we are at our most vulnerable and least able to make an informed choice – and we would be very open to being manipulated by anyone who seems as if they know what they are talking about. Are you proposing to teach school kids how to commission services?

      ■How can we best ensure that the NHS commissioning budget, held by the new NHS Commissioning Board, is allocated transparently and used with proper accountability to the public at local level, and Parliament at a national leave?

      I would have thought this would be easy enough. What worries me is that the the NHS commissioning budget, which is tax payers’ money, is going into private pockets.

      ■Are we doing enough to make sure the NHS at local level has the freedom it needs to take locally-based decisions?

      I don’t know. I’m losing the will to live.

  2. Dr. Amresh Chopdar says:

    The government ought to keep its nerve. Always organisation and people with vestiges of interest would try to gain concession. It’s reasonable to include nurses and public health physicians into the commissioning board. However, the hospital doctors and managers must be kept out. Commissioners and provider don’t mix in the same group. Please keep your nerve. This must be done if the NHS ahs to improve. The commissioning board must have their monthly meetings in two parts one open and the other closed for sensitive maters.

    Following advice and recommendation from his GP the patients must be given the options to be referred to a hospital or consultant of their choice irrespective of locality and distance from their residence.

    • Professor Paul Bywaters says:

      Why can’t commissioners and providers mix? It’s called collaboration, in which both hospital and community services have a common interest in providing the best quality care for patients at the least cost. In fact, why split commissioners and providers? No need for bureaucratic contracts. No need for competition between providers, leading to overcapacity. No need for commercially sensitive, private meetings. No need for hospitals and community services to shunt costs between them. Just collaboration.

    • Anon says:

      Whilst its right to keep provider & commissioner seperate how do we ensure that the Consortia will also ensure that the local provider survives? where there is a close realtionship in rural areas we are already seeing more collabortaion than competition which is good, however in city centres with a number of agressive FTs competion is king and i’m not convinced that GP Consortia understand all the specilaist services being provided and the interelationshoips acoss these, ie if Paeds is lost, so is neonatal and therefore maternity services are no longer viable, this means gynae also goes and therefore general surgery now becomes questionable as does A&E

      I don’t see where in the current process this oversight is maintained

    • NHS Manager says:

      The GPs on the commissioning boards are also providers, not just of GMS services in some cases. How do we get over that one? Enhanced services, for example.

    • Parul Shah says:

      Health needs a holistic approach I have yet to come across a clinician who gives information in a manner that you can understand, explaining the possible treatments, +ves and
      -ves of the treatment and what can be expected from your choice. No one ever explaines what they are prescribing and diagnostic overshadowing continues.

    • Laurence Wood says:

      Professor Bywaters highlights a concern of mine, collaboration between commissioners and providers has to be the key to success. This now happens routinely in the commercial world even between competitors. I am witnessing a hangover of antagonism between a PCT and hospital trust. I am working hard to build relationships but suspicions linger. Similarly as Professor Bywaters says, it is tragic to see duplicated and under used resources. Choice is essential however but perhaps this should be limited to avoid waste.

  3. Francesco Palma says:

    You think that you can throw money at GP’s to get them to involve patients, that is exactly what the PE DES payments of £60 million over 2 years is all about. fact is GP Practices can take it or leave it.
    Go over to the Pulse website (GP Magizine) see their response and you will see what I mean. Time for the NHS/DOH to wake up and smell the coffee
    Section 242 NHS ACT 2006 ( of course the Regs needs to be updated to include GP’s) would serve well to remind GP’s via contracts where the duty to involve lies, this comes at no cost.

  4. Michael Vidal says:

    Having asked for a list of venues for the listening exercise to be circulated to members of the NHS London PPAG may I ask through this page if it would be possible for Ministers to meet with the NHS London PPAG (a) to find out what it does and how it can be used as a template for the NHS Commissioning Board and (b) to find out thier views as they are likely to be in tune with the vies of a reasonable cross section of members of the public which is the reason for thier existence

  5. Michael Vidal says:

    If GP Consortia are to be accountable they should be added to schedule 1 of the Public Bodies (Admission to Meetings ) Act 1960. One of the many curiosoities of the Bill is that Local Haaelthwatch are added to Schedule 1 of the Puiblic Bodies (Admission to Meetings) Act 1960 but GP Consortia are not so you will have a statutory right to attend a meeting of your local Healthwatch but not your GP Consortia. It is probably me being thick but I cannot see the logic of this especially as the Act adds GP Consortia to Schedule 1 to the Freedomm of Information Act so you can make a Freedom of Information Act Request to them even if you cannot attend their meetings. Just to add to the confusion you cannot make aFreedom of Information Act request to Healthwatch as they have not been added to Schedule 1 of the Freedom of Information Act.

    • Elli Pang says:

      indeed, currently, lINK are exempt from FOI.
      so are third sector and private businesses – which means that HOSTS of LINKs are also exempt. Business confidentiality rules and contracts are/can be refused to be seen for this reason. HOw can transparency and accountability in both health and (social)care provision function if – with ever increasing numbers of AWP – more and more services remain outside proper scrutiny ? How can the public know that a LINK/future HW is working if contracts between a LA and a Host remain confidential between the LA and the HOst and even the lINK members probably unaware of the agreement between them.
      Either there is accountability and transparency in service provision and those who represent the interersts of the public with all these exemptions – or there is not.
      These exemptions, both for providers of services and the public and patient involvement itself makes a mockery of the concept of accountability.
      Enquiries made on this issue reveal that I/you/we/the public/anyone would have to ask the Minister of Justice for a change in the legislation.

  6. Francesco Palma says:

    It is noted that only one real patient representative is listed to the membership of the NHS future Reform Forum, again as my previous post. I am available to be considered as a patient representative, Iam not a CEO of an organisation NHS or otherwise and have a mind of my own. What is not required is more of the same of the current make up of the listed members who are employed by the respective organisations.

    • Audrey Polkinghorn says:

      I agree with francesco. most link meetings I have attended are charity organsations fighting for their own interests. not enough joe public involved who after all use these services. The tasks involved to change over to consortia is too big and can’t be controlled in any way. I feel only the patients once again will suffer. I know this by expereince. Audrey

    • rosemary whitbread says:

      Patient representatives are notable for their absence in all groups concerned with this re-organisation of the NHS.
      The National Association of Patient Participation groups has not even been invited to be on the Listening Group.
      In many Consortia,which have already been set up in the first wave of pathfinders, there is only one ‘patient voice’ and that has been taken by Healthwatch. That organisation, which has grown out of LINK, is not a Patient organisation. It is funded by the Government and for the last 12 months in my area, has been re-assuring the public that nothing will change for them-”you will walk through the same door and see the same doctor”!They should have been encouraging public debate not soothing the way!
      GP contracts have now stipulated that GPs MUST engage with their patients. Patient groups should be set up in every surgery. In any consortia there will , in the future, be patients who could organise and represent the real views of patients. These groups may or may not be up and running yet but the structure of any commisioning organisation must include real patient voices.

    • CaroleA says:

      I feel it is essential that patient representation is a huge part of the NHS reforms.

      I am totally uncomfortable with huge budgets being handed over to individual practices without any patient input being taken into account.

      If GP’s are to be delegated large sums of public money to spend at will, I feel that there should be a ‘Governing Body’ attached to each practice, made up of patients, staff, and members of the local council & community.
      This way all views can be taken into account, reasons for expenditure fully explored and decisions can be made by the community, for the community.

      Schools had their budgets delegated years ago and the schools must involve the Governing Body in all decisions, especially with regard to spending and budgeting.

      This would protect GP’s as well as patients.

      It is not acceptable to me that any GP could be able to spend large amounts of money at will – without taking into account the views of patients and staff attached to their surgeries…Headteachers are also professionals and they cannot spend without the approval of the Governing Body – Doctor’s will need to come under the same rules.

      Mr Cameron wants us all to be a part of the ‘Big Community’ – this fits snugly into that category – in my opinion.

  7. Robert Irving says:

    I) More democratically accountable commissioning

    II) Local authority areas and commission areas should coincide as much as possible.

    III) No decision about the spending of NHS funds to be made in private and without proper consultation, as can take place by the proposed GP consortia.

    V) New private providers to be allowed only where there is no risk of ‘cherry picking’ which would destabilise or undermine the existing NHS service relied upon for emergencies and complex cases, and where the needs of equity, research and training are met.

    VI) NHS commissioning being retained as a public function in full compliance with the Human Rights Act and Freedom of Information laws, using the skills and experience of existing NHS staff rather than the sub-contracting of commissioning to private companies.

    VII) The continued separation of the commissioning and provision of services to prevent conflicts of interests.

  8. Ann Edwards says:

    There is no doubt the NHS needs to change but GP’s entered the profession to provide clinical care. I t would have been easier and less costly to make GP members of PCT boards and to give them an active role in clincial areas.

    There are no clear governance structures or accountabilty framework in place and thr sysstem is already chaotic

    • Marcus Hughes says:

      There is no doubt that GPs have a detailed and informed knowledge of the health needs of their local population. But it is also true that GPs are the most expensive commodity in the health service (on higher salaries than hospital consultants or most health service senior managers). Therefore to hand a huge quantity of extra work (commissioning) to GPs will turn out to be horrendously (and I think unaffordably) costly for the NHS.

      I agree with Ann Edwards that it is perfectly possible to achieve the ends that Andrew Lansley wants (ie. clinicians controlling commissioning decisions) by setting up boards of local clinicians, to which PCTs would be accountable for their commissioning decisions. This would allow the expensive clinicians to paid for a few hours a month of strategic work, rather than for many hours a week of the implementation of commissioning decisions, which can be done by less expensive non-clinical staff at the PCTs.

      This would also avoid the huge costs of sweeping away the existing PCT and SHA structures, and replacing them with untested models of commissioning. The savings can be used to soften the blow of some of the savage cuts that are being implemented in health and social care.

    • A Martin says:

      I totally agree with Ann, GPs provide an excellent clinical service and should not be distracted from this by trying to undertake something they have not been trained for. Their clinical input into commissioning decisions is essential but they do not have to do it themselves. It is alos important to remember that commissioning is more that purchasing services, it is about determining health needs, securing the services and ensuring the service delivered is that which is required, all within the funds made available from taxation, not a bottomless pit.

    • Christina Quinn says:

      I totally agree with Ann. GPs are paid high salaries to provide clinical care to patients not to attend endless meetings to discuss strategy and financial management. Patients will suffer because there will be less GP time available to them. I also believe governance and accountability will be a real issue. Some of the restructuring is definitely needed to cut costs but GPs are an expensive asset – we should utilise their expertise for the benefit of the patient not the government.

    • rrokuku says:

      Ann is soooo right. Don’t jeopardise GPs’ key role as community gatekeepers by tieing them up in management, admin and bureaucratic obligations that they have not been trained for. They already have too little time to spend with patients (7 to 10 minutes to deal with an average of 3 problems per patient) – do not take even more of this precious face to face contact away. If you do, this will be to the detriment of patients’ wellbeing. And will probably end up being more expensive to treat as well.

    • Dr JG says:

      Thank you, Ann, for a bit of sense. I think it goes deeper – in my area we are fortunate that the GPs heavily involved in the commissioning board are trying very hard to make it an inclusive process. But I have encountered many doctors over the years who appear to have fingers in every managerial pie as a way to help keep them away from the day-to-day grind of seeing patients. Although I have only known one to actually admit it, when it comes to clinical practice, it is largely a case of “do as I say not as I do”, yet if they are the only ones prepared to take on the management tasks, others suffer.

    • MSLC Lay Chair says:

      I completely agree, and would like to add that GPs tend not to do anything unless they are paid for it which, in the current system at least, makes me wonder about their commitment to collaborative working and service delivery in general. I am the lay Chair of a Maternity Services Liaison Committee with very good representation of commissioners, hospital trust management, clinicians, health visitors, children’s centres and service users. Who can we not get a representative from? The GPs. Why? They do not get paid for the 3 hours every 2 months during which we meet. Other members find time within their equally busy schedules, and users obviously turn up for free!

  9. Terry Jones says:

    Patients, and just as importantly the public, who fund the NHS, will only be properly involved when they are represented on the decision making bodies in equal numbers to GPs. GPs have a clear conflict of interest as was clearly demonstrated when they decided they did not want responsibility for their patients “out of hours”. The public was clearly not involved when that was agreed to!

    • Laurence Wood says:

      It will be difficult to acieve true public engagement in commissioning because clinicians are not used to this scrutiny. They also may be embarrassed because of the high reward culture that has developed within the NHS. Any engagement to be meaningful has to be at a very early stage in the process otherwise it merely becomes a tick in the box exercise.

  10. andy mcgeeney says:

    Bring back community health councils. Dont hand the health servicies over to ‘market forces’ and profiteering. Increase democracy so local people can influence local decisions that are publicly transparent.

  11. Patrick Carroll says:

    Honesty with the general public would be helpful, if the centre dictates the universality of healthcare then GPCCs are seriously limited in how much of the commissioning budget they can use in terms of local priorities.

    We need a national debate about what the NHS can and can’t do.

    • Dr JG says:

      I agree, but what we are Likely to get is a system where GPs are expected to meet unlimited demands with finite resources. With every unit of power devolved will come a much larger unit of responsibility. At my most cynical, I suspect that this is a deliberate plan so that when it all inevitably goes pear-shaped, the government can blame the profession and hand the whole lot over to the private sector, in the usual government fashion. We will then have a health service as well-run as the rail system and privatised utilities.

    • adam hedley says:

      Dr JG has hit a nail on the head – move the difficult decisions of cost and sharing finite health resources to a point away from the political arena (specifically the Conservative party) and you can lay the blame for the health care short comings at the feet of the people you have given those decisions to – a braver decision is to take expert advice and then act on it regardless of the political implications – but that is utopian and profoundly stupid politically.

  12. Patrick McCrossan says:

    GP’s have been trained to practice medicine and the NHS needs their undivided attention to dispense the best and most compassionate service to their patients. If they are to do their jobs as designed then they can’t possibly have enough time get involved in playing a leading role in awarding billion pound contracts.

    No, it is much more sensible to have them and the rest of the health professional play a consultative role in the current PCT process

    • rrokuku says:

      Agreed! And I’m sure slimming down PCTs, involving more GPs (and other health professionals) in commissioning decisions, requiring them to take on more public health/preventive work, would help as well.

    • Amanda Farley says:

      Totally and utterly agree with this point made by Patrick McCrossan. As both a patient and a health worker (health visitor) I am able to see that my own excellent GP is overburdened and over worked already. How are GP’s expected to take on this extra responsibility in addition to their clinical work?
      It would have been more cost effective to have GPs playing a key role in PCT decisions.

      But I have no confidence the Govt will listen to our voices here, I suspect this is a “lip service” exercise to enable them to tick the “consultation with NHS employees and patients” box.

  13. A Roberts says:

    A key issue in “clinical lead’ commissioning is dealing with conflict of interest. Fraud is not unknown in the medical community. Most commissioning consortia will also contain the provider of some services. I think the only way to deal with this effectively is by full transparency. Michael Vidal’s point about public access to meetings is interesting but there would have to be no closed sessions for “sensitive” subjects.

    Would a requirement to publish all tenders and the rationale for selecting the winner(s) provide sufficient light?

    • Michael Vidal says:

      I would actually go further than A. Roberts and say that for all contracts over £10,000 a member of the Local Healthwatch should be on the tender panel to ensure that the patients view on the suitability of the tenders is taken into account.

    • NHS Manager says:

      They already are involved. Procurement is done under EU law. Despite what Mr Lansley might think. It already is a transparent, fair and accountable process. Thanks to the managers who do it.

  14. The public are not medical professionals, leave the decisions to those scientists who have unbiased data on the effectiveness of various options. These decisions should also be free from political interference. Often healthcare delivery decisions have implications with timescales beyond the next election, so MPs shouldn’t be allowed to agitate for ‘jam today’ in order to be seen to be doing something.

    • Anthony Rodriguez BSc Health Studies says:

      There are no such thing as “unbiased data”. All data has some element of bias, no scientific model is perfect. It is patronising to patients (aka people) to say that only scientific professionals should have a say. Patients are the ultimate health “experts” in modern health care. They should have input into the area health boards that are missing in the Lansley plan. Patients need to find a voice and be less passive recipients of medicine, they need to be partners in health care.

    • Patient says:

      Scientists are by no means unbiased, I’m afraid. The growing antipathy to complementary healthcare from the allopathic community, as well as from Government, is a sad reflection of the lack of bias in many so-called experts, and evidence of the disturbing sway that drugs companies have over decisions about healthcare. As a patient, I have taken pains, and paid my own way, to equip myself with choices where none exist in the allopathic world. Thankfully, I have found other ways of successfully treating ‘untreatable’ conditions for myself and family.

    • NHS Manager says:

      I am a trained scientist and have been involved in numerous clinical audits. I resent and argue with the suggestion that I am not unbiased.

    • Research Nurse says:

      Typical NHS Manager missing the point! The two comments above relate to scientific methodology, not personal characteristics. There will never be an unbiased clinical trial or study, we just have to know how to assess whether that bias is large enough to affect the quality of the study.

      I also disagree with Gwynfor. I recruit patients into clinical trials. These patients are often very well acquainted with their conditions and current research and they should be actively involved on health boards and in decision making processes because they are best placed to tell us their wants, needs and expectations.

    • George C.A. Talbot says:

      I wonder if Patient’s concern with “the disturbing sway that drugs companies have over decisions about healthcare.” includes mental illness. Here psychiatry sought objectivity by classifying symptoms. Then pharmaceutical companies developed drugs that suppress these symptoms. Now psychiatrists prescribe these and attribute intractable illnesses to innate biological defects.

      Many trials testify to the drugs’ efficacy but missing from the model is base human nature. Its instincts can be repressed and the base character that shapes their expression wrongly formed. Repressed instincts and inappropriate base character can cause severe mental illness. But therapy and training can correct these faults when illness ends spontaneously.

      Nowadays, depth psychology is rarely used to explain and treat mental illness and I wonder if this is because it threatens the market for psychotropic drugs. Back in 2004, some giving evidence to the Joint Committee on the Draft Mental Health Bill supposed it had been written to promote the medical model of illness rather than a psychological one. See also paragraphs 1.3 and 9.2 of my memorandum.
      http://www.publications.parliament.uk/pa/jt200405/jtselect/jtment/79/79we44.htm

      The missing paragraph 10 says I sent Scrutiny a copy of [the summary of] my Human Motivation!

  15. Eve says:

    More mental health budget! More sanity will reduce strain on other parts of the NHS – trauma, addictions, etc.

    • Cinderella says:

      I completely agree. Stop treating mental health as a cinderella service. As this government crunches on more and more people are going to need the services of mental health specialists but quess what they won’t be there as budgets are being cut in the voluntary sector and in the NHS. Mental health impacts greatly on services like A&E you can’t put a sticky plaster on an expect the patient to be better….they will re-present!

    • rrokuku says:

      More sanity would perhaps come from more attention to the wider determinants of wellbeing like poverty, housing, jobs, education … not just mental health professional services.

    • Deborah Milburn says:

      Rrokuku is, of course, correct to make the link between socio-economic deprivation and poor health. However, as the government has reduced access to higher education, has limited sure start, is reducing housing benefit and chucking people with serious health conditions onto job seekers allowance etc, the strain on mental health services is likely to increase as a result.

    • Laurence Wood says:

      In my area the mental health trust is run as a separate organisation to the hospital trust. This seems a duplication as many patients in the hospital trust will have a mental health problem that could be the source of a physical problem. Is this separation the best way to provide care to patients? It certainly could result in the duplication of cost running the two entities.

  16. john says:

    to help this as a validated forum to engage and help change direction of the white paper it does need ‘connection’ to what the current BILL SAYS INCLUDING TABLED AMENDMENTS….

    otherwise its disconnected rhetoric, the questions whilst valid should link to the white paper…or better still deal with the real issues that face the NHS.

    WHICH MIGHT BE …
    PFI excess costs control(through legislation? is that in the Bill?)

    administration costs of a tarrif system, (aweful data and NHS IT)

    centralist management and overburdened inspection/tick box targets that generate TOO MANY non-jobs moving paper about

    disconnect between clinical workforce and boards/managers jumping to central dictat.

    what is needed is teams connected together, with locality strategy and control…which may well be clinical commissioning exec teams…but does that need a white paper and a push for ‘market conditions’?

    • Tess Harris says:

      I fully concur with the last paragraph above.

      We don’t need hugely expensive new primary legislation (how many government lawyers have worked on the Bill at what cost) based on a White Paper with only 33 bibliographic references (one a broken link) to effect improvements in the NHS.

      Skilled leadership, lean management approach and better knowledge management would be a superior treatment option.

  17. K Udagawa says:

    Accountability is by not letting private companies get involved. Commissioning shouldn’t be done by doctors – dumping admin on them won’t help them care for patients!

  18. sarah says:

    there are many established forums and community groups which could act as a sounding board for decisions on commissioning and services. Also you could utilise display boards within the practice and provide regular updates to the local media to keep people informed. Providing a mechanism for input should be provided. Clear communication without jargon would be useful.

  19. Anthony Rodriguez BSc Health Studies says:

    Accountability will be reduced under the Lansley model as leaves private consortia in charge with no area health boards to oversee their activities and keep a tab on their spending. Merge the SHAs, PCTs and Health and Wellbeing boards into area community healthcare commissions as intermediaries between central government and consortia. They should be accountable to the local community and the National Audit Office and be availabel online.

  20. James Walker says:

    GP Commissioning Consortia need to be more democratic. I was a PCG/PCT Patient Representative and was regularly outvoted en-block by the GPs. even if the Nurses voted with the patients!

    I don’t mind GPs making more money, if this is the critical ‘change factor’ but increases in GP pay need to be related to meaningful quality & performance, not to a series of tick boxes like QoF

  21. Professor Paul Bywaters says:

    Once again these questions show that the government is only wanting to hear how the reforms they have already decided on will be implemented. What if we don’t want local decision making because it will increase the post code lottery. Why are they not asking about the major issue of accountability – the Secretary of State no longer being reponsible for the NHS? What if we don’t want the NHS Commissioning Board? Is this a consultation? I don’t think so.

    • Tess Harris says:

      Hear, hear!

      It’s another tick box exercise, much beloved by civil servants. You only have to read David Nicholson’s recent letter to NHS staff to realise that these messianic policy makers plan to carry on regardless.

    • Clinical Network Manager says:

      This is the most important part of the Health Bill that frames the direction of travel. Being accountable to the Secretary of State is a must if the NHS is to be interpreted as a body that is using taxpayer funds for the good of the people. Removing this, or repealing this more correctly, is wrong, plain and simple.

  22. Mark says:

    We had a world leading, world recognised body that influenced the decisions of many countries in the recognision of evidence based value for money healthcare – It was called NICE and is being disbanded by this government.

    Do not get rid of NICE, no they were not perfect, but they regularly reviewed their decisions and corrected most of their mistakes through the process of reassessing the evidence on a regular basis.

    People did not like the fact that NICE essentially made rationing decisions butthe NHS needs to ration care and NICE did a good and mostly fare job

    That is the model to follow

    • Tess Harris says:

      NICE are doing a great job. Their Gudelines are well researched – unlike Lansley’s fatuous White Paper – and it’s very handy to have all the relevant information in one easy to read set of documents, instead of being spread across the baffling multiplicity of DH websites and siloes.

    • Michael Vidal says:

      Mark

      Under the Bill NICE are not being abolished they have an even worse fate there remit is being increased to cover health and Social care

  23. Susan says:

    Today a Doctor has received criticism on a website for raising concerns about the health bill and campaigning for improvement. The criticism was of an inappropriate nature. This unfortunate incident is a very serious matter and highlights the need to protect GPs on the frontline from issues arising from commissioning and one way I can think of doing that is to keep GP Commissioners separate at least while they are serving on consortia. I also feel this will be better for patients.

  24. Francesco Palma, Bristol & South Gloucestershire LINks says:

    Message for DH ecp: please pass on my views to the NHS future reform forum that there is a absence of grass roots patient/public/service user and carers representation on the forum by this I mean health community activists that are not in receipt of a salary/wage such as members of LINks soon to be LocalHealthwatch and Healthwatch England. A response from the forum would be greatly received, remember the whole point of this excerise is to engage with the wider health community, so please engage at this pre formative stage to concerns already raised on this website.

    • Audrey Polkinghorn says:

      Once again I agree with Francesco as a member of link I find that this organisation is struggling to keep up with the new consortia iniatives. I attend the meetings as regularly as I can and as I see it because Link have no great help or guidence from the government they are unable to grasp the enormity of it all. Andrew Lansley must be laughing at the voluntry sector who are trying to understand and move forward with these policies.

    • Laurence Wood says:

      I have great concern about LINks becoming Healthwatch. There is very little consistency within LINks throughout the country as they have all been set up in isolation.. They have different structures, governance and management arrangements. Consequently their membership are working to completely different rules and objectives. HealthWatch is so critical, this issue should be addressed.

  25. Vera smith says:

    If the public are going to be involved then you need the provider split to protect the interests of service users. Service user involvement should not be governed by the commercial interests of charities or private companies. There should be clear accountability and a role in decision making which is influential and meaningful to communities. Increasingly purchasing power on an individual level will become a significant driver in commissioning. I dont see health watch as a citizens advice bureau of health, more of a “. Which? ” magazine.

    • Anthony Rodriguez BSc Health Studies says:

      See my comments below. The service users need input at source, not after the event as in a privatised utility or banking regulator with all the awful consequences we have seen in these sectors. Lay people need a say in commissioning and planning, not yet another toothless regulator. The NHS is not British Gas or NatWest and let’s just hope it doesn’t end up like them!

  26. Nicky Norriss says:

    It is essential that there is a level playing ground when services are comissioned and that there is adequate , fair and reasonable evaluation of the providers who are competing against one another.

    The views of patients / the population must taken into account, when planning new services or service restructuring; also ‘evidence based ‘ guidelines; and the existing skills available within the providers putting in tenders.

    I feel that if a local NHS providers can provide the standard of serices required at a reasonable cost, then these should take priorities over ‘private company’s tender’ which involves dealing with the unknown, untried and untested.

    Commisioners should not be involved in commissioning any services in which they have a conflict of interest eg. if they have ANY involvement/ formal links to private companies who are involved in the tendering process.

    It also is essential that commissioning takes place in a reasonable, transparent way and that ALL local NHS providers are allowed to put in a tender. Commissioners should also take account of whether the ‘provider’ already has the knowledge and skills required in providing the servcices up for tender.

  27. Peter Walsh says:

    If GPs are to be given the lead role in managing the NHS then they should at least be employees of the NHS and accountable in the same way as any other employee should be. It is wrong to hand over control to indepnendet business people who happen to have a contract with the NHS to provide services, which is the case with GPs presently. This is a good opportunity to change a situation which only came about by accident due to the negotiations when the NHS was first set up. No one in their right mind would have designed the current arrangement as it is.
    Another important safeguard would be to make it a statutory requirment for the local Healthwatch to be represented on the GP Consortia and the NHS Commissioning Board.

    • Dr Jeremy Platt - GP says:

      can’t agree. It is precisely because GP’s are independent contractors that we will be good at commissioning, because we understand the issues around value for money and quality health care.

      The current system of primary care provision – designed by a lunatic or not – is the envy of the world.

    • A.N. SHA Manager says:

      Typical – a GP who want’s to defend the status quo. You say understand the issues around value for money and quality healthcare, I think not.
      GP’s are a self interest group and in no way should be allowed to control the allocation of healthcare budgets. You can not sit “outside the system” when it suits you, and “at the core” when there is money to be made from contracting your pals specialist services.
      You will soon find out that there is a heck of a lot more to running the largest health service in the world than prescribing a few asprin.
      GP’s are nothing if not monumnetal in their arrogance.

    • Deborah Milburn says:

      You got any evidence to back up that audacious claim about ‘envy of the world.’ Dr Jeremy?

    • Dave says:

      Totally agree with Peter! I have worked in the public sector for over 30 years and it makes no sense to give budgetary control of NHS to a contractor. GP surgeries are run as a business. The more the business profits the more the partners make. This is just GP fund holding again by another name and that did not work.

  28. Vera smith says:

    And not publish misleading information with sinister pictures of the men in black” threatening gps! http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_125848
    Or see page 11 for a truly mystifying graphic which bears no relation at all to the quoted statistic. Just because I went to comprehensive school doesn’t mean I’m thick you know.

    • Anthony Rodriguez BSc Health Studies says:

      I dislike the use of patronising oversize fonts and impersonal dumbed-down icons and presentational graphics in this document, too much a Powerpoint presentation (yawn). Use images of real people in real health care situations to illustrate the new report (if pictures are needed to underline the facts). Stop talking down and dumbing down and show evidence of listening next time.

  29. Angela Watson says:

    Gps should not be able to commission behind closed doors, nor should the local authority be able to run the show through dubious health and well being boards. The select committee have the solution, NHS commissioning authorities, bodies which would be similar to pcgs and would have proper and independent local representation. I am perplexed as to why the government thinks hwbb will strengthen local democracy, when all they will provide is a monolithic form of local centralisation. We need inclusive and proper local partnerships to inform and strengthen commissioning. gps and local authorities running the show isn’t enough.

  30. Anthony Rodriguez BSc Health Studies says:

    Local health commissions

    The local health boards buffering the space between the NHS commissioning board and GP consortia should have the following composition in descending numbers:

    Professional members: GPS = consultants, staff nurses and modern matrons = district nurses, midwives, mental health workers, occupational therapists, social workers, dental surgeons, paramedics, care assistants, environmental health officers and health promoters.

    Lay members: patients, users of hospital outpatient services, parents’ representatives, home carers, older people’s groups, youth workers, mental health service users, teachers, health charity workers, volunteers.

    Plus a streamlined administration of experienced staff drawn from the SHAs and PCTs.

    • rrokuku says:

      Agreed. We also need more clarity on what HWBBs’ powers are. A buffer is all very well but not if it doesn’t have any teeth, if you’ll pardon the mixed metaphor.

  31. Eric Blaxe says:

    My experience of GP’s is that they operate as small businesses exploiting a geographic monopoly. They appear to be organised for their own self interest and convenience. The only body to whom they are really accountable are the PCTs who are being abolished – this is truly bizarre!

    The public may, in time, develop some faith in these proposals if GP’s are shown to be more accountable and transparent. I would hope that this is done before, not after, they are handed £80bn of funds to distribute.

    • Anthony Rodriguez BSc Health Studies says:

      That is why a layer of administration is essential between the central NHS body and the consortia to stop the latter exploiting their position.

    • rrokuku says:

      It is indeed bizarre. And the ‘layer of administration ‘ Anthony refers to is what? And will have what powers? I admire GPs greatly and would uphold their key role as community gatekeepers, and would like them to have more time to talk to patients and also do some preventive work, but like Eric would also like them to be properly and thoroughly accountable to some body even if this is not PCTs. And finally is anyone going to listen to what we are saying and will any changes happen as a result?

  32. richie krueger says:

    Accountability loses its transparency when a service is provided by the private sector. Please do not forget that this is our NHS, publicly funded, publicly managed, publicly run and publicly owned. An all out no to this outrageous Bill and Keep Our NHS Public!

  33. Isla Dowds says:

    I would like to know whether this is the only way in which you are seeking to listen to the wider public. If so then it is as inadequate as your initial consultation, excluding many people from taking part, firstly becuase of the format and medium, secondly becuase, even for those for whom that is not a barrier, you do not seem to be publicising it in any way. I only found this becuase I knew where to look and went looking.
    I would also like to know why my earlier questions about the forms, publicity and accessibility of this exercise, and what you are doing to facilitate engagement of seldom heard and often overlooked groups, submitted via this website when the exercise was announced, have not been answered.
    Finally please explain why there is only one patient representative on the ‘Future Forum’, who this person is, how they were selected and in what way she is able to provide meaningful representation of the wider interests of the public.
    If you are hoping to reassure the public on the seriousness of your intent to listen and respon – this is not the way to go about it. In fact, it achieves exactly the opposite and reduces the credibility of this ‘ exercise’ still further.

    • rosemary whitbread says:

      Isla
      I do know how you feel. I live in Devon and have spent the last six months trying to find out for our patient group about the Bill and now about the Listening Panel. I had to ask the Freedom of Information department to obtian a list of the proposed practices to be in our Consortia (as it seems to be going ahead despite all this ‘listening’). There has been no public information locally and no public debate in any form. Link has organisaed a couple of meetings (not for the public).
      It has been so frustrating when you realise how huge are these proposed changes and how few people even know about them. I know it may be said that people are disengaged-that’s not helped by organisations who have a remit to encourage discussion doing nothing.
      There should be public meetings organised urgently by LINK to get people informed and talking! And they should not only have speakers who agree with the re-organisation.

    • rrokuku says:

      And inadequate though it is, even this blog may well be completely ignored. It would be nice to have some reassurance that we are being listened to and to have confidence that changes will result from what we say.

  34. glynis fulford CLNS says:

    I am dismayed and dissapointed at hearing ( are these chinese whispers
    - these usually come true)
    That a ‘local GP’ consortia in the centre of birmingham has (that does not yet exsist) has given there local District Nurses 12 months notice of redundency as they are too ‘Expensive’
    i am concerned that this is the beginning of the end for the NHS
    With vital nursing / healthvisitor services being abandoned at will to save money when providing services across a vasst muticultural and ethinic communities – who will provide these services ? the private sector !
    Is there to be no accountability- or reigning in of those who now have the power to destroy the NHS before our very eyes.
    With communiity nursing and ‘End of Life ‘ at home being at he forefront of ‘saving’ money’ together with quality and accountability.
    It leaves me most dissappointed and dispairing of the future of care for patients, their families and the nhs.

  35. Iain Anderson says:

    Again, I am frustrated in this consultation exercise by the questions which are framing the debate. The only way that ‘patient involvement should be at the heart of its (the NHS) decision making’ is through properly democratic processes which help determine 1) the budget available and 2) the sum of the desired outcomes.

    Patients only care about their condition – they will be driven only by what benefits them as a sick individual at that point in time. Citizens, however, might well care about the overall health of their community. If all of the stress is on patient choice what voice will be given to citizen’s who are not sick but do have an interest in, say, the level of vaccination in their community and all of the other *public* health issues which affect them.

    So – one suggestion – bring back the CHC’s – but give them a more powerful voice as their concern is the health of the whole community which cannot be reduced to the sum of all ‘patient episodes’

  36. Yannish Naik says:

    The proposed healthcare reforms will culminate in the end of an NHS aimed at the best patient outcomes. They will instead place profit as sole goal, leaking taxpayer’s money into companies’ pockets. The result will be a fragmented and soulless healthcare system.

    Let us not be the generation that allows this to happen. Please give up on gp-comissioning completely.

  37. Anon Anon says:

    There is no doubt GPs are best placed to understand the needs of their patients, on this premise a rehaul of the system is long overdue.

    Of course there are going to be hurdles to overcome but that doesn’t alter the overarching aims of the reforms.

    The biggest danger is always seeking middle ground. Which fundamentally leads to half-hearted attempts to implement watered down inititatives.

    BE BRAVE!

    • Anon says:

      No, GPs are not best placed to understand the needs of their patients – the patients themselves are!

      GPs are ‘jacks/jills of all trades’. They know a little about some things. They cannot possibly know or be aware of the minute details of service provision in primary or secondary care. What we actually need is representation of all services, professions, patients, relatives and carers, academics and managers on health boards.

  38. Murmur says:

    Anyone else recall what happened when we had GP-fundholders?

    Remember having to see patients from fundholding practices BEFORE those from non-fundholders, regardless of clinical need?

    I can see this coming again under these “reforms”.

    Also I fail to see how the inevitable increase in the number of private contractors in providing healthcare will improve accountability: how many commercial organisations will hide information behind “commercial confidentiality” or some similar weasel-phrase?

    As I’ve posted elsewhere: there is a wealth of epidemiological, demographic and socio-economic data available which could be used to make spending decisions, targetting resources and services at areas of greatest need. I see no sign of this being used. Why not?

    And will “increased accountability” mean an end to the half-truths, distortions, double-counting, dissembling, etc, which politicians so frequently engage in when discussing NHS finances? To borrow a line: don’t believe half of what you hear, and none of what you read! It would help if the electorate (tax payers) were ever told the truth!

    • Elli Pang says:

      I have just posted comments re accountability and transparency or lack of it … hope you find it

  39. Christine says:

    Having just separated commissioning and provider arms of PCTs GPs commissioning services will also have a conflict of interest. Some GPs will be better than others about vision and budgets. GPs do not have management degrees they will end up employing the managers that have just had to leave PCTs so where are the cost savings there ?On any commissioning boards you need a range of disciplines to ensure proper patient choice. The NHS is not just Doctors and Nurses. Once people are getting better they need Allied Health professionals like Occupational and Physiotherapists to achieve their maximum potential. Why spend all the money on getting people well and then forget to get them back to productive members of society ?Rehabilitation both Physical and Mental can be as expensive as any cancer drug.

  40. William Perrett says:

    I do not believe that GPs should be taking on more responsibility. I fear that some will focus more on the financial impact on their practices than on what is best for patients.

    I think that there is a strong case for retention of PCTs but with more opportunity for ordinary people to become members and with more accountability to local people.

  41. Dr Jeremy Platt - GP says:

    As Dr Chopra says – keep your nerve! There is no role for providers on commisioning boards. You might as well ask Richard Branson what he wants – nothing personal, but he has his own agenda! Public health people, local councillors, non-executive equivalents – sure!

    If you want locally based decisions, then resist watering down of your proposals. Rightly or wrongly, you are devolving massive powers to localities – keep it that way if that’s what you intend!

    • NHS Manager says:

      A quick reminder for Dr Jeremy Platt, politicians and the DH – GP partners are providers too – providers who can benefit financially from their individual and collective commisisoner decisions.

  42. Dr David Bossano says:

    Hallo. What happened to my post of 1 day ago.
    There were several salient points but the key one that I would like to make & see posted is that there has been a process of involving the public, the general election. There was no mandate for radical re-structuring / destabilising of the NHS through primary legislation & this should be stopped. There are more measured ways of achieving the worthwhile aim of much greater clinical involvement in commissioning.
    Thanks

    • ecp says:

      Hello Dr Bossano – your first post appears under ‘Your Views: Choice and Competition’. Tim@DH

  43. Seamus says:

    The total accounts should be on a public website with a place for people to tender lower prices and comment on the quality of what MHD do buy

  44. Roger Hughes says:

    It is sad that every government has the overwhelming need to change the NHS!, for the better is always the answer, but is it?, here we have the prospect of GP’s taking control of the commissioning of patient services, the government say that GP’s know best, why do they?, they only see the patient for very few minutes at an appointment, most GP’s know a little about a lot to be able to make a diagnosis, but not a lot about a lot, GP’s have been telling us for years that they have too much on their plates, too much paperwork, but now some are happy to take on commissioning which most have not the slightest idea as too what that means, I have voluntarily worked with the PCT in commissioning, it is a long process that takes into account the best interests of the patient, that is what I call good practice, just how are GP’s going to deal with all of this?, the only way I can see is by giving even less time to their patient list, so giving an unacceptable level of service so the end product of this bill is a a lowering of patient care and a lack of patient involvement in the services that they receive, the answer Leave Well Alone, tweak it but no massive unacceptable changes.

  45. Why can’t a simialr model to accountability for school governors/youth offender community panels be applied to GP surgeries and hospitals . Train lay people (NOT councillors) in budget and service delivery oversight/scrutiny for Gp surgeries and hospitals/clinincs.

    • Michael Vidal says:

      I agree with James on this having been a school governor I believe the critical friend model whihc is the basis of the school governor role is one worth looking at.

  46. Tim Benson says:

    We need key performance indicators (KPIs) that align the aims and objectives of all stakeholders: patients and their families, clinicians, providers and commissioners. Most patients would agree that
    the three things that matter most are: (1) my prognosis (will I recover? how long will I live?), (2) how I feel (physical and emotional symptoms) and (3) how much I can do. Outcomes transparency is central to patient involvement and accountability, but it needs to be real time, allowing each patient to monitor their own progress in comparison with those with similar conditions. We need to provide feedback on how each patient is faring to clinicians at the point of care and to patients and their families at home. This patient-level data can be aggregated for provider management, commissioning and central accountability.

  47. Steve Searby says:

    I have great faith in doctors to be doctors, rather less so in doctors being commissioners. I cannot understand the line of logic from some GP posters who advocate keeping providers out of the commissioning process when they have a monopoly on the provision of primary care services. It strongly appears to be more a case of arguing for no providers, except themselves, on commissioning boards.

    I also have concerns over freedom of information and even if request can be put to the consorita themselves, would this extend to agencies providing services commissioned by them?. Without Freedom of information being meaningful and applicable to all those providing services, then the opportunity is easily there for profit to be put before patient care without any scrutiny by the very people the government allegedly wishing to include.

  48. I work in Data Quality for the NHS and I believe we shoud open the window on performance information that gathered from the various systems that collect and collate data into information. I think this should be done at a local level, i.e. displayed by the trust within the trust to the public. Areas where we are doing well should be trumpeted, areas where we are not doing so well should also be trumpeted so the public feel informed and a healthy steady pressure can be exerted on the trusts from the public regarding areas that don’t acheive such high standards. One thing I have seen is that much data is being collected but not being effectively collated into useful information and published. I would love to see public information booths at hospitals and trusts where members of the public could view the trusts performance themselves for various departments within the trust and compare these performances against other trusts. In general I would like to see the public more informed.

    • alan cleary says:

      Mr Shaw’s submission appears sensible and valuable. I am wondering if he could suggest what data might be the most suitable for meaningful comparison and how and where in a hospital it might best be stored and accessed.

      I should have thought one of the advanced Nordic countries might be doing this already such that their method could be seen at the cost of an air ticket – does anyone know ?

    • Elli Pang says:

      HEAR ! HEAR !

  49. Alan Cleary says:

    Subject: Hospital Governor = A silent nodding toy which serves also as a rubber stamp
    “Elected Patient Governors (of which I am one) in NHS Foundation Trusts were introduced originally to the public as a highly effective, common sense, trustworthy, independent, inexpensive means of securing and maintaining high standards of patient care. That could well prove right but only if three things happen which are not permitted now.
    First a Governor should be entitled to go to any part of the hospital (obviously not theatres in use etc) note the situation and require an explanation for anything wrong.
    Secondly any Governor must be able to have an item required to be debated placed on the Agenda (safeguards against repitition and irrelevance) for the next Governors Meeting irrespective of opposition from administrators, or weak colleagues or Directors who may themselves be strongly dug-in in their jobs or just wish to sweep an issue under the carpet.
    In addition the press and media should be invited to every such Meeting.
    The system is not working and without those features added it never will.”

  50. Michael Vidal says:

    The idea behind Healthwatch is to strengthen the patient voice. However the statutory provisions to allow this will ensure a weaken patient voice. By making Local Healthwatch accountable to the local authority you create a conflict of interest as was pointed out in a number of responses to the white paper. Further in this transitional year the majority of LINks have had thier bugets which are not ring fenced cuts. This raises concerns for Healthwatch and reinforces the argument that Healthwatch should be funded centrally by Healthwatch England. Just because Local Healthwatch is a local organisation does not mean it has to be accountable to or funded by the Local Authority. Indeed if it is to have public credibility and trust it should be wholly independent of the Local Authority which is responsible for social care which is one of the areas that Local Healthwatch is suposdto monitor.

  51. alan cleary says:

    Elected Patient Governors (of which I am one) in NHS Foundation Trusts were introduced originally to the public as a highly effective, common sense, trustworthy, independent, inexpensive means of securing and maintaining high standards of patient care. That could well be right but only if three things happen which are not permitted now.
    First a Governor should be entitled to go to any part of the hospital (obviously not theatres in use etc) note the situation and require an explanation for anything wrong.
    Secondly any Governor must be able to have an item required to be debated placed on the Agenda (safeguards against repitition and irrelevance) for the next Governors Meeting irrespective of opposition from administrators, or weak colleagues or Directors who may themselves be strongly dug-in in their jobs and wish to sweep an issue under the carpet.
    In addition the press and media should be invited to every such Meeting.
    The system is not working and without those features added it never will.

  52. Ian Shaw says:

    We need to ensure that FTs have public board meetings. We need to Beef up commissioning (not reduce it through GP consortia!) so that Provider trusts (and any other qualified provider…) are properly held to account. There should be more patient representation on the Boards of PCTs and PCTs should have `govenor councils’ on the same basis as FTs that ensure that public voice is heard. Please Please dont have elected representation on Boards – politicians have a different agenda to services…

    Please also ditch these reforms and get back to a reformed PCT with more patient and GP representation

  53. Alan Cleary says:

    I question the genuineness of this Forum since my own submission,tendered in all good faith, is repeatedly deleted.

  54. Tamsin Ford says:

    We should be adopting evidence-based health care and policy and should monitor outcomes and not just process – we should look and reflect on the data gathered which should be used to foster reflective practice and not to rank people or to allocate funding. Ranking tells you nothing about quality (just look at the damage done by school league tables) and instantly demoralises those whose results are lower than average (which will be about half!) – very few services will be universally dreadful or excellent and all could benefit from honest and open reflection on what their outcome and process data could say about how things can be improved. Even the best services will have things that could be improved

  55. ruth marsden says:

    Still waiting for Future Forum to focus on Healthwatch which is the part of the Bill which should enshrine ppi.

  56. Rosemary Clarke says:

    I haven’t read all the comments above so my thoughts may well already be covered. My particular interest and concern is about dementia. It is well known among other carers of people with dementia that many GPs are still not providing the right sort of help, not directing people to the right sort of help, and in some cases even still dismissing people entirely. For all I know some GPs may have similar blind spots in relation to other diseases and conditions. It fills me with concern that it is these people who will have to the power to decide how money is spent and what services are bought. I work closely on various groups with my local NHS commissioners who since the advent of the National Dementia Strategy have a clear and profound grasp of all the issues and the needs associated with dementia. It seems an utter waste that all this expertise and indeed passion and commitment is to be thrown away.

  57. Adrian Lambourne says:

    Q How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?
    A One option would be to have bodies sitting between the DoH and hospitals/GPs who know a bit about health care and financial management, who are accountable to the public at monthly board meetings where they have to report on how the money is being spent, why they have chosen route A rather than route B and where the public can have their say in consultations on future decisions. With their prime aim being to manage health care at a primary level, they could be named Primary Care trusts or something similar.

  58. Giri Rajaratnam says:

    The first and primary accountability must be to parliament. This is because, the citizens of this country contribute their taxes to parlaiment. In this context, the S of S for health has to take responsibility for improving the health and reducing inequalities. It is unfortunate that the S of S has refused to take this responsibility. I accept the need for the S of S to delegate some of these responsibilities to the proposed new structures. The important issue is the ability of the NHS to provide an reasonably accurate picture of how health has improved or not as the case maybe. Part and parcel of that is understanding the contribution that the NHS and other partners make to these 2 goals.

    The second issue is accountability to the local communities – I think this has to be through “HealthWatch” which means that this new organisation needs considerable support. In my view, HealthWatch needs a minimum of 2 days a week support from an experienced public health specialist to enable it to come to a view about how well or badly the new commissioning system has fared.

    • Michael Vidal says:

      Giri – While not necessarily disagreeing with you I feel if Healthwatch is to suceed in its duty it needs two things neither of which it will get under the proposed arrangements. Firstly, it needs proper and secure funding. It should not be at the mercy of the Local Authority for its funding. As has been seen this ‘transitional’ year with LINks funding when Local Authorityfunding is under pressure Healthwatch funding will be the first thing to be cut. Also I cannot see how Healthwatch can plan its work with any confidence wihtout proper funding.

      Secondly, Healthwatch needs to be independent of any body that it has to monitor. As it will be accountable to and funded by the Local Auhtority this will not be the case. Pateints and the Public will not ahve any confidence or trust in Healthwatch if it is set up, funded and accountable to the Local Authority. This will especially be the case where the problem is with the Local Authority Social Services Department. Can the DoH Ministers please note I am talking about perception not necessarily what actually happens. It is quite possible that a local authority will have a hands off attitude however I doubt if many members of the public or patients will believe that.

  59. elisabeth dodds says:

    i live in rural cumbria, medical practice, the nearest in 2.5 miles away and has a dispensary. the local community hospital is 10 miles away and the nearest general hospital is 25 miles away. a bus comes through the village once a day, and one stops on the main road at the top of the village 0.5 miles away hourly.
    specialist hospital serves, such as cardiac, paediatric are at least 60 miles away.
    how will patients get to these services? it is challenging enough getting to the nearer ones and if you do not drive the logistics are a nightmare. plus if an patient visiting is very difficult. fuel costs are also prohibitive.
    where will the infrastructure be to address this? healthcare in rural
    areas is a very different challenge to urban areas.
    i am getting 60+ and find myself really fearful of becoming sick and i am fortunate in having access to resources. what will it be like for people who through no fault of their own have limited resources?

    • rrokuku says:

      Not dissimilar to many other rural parts of the country. And we have a growing older population too. We can’t rely on the Big Society (i.e. do it yourself) for everything. Perhaps some attention to the wider determinants of wellbeing – e.g. public transport – would be a wise investment?

  60. a clinician says:

    My concern about these proposals are that whilst many GPs are excellent at advocating for their patients, they are like all us human and with increased pressure which budget holding will all most certainly bring they will have less time to listen and I fear that only the most articulate will be heard. I fear under the new proposals, having any illness which renders me less articulate than I am now. Please think about how services for vulnerable groups e.g. people with mental illness, recovering from head injuries, with a learning disability, frail and elderly will be provided.
    Responsiblity and accountability should be shared. However if the government are intent on giving one profession commisioning status then why not speech and language therapists who are experts at enabling communication from those least able to communicate. ( I am not a speech and language therapist)

  61. Eileen Dickinson says:

    Foundation Trusts are already accountable through their Trust Boards, membership Council, Monitor as well as the Care Quality Commission. All of these work well and standards of care (at least in mental health where I work) have improved over the past decade. The government should not be dismantling things that have a proven track record.

  62. Corinne Camilleri says:

    How are the Consortia going to be held to account for both quality improvements and health outcomes? There is no sufficient mechanism in the Bill.

    Also, I want the Secretary of State to do more than just ‘act with a view to securing the provision of services’. There are lots of things I act with a view to securing that never actually happen.

  63. Noel Parsons says:

    I fail to see how giving overloaded GPs even more to think about or passing commissioning decisions and responsibility over to a private, profit-making organisation can possibly increase accountability. How about leaving the current PCT structure in place, but making the senior posts in the PCT subject to election by the residents in the area covered by the PCT? At least that way there’d be a local connection to the PCT – we could have a referendum on whether to use AV or FPTP for the elections!

  64. Dr Tom Yates says:

    There is nothing wrong with increasing accountability and involving clinicians and service users in healthcare planning. However, it is important to recognise the valuable skill set that public health specialists bring to the table. It is also important that preventative medicine and diseases predominantly suffered by quiet or disempowered sections of the community are not marginalised if well organised, often pharmaceutical industry funded, patient groups get a place at the table.

    However, as Clare Gerada has pointed out, there is nothing to prevent greater clinician or patient involvement in PCT led commissioning. Indeed, this option would avoid the cost and loss of institutional memory associated with a major reorganisation. NHS Oxfordshire who currently commission services where I practice have one percent management costs, which does not seem excessive to me. Some of my most thoughtful peers have trained in public health and now work in PCTs. I think that Cameron’s descriptions of them as ‘distant Whitehall bureaucrats’, etc, have been shabby.
     
    It is important to remember that PCTs initially covered smaller areas and, in 2005, were reduced in number by approximately 50% to achieve greater efficiency. In this rush to achieve localism, it has not been recognised that with greater localism comes increased administrative cost, as discussions and decisions are repeated in multiple smaller units.

  65. Sarah Dalton says:

    I think the best way of improving local NHS availability would be to include a more diverse group of people in the local implementation of the changes. The White Paper tries to envisage greater democracy but this cannot be realised if other forces are at play like “the old boy network”. If there is a true local democracy when it comes to health then patients’ real illnesses will be dealt with giving best value for local resources, rather than for instance central goals for this and that dictating what a surgery is incentivised to treat and possibly distorting the picture.

  66. Rod Whiteley says:

    There needs to be better accountability to individual patients, their carers and their relatives, though a responsive, effective and local complaints system backed up by sound advocacy. At present, complaints about the NHS are too often fobbed off with excuses, or disappear into a labyrinth of bureaucracy, while advocacy services have a limited remit.

    Combining advocacy with a wider responsibility to improve the quality of care would allow a complaint to be followed up independently by the advocacy service, leading to improvements even if the original complaint is dropped. This aspect of the HealthWatch proposal could do a great deal to improve the NHS. Although local authorities appear to have the option of keeping advocacy separate, those that do will lose the synergy of a comprehensive HealthWatch.

  67. Duncan says:

    If GP’s have a personal self interest in the commissioning process ie money not spent they get to keep (albeit indirectly via investment in the practices they own), this will generate huge conflicts of interest, will cause deep suspicion regarding decions made and will generate a scandal that will dwarf the MP’s expenses scandal – the sums involved are so much higher. Money will be short – what little there is must go to commissioning efficient, important services. The financial stake of those involved in decision making must be explicit and transparent – the process is bound to be controversial and any hint of financial impropriety will cause it the collapse. I fear picketing outside the practices of those GP’s involved in the commissioning process if popular and important services are rationed. This will be much worse if there is a suspicion (even if unfounded) of personal financial motivation. I’m sure this is not the intention of the reforms but it needs to be made clear with cast iron guarantees.

  68. Tom says:

    My concerns are that doctors are not the best people to adminster funds. Doctors treat people not balance funds.

    I’m not saying that we need armies of administrators – We have been there and we cannot go back to it.

    Ten years ago hospitals were about long waits and inefficiency, over the last 5 years I have seen a dramatic change – Short waiting times, seeing the consultant reasonably near the appointment time and getting the treatment when I need it.

    We do not need to tinker with something that is no longer broken. Please liten to the ordinary people.

    • rrokuku says:

      Also please do not burden GPs with the dilemma of having to balance budgets when they they will be put in circumstances that, in the best interests of the patient, may require expensive treatments.

  69. Jeremy Nobes says:

    I feel there is a risk that patients with chronic conditions may have difficulties if they move house and want to sign up with a new GP. If that person has a history of hospital admissions and multiple appointments this may discourage the GP wanting such a high cost patient on their books. This did happened the last time GP’s held their own budgets!

  70. ruth marsden says:

    As the recipient of countless comments by LINk members about ‘credible independence’ being fundamental to Healthwatch, I urge two things (a) that the funding allocations for LHW come direct and intact from HWE (Currently, increasing amounts of these monies are being siphoned off by the Local Authorities) (b) that support staff be hired directly by LHW. This is an option of the Bill but needs to be mandatory.That way, good hosts can be retained,but the poor ones dispensed with. (Currently, many LAs do not see/will not acknowledge the deficiencies of some hosts and take the easy way out of renewing contracts regardless.) Host staff need to be LINk/LHW-facing, not LA-facing.

    Ruth Marsden, NALM.

    • Michael Vidal says:

      While largely in agrement with Ruth my reading of the bill is that the Healthwatch staff will be employed directly by healthwatch the reason for this is that as the local authority under the bill will not be making the arrangements with the host but with the healthwatch organisation I am not sure that there will be a host organisation to employ the staff. Also due to the delay in the start of Healthwatch the Secretary of State will have to consider making staff transfer schemes whihc would have the effect of transferring the LINk staff but not the organisation to Healthwatch.

      I totally agree on Ruth’s first point.

  71. Fi says:

    We had “World Class Commissioners” – recognised around the world as an excellent system of identifying population based needs through public health experts and strategically purchasing services that would both meet the needs and improve social inequalities – it was a system manager – unfortunately the proposed reforms remove the broader system manager approach.
    GP friends and colleagues (who have been PEC Chairs) who have been involved for the first time in this years commissioning round – are clearly saying thatthey do not want to be involved in commissioning and that they will contract the function to the likes of KPMG – how is this an improvement?
    In terms of accountability I am not convinced the reform provides democratically accountable commissioning. The proposed GP consortia can make decisions about spending the NHS Funds in private. New entrants to the market must compete on a like for like basis providing care for complex cases and delivering research and training.

    The goverment does not have a mandate to hand over my tax and NI contributions to self employed GPs who are private businessess and not public servants and in one stroke essentially “privatise” the NHS. The imposition of the reforms is undemocratic

  72. lois orchard says:

    Locally based decisions?? !!! the opposite of what is needed. An established baseline of quality services across the UK is what is needed, not niche services, that owe more to the interest of the medic behind them rather than responding to actual need. Post code lottery gone mad.

    Given that you are promising ‘engaged GPs’ even more money to get involved in commissioning had you not thought that the most economical way forward is to ensure PCT boards posts are filled by GPs with a mandate? What you are suggesting will cost BILLIONS of NHS money ALL diverted from providing the services that the UK population wants and needs….

  73. Dr J Martin says:

    If we are to maintain a good relationship between GPs and patients then commissioning decisions must be transparent and the accounts of commissioners open to scrutiny.

    Imagine if/when we hear of doctors refusing treatment/or commissioning a cheaper options in order to boost their salaries or profits (the inevitable bad apples that exist in any profession)… If patients believe that GPs are making decisions for any reasons other than patient health then that relationship will be ruined forever.

  74. It's a public service and should not be for private profit says:

    Abandon these costly and stupid plans is the answer to all your questions. It woudl be far cheaper to make improvements to PCTs than to start form scratch again. if you are determined to press ahead with yet another reorganisation which wastes SO MUCH productivity you must do the following:
    GP commissioning boards should be forced to form on geographic boundaries, aligning practice boundaries with local authority ones and not picking who they want to join up with – it makes no sense and makes needs assessments and allocations impossible otherwise.
    They must meet in public, have locally elected councillors, nurses and other allied health professionals and patients as voting members of the board
    They must be accountable to health and wellbeing boards
    there must be a statutory duty of partnership working, to commission jontly with social care and to commission prevention, and a duty to involve patients at every level, in designing, commissioining, delivering and monitoring services, and guidance of how they should do that – it should not be about consultation – it shoudl be about co-production.

    • rrokuku says:

      I coulod not have put it better myself. Now the challenge is how are we going to get the powers that be to listen and change things as a result of what is said?

  75. JJ says:

    All this stroking of clinical staff who aren’t GPs that’s going on at the moment, telling nurses, AHPs and Consultants that of course they can be part of the commissioning consortia….how is this going to work without supreme conflicts of interest?

    Consortia will be commissioning care from the hospitals and clinics where the nurses, AHPs and Consultants are employed, or from their ‘rivals’ (in this new oh-so-friendly marketplace). How can they be part of that decision-making (without complicated declarations of interest and constant dipping in and out of meetings as these conflicts arise)?? Only if they are not currently employed by any qualified provider of any of the services they might be part of commisisoning. So, like the existing PCT commissioning decision-makers who have clinical experience then….

  76. Karen mett says:

    The whole point of the Comissioing changes is to make GPs accountable and responsible. This can only happen if they feel the reward and pain of doing it properly. This requires the much vaunted but never detailed Quality Premium. It should mean that at least 20% of a GPs pay is at risk if their Consortium fails. They should be the majority on any Consortium Board. change this and we losse the Commissioning part of the reforms.
    I would put other Health Professionals on the Boards of ‘new’ PCTs.
    Replace their Non execs. Add on Councillors and bring PUblic Health into these new Orgs (as said in the coallition agreement) they should also oversee a 5yr programme of GPCC development
    BUT act now because despite Clusters, Commissioning is falling apart. To few, disenchanted confused staff-months and months of uncertainty and no end in sight-let’s stop the miss management by our leaders and get some people in charge who really have an understanding and vision for commissioning. ( not the current bunch of friends!)

  77. SMD says:

    Gp commissioning – a nightmare! GPs don’t have the in depth knowledge of all clinical areas to commission effectively, sometimes let alone understanding of the macro financial manage ment involved. Most sensible GPs don’t want to do this, and would readily acknoweldge their lack of expertise in required areas. In my experience there are a few however who are using their anticipated power to threaten provider services who dont do as they are told – for example – unless you see my patient yesterday we will ensure you are decommisisoned asap when the time comes! By the way only the yesterday is an exaggeration here, the person had in fact been seen the morning after referral but this still wasn’t good enough! The thought of maverick GPs with such crazy expectations and such a poor understanding of clinical issues wielding such power is terrifying.

  78. A Christopher says:

    GPs are not the only fruit! Why only GPs? They are far to busy to engage with all the minute detail of commissioning, and that detail needs to be done! So they pay others to do it, what has been achieved? Nothing! The PCTs and SHAs have been villified, they did a good job, were not underperforming (a lie) where not over managed (another lie) positively undermanaged if anything. Put the few GPs who have the time or inclination to be involved on Commissionin boards and let the rest get on with the day job, they will anyway and only a few will engage. Any GP commissioning event being put on cannot get GPs to attend, they are too busy. They cannot get cover.
    GPs are much more expensive than NHS managers, so where is the saving?

    Put the patient and public on commissioning boards thay work! Not on private company boards brought in to commission by GPs who will not be involved anyway, so stupid, so ill thought out, so unworkable. Stop these fundamentaly wrong reforms now.

  79. Elaine Tamkin says:

    Like many colleagues when I entered GP I did not expect to be doing anything other than looking after patients. Running my own practice soon put paid to that notion. With the onset of PBC I learned that each clinical decision I take is actually a resource allocation decision. I do not think that any clinican of any discipline can get away from the fact that they are spending limited public funds and it is our responsibility to spend well. The view of our consortium is that if you ‘only want to look after patients’ do so , just keep within your budget and we will take care of the commissioning.
    Gps have the biggest opportunity to make changes for the benefit of their patients that we have ever had. We do them no favours if we pass up on this.
    We are making every effort to involve service users in the consortium through our involvement with Neighbourhood groups and the local authority. This is a work in progress but for the first time in my practicing life (24 years) Gps are actively involved in public health.

  80. Jean Hardiman Smith says:

    Re the NHS Future Forum

    I have deeply held doubts about the validity of a so called listening forum when the majority of NHS users – the pensioners – do not have a voice. The National Pensioners’ Convention represents over a million pensioners, is by far the largest pensioners organisation, and yet does not have a representative on the Forum. This is undemocratic and unacceptable. As a member of the NPC Health Working Party I would be delighted to hear your comments on this, and will forward them on to the General Secretary Dot Gibson for her consideration. Please do not say that we can make our voices heard via the internet, as you must know this does not carry anywhere near the same weight as being able to participate in a face to face meeting. You will appreciate the urgency of this since feedback is due at the end of May. We are also in the dark about any consultations which are due to be held, which our members might wish to attend. These do not seem to have been well advertised.

    Regards,

    Jean Hardiman Smith

  81. NHS Manager says:

    Practices will be accountable to their commissioning group. The commissioning groups will be accountable to some kind of regional commissioning board. The regional commissioning boards will be accountable to the national one.

    In the present situation practices are accountable to the PCT, the PCT to the SHA and the SHA to the DH.

    These reforms are costing the NHS money at a time when the QIPP programme is supposed to be saving money.

    QIPP is involving clinicians in commissioning and redesign of pathways because that is the only way to save the money and to continue to care for patients.

    The “reforms” will change nothing because the model that will come out of them will be model that we already have because it is the only one that works.

  82. Jon Holt says:

    Where is the voice of the patient in this massive upheaval? If ‘no decision about without me’ was a reality rather than hot air than this whole messy project wouldn’t have got off the launch pad as there is scant evidence that patients or the public understand it let alone want it.

    • Michael Vidal says:

      Jon

      Those members of the public who can make any sense of these ill thought out rushed package of ideas would prefer a frontal lobotomy than these reforms

  83. Pauline Cross says:

    Who will be accountable for the quality, monitoring and evaluation of commissioning decisions in relation to maternity services?
    From where will GP consortia access specialist maternity and midwifery expertise and how will they monitor those contracts without that expertise? There should be a senior midwife on the boardof each GP consortia(hopefully that name will change!) as well as nursing representation and other AHP.

  84. Pauline Cross says:

    Maternity Service Liaison Committees play a vital role in ensuring that service-users inform and influence maternity services strategic planning. They can keep an eye on services and ensure that rhetoric translates into service changes that are noticable to service-users. they must be placed in such a way that the NHS commissioning board, GP consortia and Public Health depts must consult and involve them in commissioning decisions.

  85. Dag Saundersw says:

    I support the move to bring Public Health more into the local authority world and to establish more effective public and patient representation organisations ie Healthwatch although these must not be part of local authorities as their independence will be undermined. The remainder of the proposals are ill thought out – there are many better ways of involving clinicians more effectively in commissioning but no major changes should take place until they have been well considered and tried out. Given that PCTs are being demolished at present I would suggest using the PCT clusters as formal PCTs with local commissioning groups comprising GPs and others including representation from acute hospital consultants, nurses, paramedics, local authorities and public/patient representatives to work to clusters and the National Commissioning Board.

  86. Paul Meadows GP says:

    I think calling commissioning “GP Commissioning” is both misleading and canny. I think it’s misleading because there will only be a limited and (in real terms) shrinking resource to devote to healhcare and the population needs are not known to individual GPs or Practices. Consortia will need to do a similar range of things to those currently done by PCTs. Consortia cannot more easily engage public and patients than PCTs can, and in any case such engagement needs to balance particular interests of pressure groups against the wider health need. In my view there is only a small, but real, opportunity to restructure some aspects of healthcare to use resources more efficiently. I think the move to GP Commissioning is canny because it distances the Secretary of State from decisions, leaves new organizations with the responsibilty to reduce services in line with contracting real budgets and misleads the public into thinking that “GPs” are those responsible.

  87. Tony McGough says:

    Patients are local, aren’t they? Treated in one place (usually). So this is a set of local problems for local institutions.

    Customer satisfaction is an important metric for private companies, and the techniques used by them might be translated for healthcare by NHS managers determined to do so. It would take determination and courage, but could be done. And the results made known to the Royal Colleges, Parliament and so on. Roll on that happy day …

  88. George C.A. Talbot says:

    As the NHS is funded nationally, “the heart of decision making” must be national and must limit what patients receive. To best serve them, NHS staff must be dedicated to their needs. But management must consider the needs of its staff, the costs of treatments and budgets and the quality of its assets, well into the future. This is a massive task that must include concern for the culture that shapes how people behave and what they expect. I consider structure and politicians in Advice and leadership. True costs are not the same thing as market prices.

    The first two questions assume commissioning and the purchaser-provider split. This has added over £10bn/year to costs with no known benefit. I urge its abolition. Expecting “the public” to understand the many hard choices required to run the NHS is naive as is expecting “consortia [to] engage fully with patients, carers and communities”. Local freedoms depend on delegation and on responsible behaviour by all.

  89. Anon says:

    Patient opinions must not carry more weight than clinicians. Decisions cannot be made based on the convenience of the patient, we cannot provide good healthcare for all with the budget we have without the patients meeting us halfway. All healthcare professionals need to provide oversight on health care decisions, not just GP’s. The simple solution to this is to put in place measures to ensure PCT boards include adequate representation for clinicians.

  90. barbara p says:

    PCTs and SHAs are already accountable to the public, with duties to carry out commissioning, involving not only the public but also healthcare professionals and local councils.
    PCTs were originally set up to involve the public and professions and to respond to local needs, and were beginning to get to grips with the commissioning process. Now all the skills and expertise built up over the years is being lost. So “How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?” – easy – keep the best bits of PCTs. Sure they need some trimming, but the answer to this particular set of leading questions surely is :by keeping the structure of SHAs and PCTs.

    • Wendy Watson says:

      Actually, PCTs were accountable to no-one. Not even the CQC could challenge Hull PCTs decision to buy a yacht. Remunerations are through the roof. One SHA worker enjoying £1,291,000 real cash increase on their pension pot in 08/09. Lack of knowledge of the subject led to the need for world class commissioning, and yet another raft of associate directors on 6 figure salaries to cope with it. Analogy. What self respecting plummer would send his wife for the parts for a central heating job? Yet in the family she would be considered the best ‘shopper’. This is identical.

  91. Michael Vidal says:

    How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?

    If commissioning decisions are to transparent then as a minimum Commissiononing Consortia should be added to Schedule 1 of the Public Bodies (Admission to Meetings) Act 1960. It is nonsensical that the local Healthwatch Organisation has been added to this Schedule but GP Consortia whihc is the body whose meeting people are more likely to want to attend has not.

  92. len roberts says:

    Accountability is key to giving assurance to patients in a time or rapid and risky change. Local authorities are democratically elected, and their Overview and Scrutiny functions need to be strengthened. But local government is political. That is one reason why the HealthWatch proposals are so important as a separate, and citizen based watchdog. But the current proposals are fatally flawed and weak: local healthwatches are to be financed (without ring-fencing) and judged by a key provider body – the local authorities are the providers of social care, a key component of the HW remit. This is clearly wrong in principle, and cannot be justified on any terms: to go ahead on such a wobbly basis is fatal to public understanding and support. It is a national political decision, but has no other basis. Local Healthwatches must be 100% independent, and able to act fairly, but without fear or favour. It must be a citizen led movement, with strong professional support. And it must be visible to local communities. HW England and the local HWs should be one steamlined organisation, not influenced by those they monitor.

  93. Suzanne Bannister says:

    As the director of a countywide HIV and sexual health charity, my concerns are around how we will ensure effective communication with multiple GP consortia, and achieve consistent and sustainable funding, as opposed to postcode lotteries based on the special interests of GP’s. The other concern is that GP’s have a very clinical bias, whereas most voluntary organisations have a social care bias and there now needs to be a process where the medical model and the social model come together and are able to use appropriate measuring tools to evidence outcomes in a way that GP’s will understand. My concerns are that GP’s do not have the indepth knowledge and expertise in specialist areas (such as HIV, which is the field I am in), but will now be responsible for commissioning services.

    It may be useful to develop “topic” groups where GP’s, voluntary sector and local authority reporesentatives are able to come together and discuss the particular needs in their specialist area, which can then be fed back into the GP consortia by selected a representative?

  94. fay says:

    By open reporting & ensuring that patients, carers and communities are on governing boards, through councils etc?
    I find it difficult to see that the NHS commissioning budget, held by the new NHS Commissioning Board, will be allocated transparently and used with proper accountability to the public at local level through GP’S. GP’s need some say but how many are trained in accounting, commsioning ? Councils are PCT’s in the past have seen the whole bigger picture.

    Foundation trusts has given the local NhS services greater freedom, this should continue

  95. MRobertson says:

    Give more support to You’re Welcome, and don’t water it down by making it self-certificating – make the processes more robust. It’s a fantastic mechanism to make health serivces more responsive to the public they serve, not only young people but practical changes that benefit all ages. This fits so well in to some of the mechanisms for public engagement talked about in the white paper and provides fantastic opportunities for young people, as well as making them more knowledgeable users of health services in the future.

  96. Paul says:

    How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?

    Have Consortia set up publicly accessable websites where details of commissioning decisions are summarised for other to examine. Standard headings can be used such as:

    Evidence of Efficacy (what research exists to show this will be effective and what is the estimated effect level, displayed as NNT if appropriate)

    Evidence of Cost Effectiveness (what is the cost of providing this service)

    Details of alternatives that were rejected (What other options were considered and what are the resons for rejecting them in favour of the commissioned service)

  97. Paul says:

    How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?

    Have Consortia set up publicly accessable websites where details of commissioning decisions are summarised for other to examine. Standard headings can be used such as:

    Evidence of Efficacy (what research exists to show this will be effective and what is the estimated effect level, displayed as NNT if appropriate)

    Evidence of Cost Effectiveness (what is the cost of providing this service)

    Details of alternatives that were rejected (What other options were considered and what are the reasons for rejecting them in favour of the commissioned service)

  98. Judy says:

    As a mere member of the public I would like to be able to have the confidence to go to my Doctor when I needed to see him and know that he was actually doing what he was trained for i.e caring for me and trying to help me and not have his mind on administration problems and funding. One would hope that care was not totally dependent on the practise budget. I am not totally naive to the need to balance books, but surely it is good to remember the “Do no harm” statement…this means that if a more expensive drug is needed to prevent harm or on going illness then this is the road to travel. Doctors are Doctors not accountants/ office managers, Let them get on with their job.

  99. Philip Radford says:

    I would like to suggest that the whole culture of ‘Commissioning’ that has grown up in recent years is a massively expensive waste of time, engaging large numbers of primary care and secondary care managers in expensive activity for which there is very little evidence of benefit.
    I don’t believe that the healthcare needs of most areas of the UK differ that much from each other, so why do we need all these commissioning bodies at all, currently PCTs to be replaced by GP consortia – just think about the amount of time that this all takes, the salary costs etc. which could be spent on patient care.
    The alternative is to have nationally agreed standards for NHS care that are required to apply everywhere and then in each locality some form of local board composed of representatives from primary care, secondary care etc. charged with implementing these.

    • Wendy Watson says:

      Fantastic. Exactly my sentiments. NICE guidelines are debated by the top personel in each field… rigorous scrutiny to ensure fairness and value. Why let others without the expertize loose on something they don’t understand. Well said Philip!

  100. Richard Wallace says:

    Loose the post code lottery.
    Make the same standards, and quality apply across the country.
    When you make a car, be it Ford, BMW, Kia or Toyota the same rules apply as to how it is built. It may look different but the rules still apply.
    Why can individual PCT’s and even departments choose which rules to follow and which to ignore and put it down to cost savings? or we didn’t know about that.

    • Wendy Watson says:

      Man after my own heart here. We have NICE guidelines – developed by clinicians and responsible stakeholders, then PCTs can pick and choose which they bother with. With little knowledge also. Billions of pounds is spent by PCTs undeciding these guidances – yet paying themselves incredible salaries. World class commissioning had to be invented to help with their lack of expertize in the subjects. How can Hull PCT get away with buying a yacht for half a million pounds? The CQC not allowed to say anything. Total madness in my book. Also the ‘cuts’ are meant to be in management costs, but have been passed onto the frontline. Everyone now believes there have been cuts, yet the reality is that the increase in budget was honoured. PCT management costs were intended to be reduced by 30%, not nursing jobs lost.

  101. Prescribing Advisor says:

    Conflict of interest for GP consortia – The previous government told PCTs that they could not be both commissioners and providers of healthcare. So community nursing and other services such as podiatry, physiotherapy had to be offloaded to another organisation. Fair enough our PCT will no longer be a provider of healthcare services it will only commission and therefore no conflict of interest. However what to do GPs do? They provide healthcare services, but now they are to be commissioners as well. How can this be if PCTs were told they could not do it?

    How is the conflict of interest going to be managed here? GPs commissioning themselves to provide extra healthcare services to the local population…. erm doesn’t seem quite right to me.

  102. Prescribing Advisor says:

    Not all decisions should be made locally – remember concerns about post-code lotteries relating to treatment. It will be helpful if there are some national standards to avoid these criticisms; these can be beneficial to create a level playing field- 28 day prescribing would be one such example.

    • Wendy Watson says:

      Exactly. The paying public want a ‘national ‘ health service, not the invented local need nonsense invented to create further bureaucracy.

  103. Roland says:

    I’ve just received an email to say that the NHS Future Forum is working with Regional Voices to arrange “listening events” for “patient, service user and carer groups and the wider voluntary and community sector leaders to have their say” but when I checked for the nearest “listening event” to me, I found that there is only one such event (in Exeter) for the entire South West region. Why? The South West is a large area, and a lot of people won’t be able to get to Exeter. Or is that the point? Is it because “patient involvement” is not really going to be at the heart of decision making?

  104. Edmund Dunstan says:

    Reduce the democratic deficit in the NHS by ensuring that elected local opinion, e.g. from local authorities, is involved in commissioning, and requiring that all decisions not involving individuals are made in public. “Commercial confidentiality” can have no place.

  105. Dr Lisa Silver says:

    The reforms are asking GPs to undertake a task that is broadly going to be impossible to achieve. We as GPs are being asked to slow/stop the upstream traffic from our surgeries into the secondary care sector. However the front door into our surgeries is wide open and there are no brakes on anyone consulting us for anything they so desire. Although we can bat away many of these requests ( this week I had someone asking for suntan lotion as he thought that it was too expensive from a chemist), this open door to general practice creates unlimited demand and does lead to activity up the chain. Politically incorrect this will sound unless there is some mechanism either insurance or a charge to enter the NHS, we are never ever going to be able to curb demand.

    • Wendy Watson says:

      We need to work to strong National Guidelines – developed by NICE, and put in place by a National Commissioning board – run by clinicians.

  106. Derek Watkinson says:

    I worked in an NHS logistics role having previously worked in telecommunications development roles. In the latter quality training was available and was a key part of ensuring the different groups involved could work together and ensuring departments could obtain and keep accreditation to quality standards like ISO9001.

    I don’t know about the NHS medical services but across the support services I saw numerous examples poor inter-working and other problems that ought to be being identified and resolved. The lack of training for support staff in basic quality assurance principles and anybody with responsibility for quality improvement between departments made any attempt to improve matters beyond the remit of my immediate line manager next to impossible.

    I don’t have a view on which method/framework is best for budgeting, commissioning or other activity within the NHS but I’ve found nothing on this site about examining/measuring how well all parts of the NHS inter-work before, during and after changes are made to ensure changes improve quality throughout the NHS.

  107. Colin Slatter says:

    I agree completely with Prof Bywaters argument that commissioning should involve a range of clinicians and patient representatives, and that the separation of hospital clinical staff in the process is artificial. If the objective is to deliver improved patient care, effectively- then we should be involving clinicians more broadly and supporting patient representation to ensure the delivery of services meets their needs. I have a serious worry that creating local HealthWatch with a larger agenda, asking local authorities to play a significant monitoring role and expecting a seemless transfer from LINks to the new world with a smaller budget, is a recipe for disaster.

  108. Roseanne Meacher says:

    There are many patients for whom GP commissioning just doesn’t fit. How does a GP consortia commission services for conditions it sees rarely or for services it only uses a few times a year? I very much hope that the commissioning board takes a strategic view and plans some of the services that are required for the population – leaving things to the market will be chaos and result in a fragmented service. I also can’t see how replacing 200 odd organisations with more than 500 – all needing to perform the same negotiating tasks – is going to reduce costs or beaurocracy – I agree the PCTs need reform but this sounds like 2.5 times the cost!

  109. Helen says:

    I work with vulnerable groups of people in the NHS and am worried that the health inequalities they currently encounter as documented in many national reports will not improve. When we talk about who should be part of commissioning there are a substantial part of our communities whose voices are rarely heard, namely those with disabilties already marginalised in our society, who will represent and involve these groups?

  110. Alison Forrester says:

    I agree with Roseanne Meacher – it makes no sense to force a top-down reorganisation on the NHS at a time when we need to save billions. PCTs have become the scapegoat because financial accountability lies with them and they have to make many unpopular decisions – but at least this is population-based health care, trying to ensure equity and access for all, and fair commissioning decisions. Many dedicated health professionals are involved, including those with a clinical background.

  111. Alan Pucill says:

    If the aim is accountability, the last thing we need is the private sector involved. As soon as organisations start sub-contracting services buck-passing becomes endemic.

  112. Katharine de Villiers says:

    It is not obvious to me how more marginalised groups will make their needs known as they are less likely to get involved in patient consultations.

    I also second comments that raise concern about the public having too strong a say on spending decisions given that media scares are very influential in how the public sets priorities.

    Also, I value my GPs for thei medical training and would like them to devote as much time as possible to using their skills for improving health not for financial management.

  113. Consortium Manager says:

    Yet again today the news is full of declarations that the new policy will hand over to GPs 80% of NHS resources. For heaven’s sake, they already control the commitment of this resource (practically everything except the cost of people who take themselves to A&E). The referral and prescription pads are effectively the cheque book of the NHS. What will be different is that the people who commit the resource on behalf of patients will actually have some say in the design of the services they are paying for.

    Much of the debate around whether or not GPs should be ‘given’ control of these resources is therefore irrelevant.

    • Iain says:

      And exactly how – when referring a patient with an undiagnosed condition – does the GP have any idea what that referral will cost the NHS or what resources will ultimately be needed for that patient.

      GPs may be the gatekeeper – but the resources MUST be funded and in place regardless of whether or not the GP sees any need for them. Commissioning is not a simple matter.

      Effectively GP fundholding failed because GPs were NOT required to fund the susequent care of the patient’s they referred but assumed that the PCT (or equivalent) would do so.

  114. Jennifer says:

    I am very concerned about a number of aspects of the current Bill. PCTs have been given a bad press because of hard decisions that always have to be made but there is considerable experience and expertise within PCTs. Many were formerly clinical staff and many have a good understanding of the the needs of the patient or client.
    GPs are not necessarily the best people to commission services as they have so little experience of working with many parts of the population. In many cases GPs are the ‘problem’. They are frequently unwilling to undertake new initiatives without considerable remuneration and do not currently design their services around the needs of the patient.
    GPs will probably cherry pick much work for themselves and be well rewarded. If GPs had really wanted to become involved with commissioning decisions, I feel sure this would have happened before.
    Because of the complexity of commissioning, I fear we shall replace one organisation with a very similar but far more costly one.

    • Wendy Watson says:

      Complexities in commissioning decisions appear to have eluded many PCTs. Why does Hull need a yacht for example? And if it really is that beneficial to health – why doesn’t every PCT have one? Why have commissioning at all? Commonsense decisions have already been established by experts in NICE committees. The National Commissioning board should heed those recommendations. GPs should act on those mandates. Commissioning is 90% + bureaucratic rubbish.

  115. Disappointed says:

    Will somebody PLEASE look into the Ambulance HART. A phenomenal amount of money is being ‘invested’ in these teams. They largely replicate the work of the fire service and take resources away from the core business of the ambulances services they are supposed to work for. They spend the vast majority of their time training, debriefing, resting or sleeping. They are all experienced paramedics and should be responding to the patients who need them – not waiting for some potential event to occur. In the meantime they are bored, deskilled with respect to their core skills and the boredom leads to conflict with ‘ordinary’ paramedics. On a national level the amount invested in these teams is obscene.
    Please – will somebody put a stop to this waste…..
    I appreciate what the purpose of these teams is but – being realistic – is it value for money?? We need an investigation – urgently.

    • Wendy Watson says:

      I agree. Nonsensical waste of money – like Hull’s yacht for socially disadvantaged kids to learn a skill on – half a million pounds! ‘Outer space project manager’ aiming to gert NHS workers and patients identify with their wider green issues. Barmy

  116. Professor David Hands says:

    I am appalled by the way in which this mendacious, duplicitous and autocratic government has approached this exercise. If the government has proposals to improve the NHS it should be clear and honest about them and provide the evidence on which their proposals are based. It should then consult properly and produce an independently audited analysis of the response. This bogus ‘listening’ exercise is yet another example of the depths to which both government and the corrupted civil service have sunk.

  117. Steve Elliott says:

    You just don’t get it, do you ? Your idea of democracy is like Colonel Gadaffi’s. Your headline question can really only have one answer–democratic representation from local people, preferably by direct election, on decision- making NHS bodies. The Foundation Trust model of membership doesn’t cut it, flabby concepts of patient involvement are pathetic, and the proposed governance arrangements of GP Commissioning Consortia are a democratic outrage.
    So your detailed questions are lodaded and irrelevent.

  118. Alan Spicer says:

    Is the Government being a bit disingenuous here? Patients will always want the best (not sure how that is determined) with a definite lean towards ‘want’ rather than ‘need’. Currently a GP determines this using guidelines issued by the PCT / NICE etc and can then deflect most criticism using those guidelines. With patient involvement at the heart of the proposed decision making, this line becomes more fuzzy. Is an expensive drug that prolongs life by 4 or so weeks a want or a need? Is quality of life a want or a need? Who can determine, if not the patient or carer, what quality of life is acceptable? If patients disagree with the decision, how do they get redress especially regarding the former which is time critical? Is 4 weeks of extra life worth 20 knee operations bearing in mind that the extra life issue is not necessarily age related?
    Patient power is an ideal that may be difficult to achieve when it comes down to balancing ‘want’ and ‘need’ with the money available.

  119. Alan Spicer says:

    The proposals will probably not stop so called ‘postcode lottery’ but may well, in fact, exacerbate the problem. The proposals indicate that your GP can commission/approve appropriate treatment but Practices in the most deprived areas will always be a bigger drain on the Consortia’s finances. With the Consortia Board having a responsibility to manage their budget, it isn’t beyond the realms of fantasy to see a situation where some minority high cost treatment is repeatedly denied because of financial reasons or, worse, because the Practice concerned is not ‘playing ball’ with regard to other targets like referrals, prescribing or engagement. Neighbouring Consortia may have a different set of rules. As to my previous posting, what redress can a patient invoke if they are being penalised by either living within a Consortia that won’t fund their treatment or their Practice is Persona Non Grata?

  120. Prescribing Advisor says:

    Although this question relates to accountability of the NHS to the patient, what about the accountability of the patient to the NHS? Should there not be some onus on the patient not to waste GPs time, not to turn up asking for bottles of suntan lotion (as per Dr Lisa Silver’s post), not to attend A&E with a splinter in a finger, not to order prescriptions on repeat when they are not needed, to tell the Dr if they stop taking their medicine, to engage in a healthy lifestyle rather than thinking a pill will enable them to continue with an unhealthy one. Where is the accountability for the patient?

    • Michael Vidal says:

      In practice these proposals are highly unlikely to lead to greater accountability to patients by the NHS indeed as the proposasl stand there will in fact in all probabilty be less scrutiny of health services especially if it is left to the local authority as a whole instead of a scrutiny committee. As far as Health Scrutiny Committees are concerned the proposals in the bill show a complete lack of understanding about how Health Sc rutiny Committees work. I have attended a number of scrutiny committee meetings and have normally been allowed to question the representatives of the local heath bodies. If the proposals in the bill are kept in there current form I would not be able to do this in the same way if at all. I do not see how this improves accountability.

  121. Dr Jacqueline Marshall says:

    I would love to be accountable.
    As a GP Principal of a pathfinder consortium I should be.
    We went “live” on 1 4 11. But as of yet (mid May) we do not have a budget nor do we know how to access funding streams.
    As a parting shot the PCT has hired a private company to “List cleanse” ie write to every patient (allegedly) and tell them to reply if they wished to remain registered with their GP.The letter was only written in English. So many patients have not responded including elderly,demented,mental helath,children (and those at risk),learning needs,disabled,housebound,those for whom English is not a 1st language,and those who do not respond to circulars will shortly be removed from their GP list against their GP’s wishes and probably without their knowledge.
    Apparently the idea is to save money.Each patient removed is 68 pounds per year saved;that is until they goto a+e or a walk in center and then the cost to the tax payer will be 80 pounds.
    I am told that the drivers of the list cleansing do not care-it’s a different budget.

    • Michael Vidal says:

      Dr Marshall raises one important point. How are the pathfinders and early adopters being funded as Local Authorities and PCT’s are unlikely to have the spare funds to fund them.

  122. Jo P says:

    I feel that not all GP’s want the responsibility of commissioning care for patients. Also, I believe a more balanced approach would include a range of other healthcare professionals.

  123. stuart White says:

    (1) The Torylead coalition has no mandate from te electorate for this Bill.
    (2)It has been made transparently clear by Shirley Williams and JohnHealeys attendtion to the details of the Bill that in effect this bill to open the NHS up to the Free Market and increased levels of privatisation.
    (3) These proposals have not been put to the electorate and the Coalition has no mandate for this bill.
    (4) At the heart of tis bill is the policy direction espoused by Daniel HArman MEP and M Gove et al. EG that the NHS is a 60 year old mistake!
    (5) The Proposer of this Bill and his leaders Cameron and Clegg have no credabilty left.This Bill should be abandoned.
    (6) ABANDON THS BILL

  124. Scott Durairaj says:

    Lets face it if we leave the NHS in the hands of GP’s there will be no NHS. The good GP’s are in the minnority, lets not forget that most GP practices are already private buisnesses.

    The NHS has battled with GP’s for years over improving patient care, remember the ‘polyclinic developments’ ensuring GP could be accessed 7 days a week outside of working hours to assist those patients who have difficulty accessing healthcare as they will lose pay to do so in working time. It was GP that petitioned against that saying how bad it would be for patients.

    Im sorry let GP’s do thier job of treating patients and lets get some good ones involved in commissioning but ‘lets not just give the self interested man a mirror’ as thats no way to move forward.

    What about specialist commissioning like the Trans carepathway or mental health services GP struggle with dealing with primary care for these issues never mind commissioning.

    • Wendy Watson says:

      I have investigated the amount of money spent on ‘commissioners’, the ridiculous projects invented and layers of over paid Directors and associate directors in PCTs. Totally unaccountable also. Half a million on a yacht for socially disadvantaged youngsters – yet not even the care quality commission or parliamentary ombudsman had the power to prohibit!
      GPs and clinicians are best placed to commission services. Due to lack of clinical knowledge, ‘world class commissioning’ had to be introduced, to assist in this field. This led to further rafts of associate directors on £80k plus per annum.
      There have been no cuts in the health budget, but the PCTs were supposed to make 30% cuts in their own budgets (management costs). This appears to have been passed onto the frontline. Andrew Lansley is quite right about cuts in bureaucracy – we just need to help achieve cuts in the correct places. The latest nonsensical post advertized on the NHS jobs website ‘outer space project manager’ aiming to get NHS workers and patients to identify with their wider green issues! Look at what is going on here. Accountability to a central clinically led National Commissioning Board is a must.

  125. Lynn says:

    If you took away all the targets inherited from the Labour party, and the highly paid managers who have been appointed to ensure they’re met, a vast amount of money would be saved. Doctors shouldn’t admit patients according to targets – this should be done on clinical need. I’ve worked in the NHS for most of my working life and these targets are mostly unworkable and time consuming – as well as expensive.

    • Alan Spicer says:

      In black and white, this sounds logical until you consider:
      1) When targets were not there, waiting times for certain procedures were unacceptably long.
      2) The “highly paid managers” tag line is misleading. Yes there are managers earning £70K+ but those are few and far between and generally ex-clinicians now working, or part time working for the PCT/SHA. Most ‘managers’ who monitor these things are lucky to get half that (still a very good wage) and this tends to be a small part of their job.
      3) Clinical need is a perfect criteria but this does not take into account budget, other priorities and want against need.

  126. Community nurse says:

    I have concerns about GP’s commisoning services when they dont always understand and don’t take the time to find out what the ‘less attractive’ services provide. The comments that suggest some current practices do not put their patients first or run their surgeries as efficient patient centered enterprises are well founded and I worry that giving the budgets to GP’s, if not properly monitored for quality and don’t operate an ‘being open policy’ will just result in patient care being sold out to make a profit. I would like the government to assure me and my colleagues that there are robust procedures in place to prevent this.

  127. Madammare says:

    I haven’t seen any reference to the centralising of ‘types’ of illness to specific hospitals, nor the closure of so many hospitals.
    While I accept the recession is partly responsible for the latter, I have real concerns as to the loss of easily accessible emergency treatment; at the moment air- or road-ambulances are already having to bypass the nearest hospital in order to reach the one best for ‘this’ patient.
    Efficiency may be improved at such centres, but at what possible danger to the patient? Every second counts in some cases, and surely the nearest initial treatment with transfer for specialised treatment later would be less dangerous? I know the ambulance is well equipped
    for basics, but not with immediate IC needs.
    I am reassured that free care is not in danger, but hope our already over-stretched GPs won’t be asked to concentrate on anything more than the immediate care of their patients…

  128. Sue says:

    Dr Marshall raises very important concerns about the lack of detail relating to how GP Consortia may work.

    My view is that all Consortia meetings and financial dealings must be open and clear to the public.
    All Consortia board members and those with an interest (shareholders) must make declarations of interest at all meetings.
    Thirdly, all Consortia have a duty to demonstrate that they are involving and responding to the wishes of the populations they serve.

    The ‘list cleansing’ exercise Dr Marshall refers to doesn’t sound too bothered about the needs of the local population. More like ‘follow the money’.

  129. susan wright says:

    I no longer think it cynical to think that the proposals are so likely to lead to a less good NHS that the political ideology of ‘privatisation’ becomes increasingly popular. I think this intention is becoming as clear as a pikestaff.

  130. Sarah-Jane Speech and Language Therapist says:

    People from all groups that the NHS serves need representation in local forums that are integrated into the commisioning process.

    Those with communication difficulties that we as Speech and Language Therapists work with have – by definition – additional barriers to getting their voice heard and their needs recognised by those with the power to make decisions. One way to help proper accountability to our client groups would be to include speech and languge therapists on The National Health Service Commissioning Board, Commissioning consortia and Health and Wellbeing Boards, and for those therapists to make it their business to consult and invite and support the experts (ie the patients) to get their views across.

  131. Sam Allen says:

    The NHS is already accountable to the government, who are in turn responsible to the electorate. This seems like a ploy to disassociate problems in the NHS from the government if there are are separate accountable bodies then any problems can be palmed off on them instead of the blame being placed where it belongs, i.e. on the massive spending cuts the current government wants to impose.

  132. Bob Hudson says:

    It truly beggars belief that the Government is willing to hand over £80 billion of our money to a handful of private businessmen (ie: GPs) with little or no accountability for how they behave. This must be stopped in two ways. First, commissioning should be the task of a range of stakeholders working in partnership – not be simply the plaything of a few Alpha Male GPs. Second, accountability and governance arrangement must be much stronger and clearer.

    The role of users, patients and carers is also far too weakly couched. Local HealthWatch is an improvement upon LINks but will be toothless unless it is far more professionally organised and better funded. The Health & Wellbeing Boards are in danger of becoming paper tigers and need to be given stronger powers viv-a-vis commissioning consortia.

    And how – as a user and taxpayer – am I able to have some say in what is going on in the National Commissioning Board, CQC and Monitor?

  133. Mental health Manager says:

    I totally agree with Scott’s comments above. GPs are trained extensively to deliver healthcare, they are not trained in buisness management or commisisoning. The public fund the education of doctors precisely because they want skilled clinicians not part time administrators.
    Also, this picture of your friendly local GP who knows you and your family is a total myth and so knows what you need – they refer people to specialists precisy because they don’t know and need specialist knowledge that they do not have. They have to be ‘ack of all trades and master of none’ who act only as gatekeepers and basicly the Government wants them to close the gate as much as possible so less people get through to acute and specialist services.

    If you want clinical input into commissioning decisions then just make the Boards of PCTs at least 60% GPs then they are fully accountable to the public for their commissioning decisions and the infrastructure which holds all the local history can deliver their decisions. Absolutely no need for this ridiculous rebranding of the same function. By default GPCCs will have to be mini PCTs by any other name.

  134. Giri Rajaratnam says:

    I agree with many of the comments and the sentiments expressed by colleagues. There is however, some important issues in this question. The system in England is that we thru taxes collected by parliament and administered by parliament fund the NHS. There is therefore no escaping the responsibility that the S of S has for delivering on the health of people of England. I think the S of S is trying to evade this responsibility and must not be allowed to get away with it.

    The issue of local accountability is important and there are 2 aspects to this: value for money and outcomes (including equality). Given the complexity of these issues, health data will need to be translated annually. I would expect the DPH as part of his annual report to express a view on the extent to which local health and care needs have been met in light of advancing knowledge.

    Giri

  135. Giri Rajaratnam says:

    The second part of this question is about patient involvement. It is unclear from the question exactly what is meant. My experience of working with senior people (unfortunately I am one of those) is that despite the considerable literature on the subject, they do not understand what this actually means. My strongest suggestion is for those people and for those at DH to read the literature carefully. There is plenty of good stuff there. Good examples of actual practice – lots; eg, clinical networks such as cardiac and stroke or cancer have some good experience.
    The very difficult area is in relation to priorities and resource allocation. Even here where the remit is pretty specific -informed members of the public can contribute. In my experience, DH mandated committees are a different matter altogether – in the ones that I have been involved in, although members of the public have tried and have been supported by the officers – it has always been a frustrating experience of the individual concerned. So the answer is – do not allow DH to mandate committees!!

    Giri

  136. Richard A says:

    GPs do not have the necessary managerial experience, perspective of the organization, the technical knowledge or the administrative resources, to manage the NHS alone. The use of private companies to provide administrative services would add to costs. The proposals also make just the same kind of mistake as Aneurin Bevan did in setting up the NHS when he gave so much power to one group – in that case the hospital consultants. Further, with GPs being so close to their patients and seen by those patients as being responsible for decisions on costly treatment, a wedge will inevitably be driven between them.

    All types of health professionals (not just GPs, but also hospital doctors, pharmacists, midwives, nurses etc), advised and supported by experienced managers and administrators employed by the NHS, should have the key role in running services at local level, subject to appropriate local democratic accountability and periodic national review.

    It is unfortunate that the government has suppressed and ignored data showing patient satisfaction at an all-time high just before it took office. In the interests of accountability, it should publish that data without further delay.

  137. Jessf says:

    I don’t see what is accountable about spending billions of tax payers money to change a system that is performing better than it has done before for an untried, untested and non validated model. Particularly at a time when huge savings are supposed to be made.

  138. Emmerson Walgrove says:

    The Government intention to ‘pause’ and listen on NHS reform of which various health and social care organisations were delighted when the bill was first announced, and the Government promised that the principle of ‘no decision about me without me’ would be central to the new plans.

    However, as the bill progresses through the Commons, it is becoming clear that what is being said doesn’t match what is written in the bill.

    For example, the bill devolves a great deal of decision-making power down to local authorities and GPs, but opportunities for public involvement are little changed.

    HealthWatch, as outlined in the bill, does not represent a sufficient upgrade from existing involvement structures – there should be a far greater range of ways to get involved, especially for already-marginalised groups such as those affected by mental illness. How is ‘no decision about me without me’ to become a reality.

    This is the most radical change our NHS has ever seen, and we need to be sure that the new system will work for everyone, we need to remind the Government and our local MPs that the NHS belongs to all of us and they promised not to leave patients out.

    • Michael Vidal says:

      Emerson – Rather than different mechanisms to capture the views of all the different service users in the NHS Healthwatch needs to ensure that its membership is wide enough to include the views of all service users. This can best be achieved by close working and cooperation between the voluntary secor groups that work with the service users and healthwatch. However wht needs to be avoided and there are hints that this might happen is for the local auhtority to have sole appointment rights to the healthwatch governing body.

    • Michael Vidal says:

      I havenoticed that an important not is missing from my reply I meant to say that local authorities should NOT have sole appointment rights.

  139. Joanne says:

    If this government is so keen on getting rid of bureaucrats why is it forcing GPs to become take on the roles of those they are trying to get rid of? I want my GP to be a GP not weighing up the cost of the care I need against their bottom line. It is compromising the patient / GP relationship. I will be left wondering if what is being prescribed is the best treatment for me, or the cheapest.

    I fundamentally disagree with GPs becoming fundholders. And if the government wants the NHS to take note of private industry – would Tesco ask its till workers to do the buying of bread or any other commodity? No. Just because those on the till see what people have in their baskets it doesn’t give them the knowledge to buy the best product at the best price that the customer wants / needs. Expertise of managers should not be underestimated.

    This whole ‘top down’ reorganisation, of which it has no mandate for incidentally, should be stopped. It will destroy the NHS.

  140. Rachel Atkinson Speech and Language Therapist says:

    If you want service providers to be accountable don’t allow private companies to use NHS money to provide healthcare services, do it in house. Private companies are accountable only to their shareholders. That’s their legal obligation.

  141. Cyril Richardson says:

    I am concerned that if the doctors practices are given more control than they have at present with their private contracts with “the NHS”, then there are likely to be more people like myself “thrown out of the practice on the say-so of a nurse” rather like a kangaroo court simply because I questioned the inadequate system of appointments which between the hours of 12noon and 4.0pm was closed to queries of any kind and with a request to ring an 0845 number.for help. It was and I think still is, closed from 12noon on Friday until early Monday morning
    I had what I onsider lukewarm help with an appeal and procrastination such that I gave up th to wrote to a Minister except that the Govenment changed colour

  142. Marie Clayton says:

    GP involvement is essential for Commissioning good quality services for patients and for service redesign and no-one argues this point, but my concerns are that the Government are blinkered where commissioners are concerned. Who is the objective party here, keeps feet on the ground, is realistic and interprets what GP’s want to commission and puts these into practice (its Commissioners!). GP’s cannot commissoin alone and even if skilled up they are doctors not managers. It is essential (and I speak from extensive experience) that we need to ensure that Commissioners voices are heard and that the Government listens to Commissioners as well as clinicians – its not just clinicians that influences change.

  143. Laurence Wood says:

    Ruth, I have great concern about Healthwatch being formed from LINks. As you know there is no consistency of LINks because of the way each group was formed and the differing management organisations.

    • Michael Vidal says:

      Laurence – As a member of a LINk steering Group however due to certain differences between Healthwatch and LINks I am not totally sure that your concerns will materialise. The principal difference is that Healthwatch unlike LINKs will be a statutory corporation. It will also have the power which LINks did not have to employ its own staff.

      The consistency that you quite rightly say as far as it did not arise from differences between the communities sered would be dealt with by leadership and guidance from Healthwatch England.

      The serious concern I have and one which the Department has not adquately adressed is the serious conflict of interest with Local Healthwatch being accountable to and funded by the Local Authority who are th main providers of social care whihc Healthwatch is supposed to monitor.

  144. bridget says:

    The people I work with (public, patients, service users) want safe, responsive, respectful health and social care services, close to their homes. They want highly-accessible simple information about what is available. They want to be genuinely involved in shaping services because they are experts by experience. And ‘services’ are supposed to be of help, benefit, use to those being served after all.

    We need to be more effective in the provision of services in the face of increasing demand and less money. People understand this. Crude, clumsy, ideologically-driven and ill-thought shuntings as embodied in the NHS bill are not going to meet those needs.

    If you really listen to people, they will give us the answers we need.

  145. Tim Hankey says:

    As an outsider my work is within health services in the UK and overseas. Whilst I have found that the dedication of frontline staff working in the NHS is second-to-none, I am not certain why we want to make the structure so complex. Surely the purpose of the NHS is to treat sick people not to create complex management structures. Close to home, have a look at the Welsh model where one Health Board manage the provision of health across a geographical region – a model adopted by most of the developed world. And the Welsh don’t have a commissioning process as such. The truth is that the NHS in general could save many millions of pounds by re-examining its multi-tiered management structure, re-examining its collective purchasing power, re-examining its operational structure and generally cutting down on its siloed mentality.
    The basic flaw in the proposed system is the assumption that all patients access healthcare via their GP. The actual facts are that approximately 60% of patients accessing secondary care have not done so via a GP and that 30% of those are not registered with a GP anyway.
    I fear that much of this ‘listening’ exercise is a bit late and that the stable door is well bolted whilst the horse is away in the hills.
    Finally, the operating requirements of the NHS are not unique. The commercial world addresses many of these issues on a daily basis and most achieve high levels of customer satisfaction. If they don’t they will not be bailed out and will go bust!

  146. paul says:

    Commissioning is too bureacratic and too complex to ever be completely transparent, and at the end of the day there is a balancing line that says ‘this is the money that we have left and this is what we need to commission locally (rather than national tariff) so A divided by B gives the price that’s paid to balance the books’. Even the national tariff is balanced with the magical fudge factor (MFF). And this is the stage that all of our reviews, modernisations, and continual changes to the NHS have got us to. To suggest that the NHS needs modernisation suggests that we’re still working the same way we did 30 years ago and we’re not. The NHS is innovative and hard working despite the pressure of hastily introduced reforms every four years or so. No reforms are left to work for long enough for the NHS to actually benefit from them before further reforms are thrust upon it.

    What needs to happen is that organisation restructuring needs to stop and change needs to be made within a stable structure, a process of gradual refinement. Many of the changes suggested by the Government could have been put into place without the massive organisational upheavals and the Government would find that there would not be the deluge of complaints and people up in arms about the latest ‘modernisations’. Millions have been wasted simply by making so many people redundant from the PCTs in a shortsighted approach to saving money that has seen loss of expertise and people that the GP commissioners will shortly be advertising to recruit. How ridiculous is this?

    • Michael Vidal says:

      I could not agree more with Paul. The ink was hardly dry on the National Health Service Act 2006 whihc was supposed to codify and update the NHS when it was amended by the Local Government and Public Involvement Act 2007. Ther ink was not even dry on this Act before it was amended by the Health and Social Care Act 2008. As all three of these Acts made structual changes to the NHS I am not surprised that the NHS is not as efficient as it could be time is NOT given for change to settle before things are changed again. What is needed is a minimum of five years for the changes bought in by these Acts to bed in before and for them to be evaluated before we have any further changes.

  147. Dr. Penelope Jarrett says:

    The whole structure proposed in this Bill is a disaster for accountability and public involvement,.

    There are significant gaps in lines of clinical governance and accountabilty, with it being unclear who is responsible for what, where accounatble officers will be sited and how the myriad conflicts of interest will be managed. At the lowest levels, the relationships between indvidual practices and the consortia are unclear even to participants, and completely opaque to patients. At the highest levels, the interrelationships between the NHS Commissioning Board, the CQC, Monitor, NICE and the DH are also unclear. Who is responsible for what? And why is the Secretary of State abdicating overall responsibilty?

    NICE is a worthwhile body: unlike most other aspects of this exercise it proceeds from an evidence base and as such has the confidence of the vast majority of clinicians.

    Patients used to have involvement with teeth in the guise of Community Health Councils. Now we have bodies being reorganised every few years, just as they are finding their feet. Our local LINk are not happy at being reorgnaised out of existence. Healthwatch and local authortities are not being offered any real power.

    Budgets should be allocated on the basis of need (not want, and not to those who shout loudest), with transient, elderly and poor populations receiving more. But more work needs to happen to improve the formulae used (which should be published) and the data which feeds into them being properly collected – census data alone are not good enough. I don’t see how this can happen in the sort of fragmented system which is being rpoposed, unless the NHS commissioing board is going to have a lot more power.

    The more things happen behind closed doors, the more accountabilty and trust suffer. Conflcits of interest should be declared. Commercial confidentiality should not be used as a reason to hide information.

    I think the conflicts of interest in GP consortia are too great to ever be meaningfully resolved. I happen to trust my colleagues who are involved locally, but I cannot see why patients should believe that. It would be far better to have a health authority, probably at area level (eg 400,000 or so population, i.e. bigger than London PCTs whch were too small), with a decent clinical involvement, not the sideline that were PECs.

    Localism should be within agreed national frameworks, such as the NICE guidelines and nationally negotiated terms and conditions (in which I would be happy to include the QOF, which is largely evidence based). These national frameworks need to be string to prevent evidence based treatments being avaiable in some areas, and not in others. I am presuming that nonevidence based treatments will wither and die for lack of evidence, despite patient protest. It would be really nice if, within these constraints, we could be free to pursue local priorities, instead of having to waste our time with the lastest bright idea of government advisors (walk-in centres, Darzi centres, Choose and Book, SCRs…). These have all been imposed on us, in the same way that disbanding the PCTs is imposed.

  148. Wendy Watson says:

    It is to the PCTs advantage to create an air of antipathy towards the current government for the ‘cuts’ the public hear about on a daily basis. Meanwhile, the public are being led to believe that the government has made the cuts. This is simply not true. The PCTs were last year given a 5.5% increase in funding, but told to cut their management costs by 30%. I lost count of how many PCTs told me they couldn’t afford £422 for my service due to ‘government cuts’. I challenged this each time, which resulted in the doors being firmly slammed in my face.

    I predicted around 10 months ago that the PCTs would try their utmost to make the commissioning job seem too complicated for GPs to take on. Their Annual Reports are a bureaucratic colourful presentation of nothingness. All very similar. I analysed a few for exact content, cutting through the intentionally incomprehensible bureaucratic speak. In reality there is very little there that we need in order to run a Health Service, but plenty there to justify colossal wastes of money on rafts of managers and the infrastructure required to support most of these pointless jobs.

    The solution is simple. The National Commissioning Board should heed the recommendations of the relevant NICE guideline committees. These committees are made up from experts in the field with lay input. Consultation processes are welcomed to engage with the public view. A Health Economist is present to ensure equity and value for the NHS.

    If GPs were to refer to these National Guidelines, we would preclude them of difficult decisions. We would stop Post code lottery healthcare. We would save billions of pounds in ‘inexpert’ commissioners having to make decisions around services and illnesses they have insufficient knowledge of. World Class Commissioning was invented to assist these commissioners to commission in areas they do not understand. Another vast waste.

    We set up the NHS as a National Health Service. Bureaucracy will always argue the need for local decisions, but the reality is, if you have a disease in London or Little Norton, you want a standard of care that you have paid National Insurance premiums for at standard rates across the UK.

    Everyone has really been fed a line (speaking with an ex PCT manager last night) that ‘doctors should be doctors, not money managers’. This should not be an issue, the doctor follows Guidelines set by experts.

    Local need, and the opportunity to have autonomy to cater for it simply fuelled the opportunist facility to ‘invent’ jobs, ( ‘Outer Space Project Manager’ (sic) on NHS Jobs website, ‘aiming to help NHS staff and patients identify with their wider green issues!) pay enormous salaries (speadsheet available) and waste money on a yacht for Hull PCT that no-one could challenge. I will forward (attach) you the email I received from the Care Quality Commission stating this lack of power.

    I am an army of one here, fighting to get the public to understand this incredible misdirection that has been pulled off by many bureaucrats and consultancy advisors. I don’t give up easily though, and shall continue to investigate throughout. I have already found £108 million of discrepancies in Management Costs. I have sent under FOI for explanations of this, and the answer is obvious. Despite the DoH (attached) confirming that no further inclusions were mandated in the management cost declarations, all who have replied so far stated it was due to the DoH changing the methodology.

    In reality, they have included nursing managers and other ‘provider arm’ managers into these costs. The 30% cuts required have been derived by losing these posts, rather than give up their own outrageous salaries. This is where the government MUST step in. Its rather like asking turkeys to vote for Christmas, asking PCTs and Councils to make cuts. Those in charge of the cuts are really the ones who need to be cut.

    Please don’t listen to the incredible stories about needing to pay for the right people. If you already have good strong guidance from an expert panel, that is all that is required.

    Thank you for your time

    Wendy Watson

    • AMV says:

      I agree wholeheartedly, when pruning anything with roots and branches, you cut from the top, not the roots, about time somebody took their head out of the sand and started going into these hospitals and cutting managers that aren’t needed, they have only been employed to save the person higher up the branch from doing more work than he/she has to, therefore start with middle and upper management. Also, why pay people off in higher management for doing a bad job? Anybody else just gets the sack with that months’ salary. Nice little earner if you go from hospital to hospital doing a bad job, you get a nice payoff of say £120,000 at each – can I do that, no!! because I’m not a manager.

  149. Tim Hankey says:

    Interesting comment from Rachel – 15th May 1222pm.
    ‘Private companies are accountable only to their shareholders.’

    Not strictly accurate- the food industry, rail, aviation, the drugs industry, finance, banking, SpecSavers,etc etc all have shareholders but they also have Regulators who are quite independent of the shareholders. And remember that those shareholders can be you and I, pension funds or the Government. So the assumption that because private companies have shareholders does not necessarily mean that they cannot deliver a top quality fully accountable service. At the end of the day we, the tax payers, are shareholders in the NHS.

  150. Alan Bailey says:

    I’ve spent 5 of the last 6 years trying, as a volunteer chair of a PPI Forum (SLaM) and then of a LINk (Lewisham), to draw patients into making the NHS more accountable. The Trusts and PCTs I’ve dealt with have worked tirelessly towards the same end.
    It’s tough and slow work. While the public are “well”, they are hugely uninterested. When they are patients, they are ill- prepared to make their voice heard. They are usually not feeling too good either.
    Changing the commissioning structure so brutally is madness.
    GPs have become increasingly involved in the making of commissioning decisions and that is exactly right. Further evolution in that direction is needed. But not revolution.

  151. FT Public Governor says:

    I appeal in the strongest terms possible for the Government to listen to the real concerns surrounding accountability. The Health Bill should be strengthened to make it mandatory that Foundation Trusts and GP consortia should hold their Board of Directors meetings in public in accordance with The Public Bodies (Admission to meetings) (National Health Service Trusts) order 1997. Already far too many Foundation Trusts hold private meetings and the department of health believes that existing governance arrangements are sufficient to ensure public accountability. This is not the view of the majority of Foundation Trust Governors. The Government wants to see reforms and changes to the NHS and this process of listening is to said to be the means by which it ensures that the legislation addresses all the issues. It is a serious error that the holding of Public Board meetings is not included in the legislation as they are fundamental to public accountability.

  152. Patient involvement is essential to ensure adequate and appropriate services but patients should not be responsible for holding service providers to account. Public accountability takes time and most people will be unable to do this and their voices will not be heard. There need to be robust accountability mechanisms in place to ensure quality of care that covers all equalities groups and meets the needs of the local populations. For example Health and Wellbeing Boards could monitor locally and Monitor could have a wider function covering equalities and access to services.

    Recommendations:
    • Specialist voluntary and community organisations such as women’s organisations, should be consulted by local healthcare providers to ensure that the views and needs of women are taken into account.
    • We recommend that the NHS works with women’s organisations to ensure that NHS services are tailored to the needs of women. Women’s organisations should be encouraged to participate in all stages of GP commissioning and should be valued and recognised for their expertise in supporting women.
    • The Department of Health must endeavour to eliminate obstacles to women’s engagement with the consultation process on outcomes for the NHS Commissioning Board and GP consortia, and is particularly inclusive of women in rural areas, BAMER and LBT women.
    • A new statutory duty should be introduced for commissioning support organisations to have to consider only the best interests of their practice populations when involved in this role and to include representatives from local residents and patients on their Boards.
    • There must be ways for service users (including women and other equalities groups) to feed in to which services are commissioned to ensure that their needs are met appropriately (e.g. through consultations, patient forums or through local organisations).
    • Mechanisms to feed in patient views and concerns, such as LINks, must be ‘fit for purpose’ and be representative of the local communities they serve in terms of gender, ethnicity, sexual orientation, age and other characteristics which are protected the Equality Act (2010).
    • Specialist equalities voluntary organisations and patient experts should be involved in the design and development of services and in commissioning decision making processes.
    • Regular impact assessments, including gender and equalities impact assessments, should be conducted and equality indicators used in health outcome frameworks as part of a comprehensive equalities strategy.
    • The Department of Health must provide alternatives for women and other vulnerable groups without easy access to the internet to interact with healthcare professionals during their treatment. We propose that local services do this by building relationships with women’s voluntary and community organisations that are already working with marginalised groups.
    • NICE should publish a quality standard on violence against women and girls and/or gender equality within patient care.
    • GP consortia should have a statutory obligation to provide evidence to the NHS Commissioning Board, their local authority and their local Healthwatch and must be held to account based on their formal constitution.

  153. Helen W says:

    It was certainly a lot easier to navigate around the “who does what” when PCTs had commissioning and provider functions – if there was a problem, you had a word with the service manager and it changed – now you have to track down the commissioning manager, work out who you need in the provider organisation and change is much slower.

    I think the idea of GPs having a greater say in the commissioning decisions is in part good. However, whenever a meeting is called, they have to understand they need to attend to make decisions – can’t be “too busy with patients” now! Why just GPs though – it should be multi-discliplinary boards from a range of healthcare professions. There is not enough understanding of the specialisms and this can lead to narrow-minded decisions being made.

    Will patients really be getting a better deal, with the GP who stands to make a profit for the “right” decision and a financial loss for the “wrong” one – is there really going to be freedom/choice?

    Integrated health and social care should set priorities together then the commissioning groups can be accountable.

    What about groups within PCTs such as clinical governance, prescribing – around quality issues, will GP commissioners really “care” enough to employ these groups in whatever format? – or perhaps this money will be spent on accountants.

  154. Stephen Hewitt says:

    If we believe in devolving power and decentralising decision-making then why is the coalition government proposing that primary family health services (eg GPs, dentists, opticians and pharmacists) are commissioned nationally rather than locally.

    There has been a lot of public debate about the commissioning of hospital services by GP consortia, which to my mind has over-shadowed the question of who commissions the GP consortia.

    Currently GPs, dentists, opticians and pharmacists are commissioned locally by the primary care trust, who will have the local knowledge about gaps in services, poor provision etc and take action to deal with them and have a degree of local accountability.

    With the proposed abolition of the primary care trusts, why has this been centralised. How will the NHS Commissioning Board in Leeds know what services we need in Bristol (where I live)?

    Just as responsibility for public health is being transferred to local councils with a ring-fenced budget, why not transfer responsibility for commissioning GPs, dentists, opticians and pharmacists to local councils as well. There seem to me to be very strong arguments for this:

    1. Integration with public health

    2. Integration with adult and children social services and health services already provided by the local councils

    3. Councils have has experience of commissioning services – health and social care, children and young people, drug services – which could be developed with expertise from the PCT.

    4. Less disruption as the relevant staff and expertise could be transferred from the primary care trust (as with and along with public health).

    5. In the longer term there are opportunities for better co-ordination with other local services that are based in the community such as housing, community safety and parks and sports services (eg prescribing physical activity instead of drugs)

    6. Local knowledge meaning better targeted services, more appropriate services. greater sensitivity to the needs of local communities and greater local accountability

    I have six monthly dental check-ups, see my optician every year or so and, being generally in good health, perhaps see my GP once or twice a year on average. I rarely have to go to hospital (well at least not yet). So it seems bizarre to me that it is only the expensive hospital treatments (that fortunately only a few of us need at anyone time) that will be decided locally by GP consortium – while in future the primary health services that everybody uses every year will be decided hundreds of miles away by some national quango rather than locally. Where is the patient choice in that?

  155. Ernest says:

    Accountability within the Health Service has never been worse. Representation on the bodies appointed to scrutinize local services from local communities is minimized following ongoing structural changes and reorganisations, mergers and re-titling of service providers. I literally do not know who I should complain to, or go too within the health service if a problem arises that I need help or support with. Local representation needs to be addressed urgently.

    Some of the proposed changes seem to put some power and accountability for the commissioning of services back into the community, but it is unclear what representation will be available for local communities on these groups with the local GP’s?

    In my view, Accountability needs to be held at the lowest level commensurate with running a Health Service, with a flat level of management, run by Clinical staff, with business managers in an advisory capacity. Reversing the current trend for non-clinicians heading up health trusts and health care services.

    In the end, the Health Secretary is accountable for the provision of an effective health service. As a politician, they can be held accountable by parliament and their electoral college in their constituency. This is not reflected down through the Health Service. Management failures, including overruns on budgets, consistently go unpunished or penalised. You never hear of the dismissal of a Health Service manager for inefficiency or gross negligence. On the other hand, managers appear keen to investigate and point the finger of blame onto clinical or support staff, often at the lowest level.

    Accountability must be clear and transparent. The Duty of Care of each post of responsibility must be written into their contracts and such contracts should be available to the general public via all modern communication means, including social media.

    The system for dealing with failures must be transparent and robust, it must provide for proper, external, independent investigation and have appropriate penalties, including criminal liability and no-fault compensation systems in place, where appropriate.

    A particular issue is that professional failures are left to what are basically trade associations like the British Medical Association to deal with. It’s time that these trade unions were taken out of the equation and a system of Independent Tribunals be established to deal with all issues of professional incompetence, misbehavior or neglect.

    you

  156. Dave Payne says:

    I also agree with Ruth Butterfield; i think GPs alone do not provide the best way of commissioning. I have worked with a variety of GPs and some are very intune with the needs of their client group and are open to explore the interventions and treatments that can be offered. unfortunately there are also many GPs who have a much narrower view and will stick to their preferred interventions which do not always give the patient the best choice of options. In fact you often feel that they have are not up to date with the latest advancments in medicine.

    Having worked in the public sector for my entire working life, I cannot understand the government wanting to give all the money to a contractor to control. GP surgeries are operated as businesses, not wholly as part of the NHS. This seems very similar to GP Fund Holding implemented by a previousl government. I am not convinced thatGP’s are not always focussed on the needs of their patients, and feel that they must have a vested intrested in running the GP Practice business in which they are business partners.

    Again, I echo the comments made by another contributor; GP’s does not always operate their surgeries for the best intrest of their patients. They need to open out of office hours and at weekends. They need to concentrate on the role of signposting their patients to find the correct specialist care instead of trying to do everything themselves. I cannot see as they have sufficient knowledge to make the best decisions about healthcare in specialist areas such as maternity, obstetrics, and mental health. Most have not been directly involved in childbirth since they were student Doctors.

  157. Jeanne Lowther says:

    I have paid high taxes all my working life and I expect to be advised and treated by a qualified medical practitioner, not to be asked my opinions or to be given a choice about things I know nothing about. I recently asked for a second opinion on my cataract and was sent a long list of hospitals which I could attend. I knew nothing whatsoever about these hospitals, some of which were miles away, and I could have ‘chosen’ an unsuitable one without a good eye clinic. As far as I was concerned it was my doctor’s job to give me his opinion on the best surgeons around, not for me to stick a pin in a list!! Patient autonomy is just a way to give medical practitioners a way of opting out of responsibility, possibly to ease the way to privatisation. It should be resisted by NHS patients at all costs. Or just lets look after ourselves via the internet and not bother with doctors at all!.

  158. Patricia Woodcock says:

    Commissioning boards should include representatives of patients, carers and the local community. Their meetings should be open to the public, and they should publish their accounts.

    I am concerned about possible conflict of interest. Preferably private health company shareholders should be excluded from commissioning boards. At the very least they should be required to declare all such shareholdings publicly.

  159. Tom Graham says:

    I don’t see why there should be any major change at all. It seems to me as a major user of the NHS following a stroke that in the last few years services, waiting times and good medical care were much improved. However since the targets were abolished last year the service is going backwards. Hospital appointments are being cancelled again for the first time in years and changes made ” in the interests of efficiency” at my local GP Surgery mean that it is now very difficukt to get an appointment and almost impossible to get one at a time to suit. In my view as a user the service wasn’t broken and the only reason this Government says it needs fixing is to let the private sector in to make money at the expense of us all.

  160. Christopher Linthwaite says:

    Commissioning boards must be made accountable to the Public by being elected and can be held to account in a court of Law if they do not achieve government set targets on waiting lists, outcomes, reinfection rates, readmission to hospital etc.

    As for Patient involvement at the heart of it’s decision making then each patient is given the information they required to make informed decisions on who is to provide the care, the provider then gives a full and comprehensive care plan for the care the patient is to be given. These will be based on national guidelines laid on the statute books involving dignity of care. If we can have laws laying down how we treat Prisoners of War we can have laws on Patient Care.

  161. Gini says:

    Healthcare providers in the voluntary sector provide annual accounts and produce an annual report. These are straightforward documents and are not costly or time consuming to produce. In my opinion, this would be sufficient for the NHS. In reality, the majority of the public will not be interested in this as what matters is that we get the best standard of care when we need it.

  162. Gordon Robson says:

    To make Consortia accountable for their decisions make them hold their meetings in Public so that they are required to fully explain why they have taken any chosen path. These meetings should be held at least 10 times per year including an AGM to present theor accounts.There must be a simple mechanism to allow ordinary members of the Public to appeal to the National Commissioning Board, by petition of at least 100 signatures, where there is a case to challenge a Consortia’s actions.
    The ability for Consortia to receive a “bank style bonus” should be removed from the Act.

  163. Michael Vidal says:

    The governments argument for why Healthwatch needs to be accountable to and funded by the Local Authority is that Healthwatch is a local organisation providing a local service and therefore should be funded locally and not nationally. While this argument is not without it fails to have regard to the powerful countervailing arguments in favour of national funding of healthwatch the two principal arguments are, firstly, there is a serious conflict of interest in the Local Authority which is the provider of social care also being the funder and contract manager for the body that monitors the social care services. In this regard it is worth noting that most LINks have had their funding cut by the local authority despite funding at the same levels as last year having been provided by the Department of Health by way of a non ring fenced pooled grant. This raises concerns that Healthwatch will not be adequately funded by a local authority seeking to save money as the funding for Healthwatch will not be ring fenced. Secondly, the integrity and independence of Healthwatch will be undermined by this arrangement which will lead people to question whether is truly working for the benefit of the people.

  164. D Reilly says:

    Some extremely important points made above. The NHS does not operate in a vacuum and mental ill-health does not spontaneously occur. The government needs to better recognise the origins of psychological distress and instead of focusing on a medical/treatment model put funding towards improved social situations, parenting support, and education. GPs are not trained in social models and cannot do everything by themselves. They do not know about the best treatments for all their patients and ongoing consultation with all allied health professionals is the only way to ensure treatments are up to date and appropriate. Psychologists, speech and language therapists etc. may have better things to do than selling their wares through free lunches and post it notes like drug companies do but their contribution is just as important.

  165. Eleanor Jones says:

    One way to make the NHS decisions accountable, transparent and sensible would be to have decisions about which medicines and treatments the NHS provides made by an independent team of specialists which impartially evaluate the cost/ benefit for each new product, and publish their findings in a transparent manner. Say, an organisation like NICE.

  166. Jane Birkby says:

    ■How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?

    A:- Publicity, a prominent figure for people to contact, and consultation of patients needing treatment.

    ■How can we best ensure that the NHS commissioning budget, held by the new NHS Commissioning Board, is allocated transparently and used with proper accountability to the public at local level, and Parliament at a national leave?

    A:- Use the Audit commission, ensure that no member of the commissioning board has any conflict of interest or bias, and make thorough checks that GPs who would abuse the system are called to account, as I am concerned that certain types of GPs will view the budgets as their private fund, disadvantaging patients. Just as MPs used the public purse for their own ends.

    ■Are we doing enough to make sure the NHS at local level has the freedom it needs to take locally-based decisions?

    Many GPs do their job because they want to treat patients, and are worried that having to administrate their own budgets would leave them less time for patients.
    I believe that patients may be disadvantaged by this policy, as I cannot see how enough checks can be made to make sure all the patients needs are going to be met.
    For example patients with Myalgic Encephalomyelitis who are already disadvantaged by the system.

    • Simjoss says:

      Except that the Government has abolished the Audit Commission which used to do a good job from a different perspective to the National Audit Office! So who will do this work. The expectation is that it will be either contracted out to the private sector accountancy firms or to the National Audit Office. And no doubt they will recruit expertise from the Audit Commission.

      I noted from a Phillip Hammond comment in response to an Audit Commission report this morning on the Today programme that for Transport there is a new quango established that will be expected to monitor the standards of delivery in place of the Audit Commission but it did not appear to be impartial. Whither NHS monitoring?

  167. David Smith says:

    The govmt’s proposed model is barking mad. The commissioning body, whatever it is called should involve GPs, but must be not of profit e.g. Community Interest Company like Nene Commissioning. There should also be an element of local democratic control. Allocation of the budget to be decided by a federal body independent of govmt. There will be some non local specialist providers but these must be not for profit also. A total quality approach must be introduced.

  168. Sarah says:

    Patient are already involved in the NHS on a daily basis, there are very effective mechanisams involved to complain. Each consultation involves both the patient and the doctor or nurse. This will develop more as long term conditions involve, and is also being developed by our comsumer culture, social marketing, facebook and interactive websites. Please can the governemnt stop spending money on something the the public can do. We do not need a summary care record, face book andthe IT industry will do it better with the population doing this themselves if they want it. Health is going to be of enormous interst to the current aging population, who are already consumers. The governemnt does not need to worry about this. Chronic conditions will themselves develop the health culture theat we have, this concept is already out of date. patients are aready involved.

  169. Sarah says:

    it would be good to have recourse to the commisioning board if local allocation of budgets did not seem fair. It would also be good to have non-medical chief executives who would be prepared to listen in new GP clusters, not simply sit on committees. It would be good to have leadership that listened to front line staff, especially with practices in deprived areas and also growing practices which have not been funded fairly historically in the PCTs. How about a comlaints process if a budget did not seem fair

  170. Justin Baker says:

    The question about how we can ensure commissioning decisions are made transparent, and that commissioning consortia engage fully with patients etc, is a dishonestly leading question, because the question presumes patients actually want commissioning consortia in the first place, which they don’t. Commissioning consortia are being planned as a means to pay GPs to take purchasing power away from hospitals, with the effect that purchasing bureaucracies and red-tape will be needlessly duplicated across thousands of new consortia, that hospitals will lose much of their power to benefit from making cheaper bulk purchases, and that hospitals will lose the power to subsidise loss-making aspects of their provision from the profitable services, which (if these reforms are implemented) will have been taken away and given to private companies.

    The question about how we can best ensure the NHS commissioning budget is allocated transparently and used with proper accountability at local level, is also a dishonestly leading question, because it presumes that patients actually want processes of accountability to be enacted at a “local” level. The way to ensure financial best-practice is to compare the performance of different regions nationally, and when patients are sick or injured, they’re much more concerned about quality of treatment than they are about issues to do with accountancy. I have never met anyone who has shown the slightest interest in scrutinising the accounts of their local hospital or GP practice, but I’ve met hundreds of people who are deeply worried about the quality of public healthcare.

    As for the question about whether we are doing enough to make sure the NHS at local level has the freedom it needs to take locally-based decisions, the answer is “no”, but Anrew Lansley’s White Paper commits to government to forcing GPs to commission the cheapest possible services, therefore totally destroying the NHS’s ability to exercise “freedom” when it comes to making decisions locally.

  171. Ben Rainger says:

    Accountability and patients is an admirable idea, but does not need the wholesale changes being proposed.
    The mantra of choice is an illusion. Are private comanies suddenly going to start building new hospitals across the country to offer all the services currently provided by the NHS in that area. No. It will be like the trains. You want to go from A to B, you only have one choice and thwy can charge what they like. The best solution is for the quality of service to be raised across the board.
    Also, promoting my doctor to be a manager of a trust appears counter intuitive. I want my GP to be seeing patients, not managing county wide consortia All that will happen is that the GP will end up employing a new management level to do the same thing as the Health Trusts, except that this time there will be less accountability as they are more removed from government control and can hide behind the GP’s.
    The reforms are esentially putting GP’s in the firing line for any cuts of treatmens that are restricted or not offered. This also does not offer the best service, as the GP or managers might have tied themselves to certain hosptials for treatments based on cost, not necessarily on the quality of care. It changes the priciple of treatment to cost instead of quality.

  172. Rachelle Howard says:

    I do not feel GPs are qualified to run the NHS. They are specialists at being Clinicians, providing care for their patients, some are better than others. They are not managers nor administrators.
    Primary and Secondary care run as seperate entities and have different priorities. Often the ‘gateway’ role that GPs operate does not work effectively or efficiently (ME referrals for example). They do not wish to run the NHS!
    I believe Healthwatch (now LINK) should be given real ‘teeth’ to be able to act in a robust and efficient way to get issues resolved positively for all those involved and to aid with monitoring of any changes made.
    I feel that the PAL service needs to continue to ensure monitoring of any changes are maintained.
    Patient Groups should be involved at all stages of any changes. This has proven to be effective in the 18 week referral from primary to secondary care and within GP surgeries to give only 2 examples.
    Patient and Carer feedback to the DoH is also a proven mechanism which achieves positive robust outcomes.
    Our PCT has been a beacon site and assisted in training other PCTs. Our community will be very sad to see it go, given the good work it has achieved, the public involvement it has encouraged and carried out.
    Stop the pharmaceutical companies taking over and this would achieve a huge change in the NHS, save a mass amount of money and get it back to its roots of caring for those that need it. It is they that cost the bulk of the NHS money, them that are in charge not the patients!

  173. charlotte says:

    I have been caused a great deal of harm by the NHS which has left me in pain and disabled. My GP surgery treated me appallingly, closing ranks and stone walling me. I will never trust a doctor again and now stay away from them, no matter how unwell I am. Trust them with all that money? No way! They’ll be lining their own pockets and pursuing their own agendas as always. Heard a good quote recently- ‘The four principles of medical ethics are a sick joke, but the patients aren’t laughing!’ Certainly true of the unethical treatment I received.

  174. James Goodhew says:

    This is by far the simplest of the 4 categories: ask for their involvement in the NHS! Ask for their feedback – what went wrong in their eyes, what criticisms could they offer, what would they like to see done better, heck even for laughs you could ask them what was good about the service!

    How can a service be ‘held accountable’ to a group of people who have no chance to inform people (those who can make a difference) of their experiences?

    If there are to be reforms of the NHS, then patients should be at the heart of them: they should be derived from evidence, and the evidence should be derived from patients of the NHS (and the providers of course, but this section is about patient involvement).

    Finally, I would add that patients are not in a position to make decisions about commissioning of care. That is why we have professionals in PCTs to deal with it. Patients are sick, and they want to be made better as painlessly and quickly as possible. Ask one – or ask thousands. You (Andrew Lansley) wouldn’t know – you haven’t bothered.

  175. Ruth says:

    Excellent commissioning of services is difficult to achieve. It is a hot potato which has landed with GPs, some of whom will do it very well. The proof of the pudding is in the effectivenss, quality and efficiency of the services delivered, rather than in the ‘transparency’ of the process.

  176. Patricia Stevens says:

    Accountability and involvement do exist at present in the NHS in the form of the members of NHS Trusts. This will presumably disappear completely if GP commissioning is introduced. So the best solution to improving accountability and involvement would be to abandon these changes and then work on ways of increasing Trust membership, using the internet, websites and social networking would be a fantastic start.

    • Michael Vidal says:

      I think Patricia is refering to NHS Foundation Trusts which do have members. In this respect I would agree with her. While the provisions in the bill in relation to the Board of Governors of a Foundation Trust are a step in the right direction they do not go far enough in my respectful opinion. I would like to see more powers given to Foundation Trust Members. In particular when it comes to changes to teh Foundation Trust constitution I would suggest that no change should be permitted to the constitution of a Foundation Trust unless support by 66% of the members voting at a meeting to approve it.

  177. shelley says:

    If we want commissioning decisions to be accountable and tranparent and as fair and comprehensive as possible here is an idea. How about public sector employees accountable to the DoH do the commissioning, and we spend time working on a workable figure of these to gain best of cental/local working. Oh hang on hasn’t that been done – yes PCTs that was them eventually beginning to work so lets now scrap them. Why if you want more transparency etc.. would anyone think it is good to effectively privatise our PCT’s by getting private firms with a couple of part time GPs on board to commission. United Health they didn’t end up completely messing the commissioning up in USA did they? They sound good lets try them!!

  178. Ernie says:

    This consultation exercise is a true test of how you can make sure that patient involvement is at the heart of NHS decision making. It is clear that the overwhelming majority of respondents oppose the ‘reforms’. If you sincerely mean that patient involvement means anything other than a sham exercise then the proposals with be fundamentally changed or abandoned. I suspect that this will not happen, indicating that patient involvement is window dressing, and Andrew Lansley’s views trump all others.

  179. Peter Rose says:

    Accountability and patients is a difficult combination.
    Patients are not experienced enough nor expert enough to be able to make the NHS accountable to themselves.
    The expert bodies that are set up do a good job although one of the best looking at financial accountability has been disbanded at a whim- WHY?
    Monitor and the various quality bodies together with NICE do a good job.
    Foundation Trusts are another way of trying to get the general public involved but the quality of governors who get elected in many cases leave a lot to be desired. One almost needs professional governors. Why do we think that laymen can somehow do a better job than professionals?
    If we want the public to be accountable get professional people involved and have the various review bodies report to the FT Governors. However there are already Non_Execs who are supposed to do this so why have another layer?

    • Michael Vidal says:

      Peter – I must strongly disagree with you that patients and the public are not expert enough to hold NHS professionals to account. When I have been at scrutiny meetings and PCT Board meetings the questions that the professionals would rather not have been asked have always been asked by patients or members of the public. The professionals do not want to rock the boat so do not ask the difficult questions.

      Also I note on those occassions when professionals do work with patients or members of the public they find the input of members of the public helpful.

  180. Janet Dickinson says:

    “Are we doing enough to make sure the NHS at local level has the freedom it needs to take locally-based decisions?”

    Not while you’re closing local hospitals and making patients travel further for their care.

    Please stop using phrases like “commissioning consortia”. It’s one of those meaningless boardroom phrases that CEOs use to make it look like they have a meaningful role.

  181. Rajvinder says:

    Foundation Trusts already have a huge scope for including patients in their decision making processes, this should be enforced and monitored. As all NHS organisations will become foundation Trusts in a few months = no need for suggested reforms

  182. gillian says:

    Today the children’s minister said that the NHS is failing to support vulnerable young people, she said: “a six-month wait for speech and language therapy can be critical; an 18-month wait can be really critical.”
    The supply of speech therapy and basic equipment for children with special needs has become a postcode lottery.
    How will the commissioning support children with severe or multiple health and learning disabilities? How will local authorities and commissioning consortia work together to deliver the new single care plan covering schooling, health and social services from birth to the age of 25?

  183. john says:

    the quick fix to the dilemma of managing where the DH /SHA’s have not/cannot done so, and which really establishes the ‘BIG SOCIETY’ VISION is to create local accountability, not national.

    the role of the NCB should be setting tariff, particularly tertiary centre rates, and moving to equity of funding away from the MFF which still steals from peter to pay poor PFI indebted UCH.

    Then monitor calibrates equity of service quality , if it has any role.

    the local accountability is through an inclusive representative patient, professional, and council supported combined health and wellbeing board which sets strategy and gives oversight to the exec GPCC, which spends the budget answering locally, not nationally.

    thus, NCB, sets Tariff, local reviews of the MFF, disributes budget, does not meddle in service planning beyond accountable tertiary planning.
    limited list and budget for this, not top sliced, so equity of access to all for choice of tertiary care referrals. thus bottom up responsibility of NCB to provide through tertiary tariff enough beds/distributed service.

    local HWB SETS STRATEGY, directs GPCC to use population derived reviewed MFF budget to provide service, and oversees delivery with joint responsibility to locality.

    thus local democracy and fiscal control via local authority supported HWB.

    THIS gets the health bill back on track, installs local oversight, and will give power to change in a way the DH/SHA’s have not/ will not/ cannot.

  184. Lindsay Booth says:

    Hi I completely agree with all the post that suggests that a more multi disciplinary approach is need rather than a narrow GP one. I work as a health visitor and not all GPs actually understand what service we provide and how important a figure we are to all children 0-5 years. We are the one professional that regularly sees children at various stages of their development so would be very well placed to look at what services parents and families needed for their children. We are often a signposter to other services for families already for parents making referrals to SALT and community paediatricians. It is also worth remembering that not all Gps attend multi agency meetings and child protection case conferences where true joined up services working takes place over long periods of time. I think therefore that much more education is needed for GPs to enhance their knowledge of all clinical and social services that families are likely to require

  185. Karen says:

    Control of the NHS must be kept strictly within the public sector. How can the decisions made be impartial if some of the people consulted have a vested interest in the final outcome with an expectation of financial gain? An organisation like the NHS has no place for profit based companies, if people want to contract out their health care then they can already do that by taking out insurance or paying privately.
    The NHS comission should be a body consisting of members of all the interested parties, and that means not just medical and clinical professionals but also patients. Sometimes in situations like this people forget to ask the patients what they want. There should be patient representatives to speak for the non-professionals involved in this proccess.

    • Michael Vidal says:

      Karen

      I would agree with you about patients and the public being on the NHS Commissioning Board but the question is how they are to be appointed we need to avoid the usual faces being appointed.

  186. Tom STocker says:

    We need to stop the patient advocacy groups’ powerful interventions on behalf of pharmaceutical corporations to lobby for the introduction of drugs that are me-toos, evergreeners, or who’s introduction and off-label usage is not yet tested. Patient and illness specific advocacy groups may look like a good form of patient advocacy byt they are compromised by their funding sources (nearly always mainly the relevant pharmaceutical corporation if not cancer etc. charity funding). Unless pharmeceutical reform is introduced that splits research funding from access in some way (which may actually save the taxpayer a great deal even if we lose a bit of export ppower).

    Patient involvement in the direction of the NHS is not a good way forward – although its a public good, its running is quite complex.

    Patient accountability is really a sly way to introduce things which don’t make a great deal of sense.

    The best way to organise NHS’s treatment funding and priorities is through the National Institute of Clinical Excellence. This process has been going only a short while, and the proper place to involve patients is at the stage of statistical analysis – a debate needs to be had about what makes up wellbeing and how tightly people value things like sight against limblessness and then to aggregate this reasonably and responsibly into a quality of life index that is then funded to a certain amout per Quality of Life Year. It’s a lot more just, predictable and manageable. Patients are often myopic because they will have emotional blind spots in their evaluation of treatments. Patients are shown to not understand risk properly and to be far too galley-ho about side effects and future complications.

    Don’t let a facade of democracy undermine the democracy and justice of NICE.

  187. To achieve meaningful local accountability, don’t recreate health authorities or PCTs by another name. Lansley is right about that. I have served many years on both and speak from experience. In contrast, external scrutiny and a challenging voice by local people in what consortia do will make them more responsive. Local authority councillors on their own cannot do this. It is not about putting people on a board for the sake of it and it is not about NEDs. Those are yesterday’s failed policies.

    As MAC Partnership said in our Ten Point Plan submission to the Future Forum: “Commissioners must be responsive to the needs and recommendations of the populations they serve. Each commissioning organisation must create and support and be seen to work collaboratively with a patient and public reference group comprised of patient representatives from local practices and lay leaders from local 3rd sector bodies and community networks. This reference group must be part of the governance arrangements of the consortium at all levels and have rights to make inputs to the decision making process of major consortium committees and particularly around strategic commissioning plans. It would exercise oversight of the consortium’s patient and public involvement activities and comment on their adequacy to the local authority and Local Health Watch. The patient and public reference group must include people from communities and groups who can help the commissioners understand how to overcome their health inequalities and comment on the effectiveness of efforts to do so.” This is not difficult. Just do it.

  188. Where user and public involvement is concerned, don’t leave it all to Health Watch, either national or local. Local Health Watch is intended to be much more than LINks rebranded – though it would be very unwise to give it complaints and advocacy responsibilities.

    As a statutory body, LHW should have a seat on the top level governance group – whether or not it is called a “board” – of the GP commissioning consortium and be able to make reports to the wider community following each meeting. It will also sit on the Council’s Health and Well Being Board. That is only right.

    Despite this high-profile role, it is essential that people in statutory health and care services don’t by default see LHW as a synonym for user and public involvement. It cannot all be left to Health Watch just as it cannot all be left to local councillors. There must be integration between viable Local Health Watch and many other types of involvement and engagement at the grass roots of clinical commissioning structures and local providers.

    To be successful businesses, GP practices and commissioning consortia need many direct “listening relationships” with their own patients. The new Patient Involvement Directed Enhanced Service (DES) agreement between GPs and NHS Employers which began on 1st April is the key to building up involvement from the grass roots in the local practices. Without that, LHW may find it is “legless.”

  189. Frieda Rimmer says:

    I believe it is foolish in the extreme to hand over so much control and inance in such an unregulated manner to anyone group. Why is there an assumption that GPs who are wholly underqualified to do other than make evidence based clinical decisions are best placed to run complex mult imillion pound organisations? Experience tells us that relying on good will alone is doomed to failure. Years of consultant driven hospital based service led to a massively centralised self perpetuing system with endless waiting lists. Who would have thought that consultants would resist the introduction of targets that had direct impacts on their private practice……but they did. Who would have thought that MPS would systemically defraud the tax payer of millions of pounds through false expenses claims…..but they did. Who would think that family Drs would buy into private companies that ensures they are paid everytime they refer a patient to ‘themselves’…..but they do and will do so even more. These aren’t bad people it is just a bad system and where you provide pemtation don’t be surprised when people are tempted. The politics is clear, the NHS is to be dismembered and there are ‘massive’ opportunities for the private sector. There are winners out there but I doubt that under this bill they are going to be the patients.

  190. Jane Khanna says:

    In respect of public accountability the government could start with making the listening consultation more genuine. There has been no mailing of households if there has been any TV adverts I haven’t seem them. A poll shows that 95% of the public are unaware of how to make their views known. Most events have been poorly advertised and closed to the public. Health officials have been instructed to carry on with the plans rather than wait for the response from the public.
    The governement does not consider itself accountable to the public otherwise it would not be introducing such a reform having specifically said during its electioneering that the last thing the NHS needs is further extensive change but rather a period of stability.
    Private companies are not obliged to consider patient views. Their primary concern is their shareholders, most of whom are pension fund managers who also have little interest in patients involvement interferring with their profits.
    The monitors role is not to integrate and safeguard care but to promote competition. Just look at the railways with fragmented services. Such an ethos in health care would be disastrous if not fatal for somoe patients.
    If the governent really wants public accountabilitywith private care then they can iinsist that any company offered a contract has 50% of board members from health staff and patients with voting rights.

    • Holly Lyne says:

      I agree with Jane.

      I also think that the commissioning boards need to have independent chairs and finance directors and need to be comprised of doctors, nurses, midwives, other specialists and most importantly SERVICE USER representatives.

      Private companies need to be prohibited from being involved in commissioning on any level and cooperation needs to be emphasised over competition, in order to ensure true accountability and fairness.

  191. David R Reed says:

    We do not want competition in the NHS, we want enforced standards of care decided at national level to ensure that all patients in all areas receive a good standard of care meeting their health need as close to where they live as possible.
    While GPs are a key part of this process, they CANNOT be the sole arbiter of choice. What we want are strong, well-informed and authoritative groups of medical specialists capable of ensuring that the provision of health care in their area remains at the highest level possible on an on-going basis.
    GPs cannot do this, their focus MUST be on individual patients and their health care; putting them in charge of deciding which medicines, treatments, procedures and institutions can provide the best outcome for patients is UTTERLY beyond their capacity.
    We already have these structures in place, the PCTs, and if these are felt to be failing in this role, then change THEM, not the rest of the system which, as surveys show, is now widely regarded as excellent.

  192. Dene Stevens says:

    A sustainable health service allows patients to take greater ownership of their health. Demand is reduced through prevention, better management of long term conditions and providing the appropriate care or treatment closer to home. It also provides a better quality of care by being more accountable to the public it serves.

    Adopting sustainability more widely will help the NHS become less of an illness service, and more of a health service. Patients will be offered more lifestyle/behavioural change opportunities, rather than surgery and medication procedures, enabling demand to be managed in the longer term. Risk preventative and self management measures should be incentivised and promoted as the default choice where clinically appropriate. Mandating health and wellbeing boards to promote actions which meet current needs without compromising the needs of future generations will be essential for a sustainable health service.

    This issue is strongly connected to the localism bill, and to criticisms that the localism bill is only selectively local. In particular there needs to be much more transparency and public awareness about budget-setting by local authorities. Greater freedom for local authorities to raise revenues should stimulate closer public scrutiny. Where authorities make decisions that create environments enabling healthier choices, then they must reap the rewards of this through reduced local expenditure on health care. Given that the direct benefits are often delayed (beyond the electoral cycle) then a mechanism should be agreed to make rewards in advance, based upon best available evidence. As a public health practitioner I have repeatedly observed cases where local authorities make decisions that incur health costs, because of the disconnect between NHS and local government. The simplest example is perhaps the marginalisation of cycling by local authorities that until now have not paid the health costs of the resulting physical inactivity.

  193. Allison says:

    As a member of the public I would like to see my Doctor when I needed to see him and know that he was actually doing what he was trained for not have his mind on administration problems and funding. Doctors are Doctors not accountants/ office managers, Let them get on with their job. But i also think if you get rid of half of the managers/executives who are in a post to save money you would have more money to spend my opinion too many chiefs and not enough indians

  194. judith garbutt says:

    I do not believe that shifting all responsability to the GPs is a satisfactory solution. some may be able to handle the responsability, but others may find themselves foundering…and as for the health authoritys, I have no confidence in them takeing patients well fare into account, as ours at this time, is trying to close down our local hospital, and make us travel further for treatment.

  195. Alan Pool says:

    How are we going to ensure that the cinderella services are going to be provided? Who listens to patients who are mentally ill. Who is going to provide these services for poor patients when no profit is involved?
    Do GPs really care about mentally ill patients or will they put them at the bottom of their wish list?

  196. Void Exercise says:

    This listening exercise has to be stopped and corrected.
    I am deeply outraged that this listening exercise has been designed and implemented in the way it is.

    - There is not enough publicity. No one I know (family or friends) know that there is a listening exercise, let alone how to get involved

    - The interface has been just designed so that new participants cannot read what others have said. Am I supposed to make my point without reading the 529 other ideas that others are discussing below me?

    - 4 different sections make the navigation more difficult, and sythetizing the information impossible. This is a good way of preventing anyone from being in the position of making their point

    - There is no summary of what is being discussed which can be easily reached from this page. A document stating clearly what changes we are exactly discussing should be visible at all times.

    - There is no information on how these random comments by users are going to be processed, valued or used. There is no statement on what guarantees that they are going to be even read by someone

    - Any ethical and true listening exercise should start by listening to patients and citizens, who are the ones sustaining whatever system we come up with, and the ones suffering the consequences of any bad choice in this respect. The only section of society who seem to be giving their view here are mostly doctors, nurses and other institution workers who are aware of this sham.

    Shame on this listening exercise, Shame on Mr Andrew Lansley. Shame on our government. Shame on this authoritarian and corporation-driven proposals.
    We are citizens. We are patients. We are tax-payers. We are consumers. We have the right to be listened to, and above all, we have the right to be respected. Stop insulting us. Stop lying to us.

  197. Joe McClintock says:

    At the national level, accountability to the public is supposed to come through elections. Where is the accountability in fighting an election on the basis that major reorganisations are counterproductive and then, within 60 days of coming to power, launching a white paper that seeks yet another reorganisation? The Health Secretary should account to the electors of this country and drop the idea.

    At a much more local level, I am not sure that GPs are any more accountable than PCTs. As a patient with a rare chronic disease, I am very concerned that GPs will inevitably find this hard to ignore when taking and treating patients. There is a blurring of accountability when the patient-doctor relationship, which should be governed by hippocratic concerns, is conflated with the relationship of rationer of healthcare (and we do realise there has to be a rationer…)

  198. shurleea Harding says:

    Fortis who hope to run the consortia fro my area (south Essex) send letters out that do not include the name of a single human being and they do not sign their letters. Given that they have had access to my medical records I challenged this on the basis that i should have given consent and I would like a name of the nameless faceless people running this this operation. I was told it was a software issue and they refused to talk top me anymore about it … I thought you only needed a pen to sign letters?

    My concern is that if this is taste of the low level ‘customer care’ we are going to get from Fortis which is already setting up it own clinics and no doubt building itself a little empire, then what hope have we of getting quality care in the future?

    Already we have stopped being people in need of care and become objects to be processed. Consortia are going to be a private enterprise and of course GP’s will look after their own interests and ignore services like the elderly and metal health!

    It is disgusting the way Fortis have had access to patient information without their knowledge or consent then tell us in nice phrased words to shut up and go away!

    The future frightens me very much indeed, especially when Fortis is a part of it!

  199. Peter Burke says:

    I feel certain that this is a short sighted ill conceived plan which is doomed to failure. The proposal is to rush through massive changes in the face of a sceptical demoralised workforce, most of whom have not bought into the plan and many of whom will positively undermine it. GPs are happy to take responsibilty within boundaries and where the situation is under their control. What they cannot do is divert huge amounts of clinical time to sieving through masses of financial and clinical evidence in order to make enlightened cost effective purchasing decisions. Widening the professional spectrum is unlikely to alter this greatly

  200. Les Fawcett says:

    There are two things in this bill which will lead to privatisation of the NHS – what most people fear and what you are trying to deny;

    The first is Incentivising GP’s to reduce the referrals they make for their patients.

    The second is the removal of key performance targets – specifically the 18 week wait.

    In best case scenarios, GP’s not giving the patient the benefit of the doubt and adopting a more cautious approach with an eye on the financial balance will reduce the number of patients referred – worse case would be unscrupulous GP’s making a lot of money out of others misfortunes. This will have two outcomes, the first is that patient’s will become dis-enfranchised and if they can they will look to top up their care using private insurance. The second is that hospitals will start to struggle given the reduction of referrals

    Hospitals faced with competition and loss of funding will either cut or reduce access to services. This again will have two outcomes, the first is that patient’s will become dis-enfranchised at having to wait long periods for their care and if they can they will look to top up their care using private insurance. The second is that hospitals will start looking elsewhere for funding, and “fortunately” the private insurance firms will be on hand to buy up capacity.

    These outcomes which are virtually certain under the proposed bill will mean that as time passes people who can afford to will move to buy personal top-up care. This will have a double whammy effect on NHS hospitals, as they will recieve less activity from NHS patients and this be forced in to an ever decreasing spiral of reduced costs and quality. Thus a tipping point will finally be reached whereby NHS care withers to something like Medicare in the US and the big health insurance companies make a financial killing.

    Nick Clegg, you say you are listening – this is why clinicians and NHS staff are concerned about backdoor privatisation, so do something to stop this!

  201. mandie says:

    I have so many issues with the proposed new commissioning process. Firstly how can we ensure that patients, with high cost but low incidence conditions ,will have access to the services they need. In my experience it is not the GP who deals with these people it is the hospital consultants who may have seen the condition before , but in many cases may not. We do not use the GP but use the Consultant, all the GP does is fund the treatment the consultant wants and deal with the day to day illnesses not the underlying condition.
    Secondly the GP will be looking at the bottom line and may not want people with expensive conditions on their list. and even if they do may not know what is avaliable to meet the need both in terms of services and medication. Sometimes it is not optimum care that will be provided due to cost and lack of knowledge.
    Thirdly I am so concerned about the Postcode lottery of provision. If decisions on commissioning are made locally what happens if there is an influx of people with a condition not covered locally , how will this be dealt with. Will there needs not be met or will they have to travel to where is may be.
    Who is going to be responsible for ensuring areas do have the specialist services availiable locally to meet the needs of its population.
    Forthly if GPs are doing what we want then to ie see patients how will they have time to Commission. They won’t they will employ others to and I am extremely concerned that Privite, profit making companies will take over the role of managing and this is not acceptable.
    As for Patients and Carers being involved. I have been involved for many years and would say that as a lone voice very little changes , so it is essential there is a mechanisum for this to happen, But it must be a legal requiremnet that all commissioners etc not only consult with but show how they are acting on what patients/ carers say. Any reps on boards etc must have lines of accountability to their constituency and this must also be appropriately funded.
    For healthwatch to succeed it must be independent and funded appropriately to have true patient involvement. This must not be solely web based like this is.
    Transparency is only as good as the disemination of that knowledge.
    LINKs is not broken why try to fix it, PCTs are not broken why change the commissioning process, we have been here before Primary care groups formed into PCTs for economies of scale, why go back?
    Let those that know about health deal with health and politicians keep their hands off and go back to what they do…. mess up everything else.

  202. Barry says:

    OK, you have got it quite wrong for a number of reasons:

    1. GP’s are not angels, generally quite a selfish bunch of individuals, who are so lazy they can’t make their own coffee and even have to get someone to log their computer on for them. Over the last few years they have managed to get an ever increasing salary yet do less work, including out of hours, I work with many GP’s in my area their is only a very small percentage I would trust with anything. PCT’s were the best way to commision but that leads me on to my next point.

    2. PCT’s – a good idea, but they have been allowed to grow out of control, money has flowed into them, and as a result we have management heavy structures massively over staffed with people on fat salaries, and you have given them the power to decide how to go forward, well they are not going to vote themselves out of a cushy job are they? So my advice is keep PCT’s but sort them out, get rid of the stale corrupt managers and bring in some fresh ideas, do we really need a Cheif Exec, deputy chief, assitant cheif manager etc for every PCT this is what needs sorting!

  203. Stephen Todd says:

    I have a good relationship with my GP, and, because I know how to work their system service is usually very good. But in my opinion their management of the practice is poor, and getting worse. They seem to be giving less service for more money. I don’t think GP’s have the necessary skills to run their own practice for the benefit of patients, let alone have more control of a wider health provision. Give them more say in terms of outcomes, yes but let them concentrate on being better at their job.

  204. John Lackie says:

    How can we make the NHS properly accountable to the public, and make sure that patient involvement is at the heart of its decision making? By making politicians properly accountable to the electorate and by not disbanding things like NICE that use evidence-based review to determine what works and what doesn’t. We could also try trusting professionals to be professional – but that is rather unfashionable and many politicians seem to think their understanding of healthcare is better that that of people who actually deliver it (and GPs are only a subset of the deliverers).

  205. Thomas Jennings says:

    I do not want commissioning consortia taking money away from NHS budgets and putting it in the hands of GPs. This requires GPs in something they are not trained to do and makes overall financial control more difficult.

    NHS needs transparency in terms of patient care, not in terms of finances. All patients care about is how likely they are to get better in a hospital. Statistics in easily viewable maps of the UK or local areas on the internet would encourage particular hospitals to increase standards in different fields if they are named and shamed.

  206. Louise White says:

    I would like to ask who will be monitoring commisioning? I have been watching Health visiting commisioning across the country. Some are adhering to the governments directive to increase and some are not. This diorectly affects vulnerable families and the safegarding of children I have even seen disparity between areas within the same SHA. If commisioners are still allowed to commision according to local politics rather than need and government directives, we are surely on a road to nowhere! Tell us listening exercise, where is the analysis of these pages and pages of comments and of compliance of your own directives?!

  207. Sally Moreton says:

    The questions this survey asks us to answer are all carefully worded TRICK QUESTIONS. The reforms designed by Andrew Lansley were not set-out in the Conservative or Liberal Democrat election manifestos (and where the Tory manifesto spoke of enabling GPs to commission services,, if passed into law, the White Paper will force them to do so – attacking the very principles of choice the White Paper pretends it’s designed to promote).

    The NHS reforms aren’t just bad legistlation, and they aren’t just designed to make multinationals rich at the expense of British taxpayers, they’re an assault on democracy itself.

  208. Peta Kerrigan says:

    At present the NHS is supposed to go for best value and have robust purchasing and providing pathways that all adhere to. This isn’t always the case. Buyers and purchasing depts. are offten over ruled if it’s for the CEO or consultants tea room etc. If this standard was more readily enforced across the NHS it would operate more efficiently without massive change. The list of stationary, and things such as coffee machines, fridges etc should be looked at nationally and tightened. The ability to but form sources other than NHS supply chain should be held firmly within the purchsing departmants, no areas should have a trust credit card they can use to purchase. All purchasing should be done in a set way.
    Locally based decisions for care are fine to an extent but you can end up with huge differences in areas that mean you end up with the “post code lottery ” issues we have seen in the past.
    Voluntary and charitable organisations are better placed to help create local community services and groups that meet specific issues of the area. The main thrust of an acute trust should be to provide an acute service to all that is free to all and is comparible nationwide.

  209. Jeanette Bailey says:

    How can we ensure commissioning decisions are made transparent and engage all stakeholder? These will need to be published on using patient and public accessable media. With provision being made for Users with disabilities. Engagement requires listening at all levels and making the time to do so. This would need to be somebodies full time job.

    Commissioning budgets via the board will need to include public membership to allow for transparency and accountability to the public, the board membership will need to ensure this.

    Local freedom is available for the User to choose their healthcare provider. Local decisions are made currently by the P.C.T’s commissioning services that they need for thier patients, in the future, this right for patient’s to choose should be protected.

  210. Jill Mundy says:

    I am deeply concerned that the changes that Andrew Lansley wants to make will end up damaging our health service.

    For example, I am concerned that new commissioning bodies will not be properly accountable and will not operate in a transparent way. GPs should not be able to take decisions behind closed doors, and other stakeholders including patient groups and other health professionals should also be involved.

    It is my personal opinion that if leading health experts such as the British Medical Association give advice about the NHS then this advice should be followed. Any changes planned should be trialled in small areas for several years in order to assess impact, and for the results to be assessed by the BMA.

  211. Geoff Collard says:

    The whole idea of ‘consortia’ shows exactly what these ‘reforms’ are designed to do. They are designed ultimately to lead to the full privatisation of the NHS – no doubt about it.

    Commissioning authorities should not be ‘consortia’ (just another name for private corporations). The restoration of local NHS health boards could be a way forward, but there is a case for having elected local authorities (perhaps independent from district councils as such) holding NHS budgets. Elected authorities would ensure local accountability so that people in each area get the health services which they want. These authorities should be composed of patients’ representatives, local councillors, GPs, and professionals from all branches of the health care professions, including cleaners, porters and nutritionists and cooks, along with an economist and delivery manager. Private companies should not be involved as they have a very different agenda – profit.

  212. Richard Worth says:

    Effective commissioning will need far more professional medical input than just GPs. Knowledgeable they are, but they cannot appreciate the complexity of many secondary care aspects and so it is essential that some key hospital consultants, senior nurses and, where appropriate, other professions allied to medicine (eg physios) are included. Public health consultants must also be fully involved as of course must representative patients. And this is not just my view – it is the view of MPs on the Commons Select Committee!

    The argument that hospital staff cannot be involved as they are also providers simply does not stand up, as GPs are also providers and so it can easily be argued that they have potential conflicts of interest.

    Getting everyone together in the same room to thrash things out is the only way. Yes, there will be arguments, but at least they will be properly informed and the decision making process will be transparent to all.

  213. Key messages and recommendations from Hammersmith and Fulham Local Involvement Network consultations:
    Below is a summary of local key messages and recommendations from local residents and communities on how they would like to be engaged in the development and delivery of health and wellbeing services. The feedback is gathered:
    • From large LINks Event on ‘Local Involvement and influence on the changes in the NHS and Social Care in H&F’ (April 2011)
    • From Older People Consultative Forum and the Disability Forum on updates on changes to NHS commissioning (March 2011)
    • From LINks AGM which focused on the Quality, Innovation, Partnership and Prevention (QIPP) Programme; (December 2010)
    • From joint NHS H&F and LINks Consultations on the Coalition White Paper ‘Equity and Excellence: Liberating the NHS’ (July – September 2010)

    Overarching Engagement principles for the GP Consortium
    • To enable communities and individuals, including those from excluded communities, to influence the shape and delivery of health services and to ensure that individuals receive services tailored to their needs.
    • To work in effective partnerships with the voluntary and community sector, HealthWatch, the Health & wellbeing Board and Public Health to improve the health and well-being, and health experience, of local people
    • Wherever possible, to support the commissioning of local organisations – in particular third sector organisations – to identify needs and deliver services for local people.

    Key Messages & Recommendations
    • To provide opportunities for patients, communities and the public to be engaged with GP consortia and its development and in ensuring that the Consortium develops an open and transparent process for making commissioning decisions.
    • To have HealthWatch, voluntary sector and service users represented in commissioning consortia (at Board level). There is need for structured support to empower patients including development of Patient Participation Groups, so that they could better participate and engage with issues affecting their health.
    • To design and deliver structured training programmes on effective service user and community engagement and representation across the GP Commissioning organisation as well as at Board level. Local voluntary and community organisations as well as service user groups – particularly those from excluded communities – should be involved in the design and delivery of the training programmes.
    • To ensure that the Consortium, as a commissioning organisation, effectively involves service users and communities – in particular excluded group – in:
     identifying local needs and experiences,
     designing / re-designing services,
     tender panels,
     monitoring and evaluation,
    • To develop overarching principles and an effective framework for patient and community engagement across the GP Consortium, Health and Wellbeing Board and HealthWatch. This should particularly apply to programmes that relate to:
     Volunteer co-ordination and re-imbursement policies
     Re-imbursement for voluntary and grassroots community organisations who engage with excluded groups and communities and with deprived neighbourhoods
     Structured patient and community representation training programmes for service user and community representatives
     Structured patient and community engagement training programmes for staff and board members
     Health and well being engagement events to capture patients and communities’ views
     Consultation and feedback events
     Communication with patients, communities and the public on commissioning decisions (you told us… so we’ve)
     Mapping local voluntary and community sector as well as statutory sector service provision
    • To organise an annual People’s Day with patients and community organisations on the panel presenting their views, experiences and recommendations to clinicians and other health and social care professionals
    • To engagement patients and communities in the design and delivery of peer led structured education programmes for people with long-term conditions and wellbeing / active living programmes and activities.

  214. Judy McCulloch says:

    I have real doubts that this government has any intention of allowing patients to be involved in decision making at any level. Throughout this ‘listening period’ I have been trying to identify somewhere where I can attend a listening event. It has proved impossible. With apparently over 200 it should have been possible to attend somewhere. Those you can attend by choice are few and far between and advertised very obscurely on the website. If you really want to listen to us all give us all an opportunity to be heard!

  215. Mencap, The National Autistic Society, The Patients' Association and 37 other charities - Listen Up statement says:

    “Listen up” – charity statement – via Mencap, The National Autistic Society, The Patients’ Association and 37 other charities

    This is a time of great uncertainty in the NHS. This uncertainty does not help anyone.

    The Government’s ‘Listening Exercise’ is therefore to be welcomed.

    The Department of Health needs to use this time to substantially improve the Health and Social Care Bill.

    Although the upheaval in NHS is a considerable challenge to all of those involved in health and social care, it is also an opportunity to address long standing inequalities.

    Currently, the Health & Social Care Bill does not live up to the aspirations set out in the Government’s White Paper.

    In order to put patients at the heart of the NHS, improve health outcomes for all and empower clinicians, we believe the Government must:

    1) Ensure GP Consortia effectively engage with all patients and put them at the heart of their plans
    2) Improve integration across health and social care by strengthening the role of health and wellbeing boards and the NHS Commissioning Board
    3) Create a Healthwatch that is independent, well-resourced, transparent and able to act as an advocate for all patients
    4) Include measurements for outcomes of the most vulnerable
    5) Ensure children’s services are embedded in health and social care
    6) Improve access to specialised services for those with complex needs

    Action Against Allergy
    Alzheimer’s Society
    The Anaphylaxis Campaign
    Arthritis Care
    The British Liver Trust
    British Red Cross
    The College of Optometrists
    Crohn’s and Colitis UK
    Every Disabled Child Matters
    Friends, Families and Travellers
    Guide Dogs
    The Lindsay Leg Club Foundation
    Learning Disability Coalition
    Lupus UK
    Macular Disease Society
    The Meningitis Trust
    The Mental Health Foundation
    Migraine Action
    The Migraine Trust
    Mind
    Muscular Dystrophy Campaign
    National Forum of People with Learning Disabilities
    National Rheumatoid Arthritis Society
    Organisation for the Understanding of Cluster Headache
    Ostomy Lifestyle
    Parkinson’s UK
    Pelvic Pain Support Network
    Primary Immunodeficiency Association
    RNIB
    RNID
    Royal College of General Practitioners (Learning Disability group)
    Scope
    SeeAbility
    Specialised Healthcare Alliance
    Thyroid UK
    United Response
    WellChild

    Ensure GP Consortia effectively engage with all patients and put them at the heart of their plans

    The Government has stated that there should be ‘no decision about me without me’ with regard to NHS treatment and services. We support this goal.

    Patient and public involvement has a long history of confusion and poor implementation in the NHS. Since the publication of The World Class Commissioning Framework, however, this was beginning to change.

    We believe that the current proposes do not do enough to guarantee that patients will be involved in all aspects of their care, most importantly in the commissioning process.

    The Health and Social Care Bill plans to introduce greater information and choice for patients in terms of their own individual treatment, and give commissioning powers to new GP Commissioning Consortia.

    We are yet to be convinced that the Government’s plans will improve patient involvement and support the Health Select Committee in their conclusion that it would not be “over-prescriptive” to require local commissioning bodies to adopt governance structures which meet basic standards of good governance.

    Our goal is to see GP Commissioning Consortia be proactive in seeking out the views and experiences of the public, patients, their carers and other stakeholders, especially those least able to act as advocates for themselves.

    Central to this would be the requirement for a GP commissioning consortia to include lay membership of non-Executive Directors on a board comprised broad range of clinical and non-clinical members. This would ensure that objective and independent voices are represented on consortia governance structures

    Improve integration across health and social care by strengthening the role of health and wellbeing boards and the NHS Commissioning Board

    Integrated health and social care offers three benefits: better outcomes for service users and patients; making limited resources go further; improving people’s experience of health, care and support. These have been policy aspirations for more than 40 years, but patchy progress and a transformed policy and financial climate demand news way of achieving them.1

    We do not question the Government’s commitment to improving integration between health and social care.

    The uncertainty around the NHS reforms, however, is putting a number of important projects at risk. Also, with the demise of the co-terminosity between local authorities and the NHS in some areas, we believe the Government’s plans needs to be strengthened to ensure that more, and not less, joint working takes place.

    One of the best ways to ensure integrated working continues is to ensure pooled budgets are retained and developed.

    To do this, it is important to strengthen the role of Health and Wellbeing Boards to make sure that where there are a number of consortia operating in the area the incentive for GP Commissioning Consortia is not to ‘free ride’ and not contribute to joint projects.
    Furthermore, it is essential that a key role of the NHS Commissioning Board must be to encourage the integration between health and social care and act as an arbiter if disputes emerge.

    Create a Healthwatch that is independent, well-resourced, transparent and able to act as an advocate for all patients

    Patients, service users and the public need a capable, strong and trusted body to offer help and advice in every area. No such body has ever existed.

    The Government’s vision for HealthWatch being an independent consumer champion that will help the public and patients influence decision makers, signpost people to support, offer information and provide advocacy is ambitious. Even with the support of a national body – HealthWatch England – this is a daunting task.

    In order to live up to the Government’s ambition, HealthWatch must be independent, well-resourced, transparent and able to act as an advocate for all patients.

    Currently the Government’s plans lack clarity, with questions being raised about the independence of HealthWatch from the Care Quality Commission, how and how well Local HealthWatch will be funded, the openness of HealthWatch if it is not subject to Freedom of Information requests and its ability to advocate for patients and service users in the complex world of health and social care.

    There is no silver bullet that will instantly create an organisation that lives up to the Government’s laudable goal. Nevertheless, more work is needed to ensure that the HealthWatch turns into the institution we all want it to be.

    Include measurements for outcomes of the most vulnerable

    Judging the outcomes of patients is an important step towards monitoring quality, improving accountability both locally and nationally, and benchmark NHS performance.

    The needs and outcomes of vulnerable people of different ages are very different from the general population and the Government’s Outcomes Framework fails to recognise this.

    We are aware that the Government has recognised this problem:
    “The Government is aware that current data and data collections cannot adequately identify certain groups at present…As the framework evolves over time, outcome indicators will be refined with a view to being able to more fully measure and record health outcomes for all groups wherever it makes sense to do so.” 2

    We welcome this recognition but believe that work needs to be done sooner rather than later to ensure that vulnerable groups are not left behind and the outcomes in general do not overshadow outcomes of vulnerable people of all ages.

    Ensure children’s services are embedded in health and social care

    Services for children are distinct from those for adults. The Government wants children and young people and their families to be at the heart of everything that they do.

    Currently this is not the case, not least because the Government’s ambition of improving integration across services does not marry up with their education reforms.

    Professor Sir Ian Kennedy’s report ‘Getting it right for children and young people: Overcoming cultural barriers in the NHS so as to meet their needs’ concluded that services for children and young people could be made significantly better and that work was needed to make sure services for children are unified and co-ordinated at a local and national level.

    There is a clear need for close collaboration between professionals in health, social care and education to ensure that children, especially those with long-term or serious health needs, do not lose out.

    We believe that more work is needed to guarantee that services for children and young people continue to improve following the NHS reforms and that a closer examination is needed of how the Health and Social Care Bill meets the recommendations set out in the Kennedy Review.

    Improve access to specialist services for those with complex needs

    Commissioning services for people with complex needs of all ages, disabilities or backgrounds has always been a challenge. This challenge has rarely been helped by the repeated reorganisations of the NHS.

    The Government’s goal of placing GP’s at the heart of the commissioning process is a considerable risk at a time of tightening budgets and increased demand for services. Although, as with other reorganisations, there is an opportunity improve the commissioning of services for people too often left behind.

    To do this, however, the Government must be clearer on which services will be commissioned by the NHS Commissioning Board and which will be commissioned by GP Commissioning Consortia.

    It is of great concern that GPs, who will often have very little experience of dealing with patients with rare or complex needs, will be asked to commission intricate and expensive services in a competitive market.

    Clear guidance, advice and support is needed if this is going to work and this work needs to be undertaken urgently.

  216. Rachel Britton says:

    We need a much wider stakeholder commissioning group if they are to take effective locally based decisions. G.P.s, as good as they are, are Jack and Jill’s of all trades. We need a Multi-Disciplinary Team, including, for example, physiotherapists, speech therapists, district nurses, community midwives, paramedics, etc. This should also include a RANGE of representation of patients and members of support services which patients rely on. These bodies should be accountable, just as school governors are.

    Many people struggle to see their G.P.s, particularly for non-urgent, chronic problems – how will the provision improve if G.P.s are caught up in commissioning? Will G.P.s receive extra training for this role?

  217. Gareth Stone says:

    The government’s “duty to provide” a comprehensive health service must be kept. Dropping this duty would erode the foundations of the NHS.

    “Cherry picking” by private companies must be fully ruled out, and the mechanism for preventing it must be clearly established.

    Any changes to the NHS of the scale currently proposed should be trialled in small areas for several years first

    Any new commissioning bodies should be transparent and accountable. They mustn’t be allowed to meet behind closed doors. Patients and other health professionals must be represented as well as GPs.

  218. Elvire Roberts says:

    It seems to me that the Listening Exercise is entirely token. There were only 2 in Nottingham and Nottinghamshire, held in the evening. I only found out about them because I am on an NHS e-mail network. Evenings are a difficult time for single parents and disabled people to access. Only one of the evenings was accessible to deaf sign language users.
    I do wonder if anyone will read these threads and alter decisions accordingly. The Listening Exercise seems to be more information-giving than asking for opinions. And if you do not have access to the internet (which is the case with many of the more vulnerable and/or impoverished members of the community), then consultation and information passes you by.

    It is important to consult in community fora, for the individual communities, to hear what their concerns are.

  219. JEH says:

    How can I trust my GP if I don’t know whether his treatment plans are based on my health needs or on what is affordable. GPs should be left to make decsions based purely on health need and leave others to priortise funding requests

  220. Julie-Ann Bowden says:

    I have become increasingly concerned in relation to the direction of travel in terms of NHS budgets moving to GPs. I do not think that this is the answer and removing PCTs is going to create a significant gap in governance of independent contractors. There is still no clear direction as to where the management of performers lists will sit. Performers lists provide PCTs with the local ability to regulate professionals and having been involved in managing professional performance concerns in primary care for the last 4 years, I am greatly concerned about how this work that assures the quality of our GPs and dentists will continue if it is transferred to a larger footprint than it is currently. I do not disagree with the move towards having a national performers list, but local intelligence and memory in terms of complaints and concerns will undoubtedly be lost if responsibility is passed to the Commissioning Board completely.

    This has even more resonance when you consider the requirement placed on Responsible Officers within PCTs currently in relation to revalidation of medical practitioners. Local professional performance processes managed by PCTs and supported by NCAS collect essential information to inform the Responsible Officer’s recommendation for revalidation.

    The reforms have not considered a whole systems approach to healthcare reform and do not take into account the impact on clinical governance systems and processes such as management of professional performance and revalidation. It would be inappropriate for the GP consortia to take on these roles as it would constitute a serious conflict of interest.

    I am concerned about the readiness of GPs to take on the role of commissioning and also the integrity of some of the GPs who have put themselves forwards. I attended a GP consortia meeting for one of our localities recently. At this meeting were the GPs who had put themselves forwards to take develop the consortia. A discussion took place regarding lengthy waiting times for Child and Adolescent Mental Health Services. One senior GP member of the consortia put forwards his explanation for the waiting times, stating that it was the middle class families who insisted on referrals to CAMHS for their children who displayed behaviour that they could not control just so they could get a label and a free laptop. This is not an isolated incident and inappropriate comments and behaviour are happening all the time.

    I am sorry but I am not ready to hand over the NHS to these kind of people. I want assurance that there will be appropriate local processes in place to monitor these consortia to ensure they are operating appropriately and are being held to account in terms of their financial responsibility. An NHS commissioning board on a national or regional level would not have the ability to undertake this role. Retaining something at PCT cluster level is imperative to continue the good work that is currently taking place around assurance and governance.

  221. Emma says:

    The concern with each consortia making their own decisions is that it will increase the postcode lottery. If the NHS is to remain fair and equitable then there must be clear debate on what is included in its universal coverage.

    My additional concern is that some areas will choose to fund interventions that have not shown to be effective through properly conducted randomised controlled trials. Safeguards are needed against this.

  222. Further to recent Kensington and Chelsea Local Involvement Network (K&C
    LINk) consultation on the white paper and at the local listening exercise (see http://www.rbkclink.org/blog/), the LINk hosted a further engagement event in partnership with KCSC, to ensure residents are informed and can influence the reforms locally.

    In addition to those raised in response to the White Paper, members raised a number of concerns about:

    1.         The gap in provisions for not those not currently registered with a GP

    2.         The reasoning for Public Health Englandbeing independent of the DH – a quango v ability to raise funds?

    3.         The loss of resources spent on investing/training in World Class Commissioning over recent years – ‘brain drain’

    4.         The emphasis (or lack of) on equality, diversity and human rights in the sub-cluster – no dedicated posts

    5.         The responsibility of engaging with the private sector on public health issues e.g. fast food restaurants contributing to the health eating agenda causes concern

    6.         The practical ability of patients to exercise choice and control

    7.         The importance of a good JSNA that is inclusive of PPE

    8.         The need to actively work with providers and the CVS to ensure support for the changes

    9.         Disappointment that the Bill and proposed changes appear to indicate a ‘revolution instead of an evolution.’

    In relation to accountability and patients, this workshop found that:

    •           Engagement at every stage of the commissioning cycle is key – from collating data on inequalities to evaluating the effectiveness of a service

    •           Participatory methods for collation and analysis of local need were essential to support effective commissioning

    •           Guidance on patient and public engagement is needed from the DH

    •           Patient Participation Groups should be supported and are an essential part of the required engagement framework

    •           Local HealthWatch should have two seats on the Health & Well-Being Board to support effective representation.  The LINk/HealthWatch should be supported to develop a framework to ensure representatives can be strategic and trans-disciplinary

    •           The role of Local HealthWatch should be resourced adequately to play its role as ‘critical friend’ effectively

    •           The role of the Health and Wellbeing Board should be strengthened to hold the GP consortium accountable for the commissioning plan

    •           As GPs will have responsibility for all, not just those registered with a GP – a planned approach is needed to engage with the wider community.  There needs to be a lead GP with overall responsibility for patient & public engagement

    •           Clear pathways of communication and reporting are required

    •           Consortia meetings must be open to the public

    •           Patient involvement is required now during this transitional stage, including at the decision making/board level.

    •           The relationship between the Health, Environmental Health and Adult Social Care Scrutiny Committee and HWBB was queried

    •           LINk/Local HealthWatch should have a supported role in training patients

    •           Local HealthWatch needs access to clear and transparent reporting on complaints from local services

    •           Strengthen existing models of representation and ‘dig down’ to localities.

    The full report is being submitted to stakeholders (including the DH) with clear recommendations and will be available from June 1st on our website (www.rbkclink.org).

  223. Orris Orrison says:

    I would prefer my GP to concentrate on providing the services I expect as his patient, and for others on his list too, rather than getting involved with issues that will take him away from his usual business.
    If he is to be involved with other meetings then let them be with a panel of his patients to discuss matters that impact more directly on them and which he can (and should be made to) address properley.

  224. Caz Harris says:

    Communication with the local community needs improving. Also with the staff, nobody seems to ever ask frontline staff about issues and we are told very little. This encourages a atmosphere of rumour in staff and users of services and this causes a clouding of transparency. This nhs bill will just replace red tape with red tape and will just cost more money that could be used directly for patients, why?

  225. Roy Scott says:

    The proposed removal of the Secretary of state for health’s ‘duty to provide health care’ is completely unacceptable and morally wrong, this will lead to more of a ‘post-code lottery’ for people in need of health care.

    My peers and I have very real and valid concerns about this bill and that the changes that are being proposed (including increasing private
    competition) will be very disruptive and damaging to the NHS.

    I do not believe that these reforms will be beneficial to the NHS. GP’s should be left to diagnose minor ailments while specialised consultants, doctors and nurses within NHS hospitals & trusts should replace the non-medical management within the whole NHS.

    I urge you to reconsider your position as the people of England are against these proposed reforms and that we did not vote for them in any way, shape or form.

  226. Dr. Ian Roberts says:

    “Are we doing enough to make sure the NHS at local level has the freedom it needs to take locally-based decisions?”
    Why do these decisions need to be taken “locally” ? Surely they are best taken evidentially?

  227. Michael Shackleton says:

    I have huge concerns about the proposed changes.
    I think it’s time to drop them and start again.

    For example, I am opposed to the proposal to scrap the Secretary of State’s duty to provide a comprehensive health service. This is a duty which has been fundamental to the operation of the NHS ever since its formation. It must be retained.

    The NHS should focus on providing quality healthcare, not on competition.
    The role of the regulator, “Monitor”, should reflect this and promote
    collaboration.

    Competition is anathema to care.

    The government’s “duty to provide” a comprehensive health service must be kept.

    Dropping this duty would erode the foundations of the NHS.

    “Cherry picking” by private companies must be fully ruled out, and the
    mechanism for preventing it must be clearly established.

    Any changes to the NHS of the scale currently proposed should be trialled in small areas for several years first.

    Any new commissioning bodies should be transparent and accountable.
    They mustn’t be allowed to meet behind closed doors. Patients and other health professionals must be represented as well as GPs.

    The Government is not listening to experts and patients as the vast
    majority express their horror at this implementation of a policy which lays the NHS wide open to predaTory private companies.

    The idiotic waving of the ‘ choice ‘ banner must stop.

    Quality and availability are required, not choice.

    True care and the pursuit of profits first are incompatible.

    Please take your appalling American led ideas away.

    They make me ill.

    Mr. Lansley,

    where will the profits that these companies make come from?

    If there is too little now, how can they take their profits unless the
    services suffer?

    Why are you creating yet another means of funnelling the people’s money into the pockets of these companies who have NO public service ethos and are driven to produce only wealth for their shareholders?

    Need reminding already ?

    ” “PM aide: health reform is chance to make big profits”

    “Mark Britnell, who was appointed to a “kitchen cabinet” advising the prime minister on reforming the NHS, told a conference of executives from the private sector that future reforms would show “no mercy” to the NHS and offer a “big opportunity” to the for-profit sector.”

    Lovely.

    Pause, listen and reflect………….and then show “no mercy” and “make
    big profits.”

    Please stop these unwanted and damaging ‘ reforms ‘.

  228. Dr Heather Williams says:

    I don’t think we really have a problem with patient involvement. There are cases where people don’t feel listened to, but local complaints and patient advocacy groups are well-placed to address this. Public satisfaction with the NHS is at an all-time high, and it offers excellent value for money and access on the basis of need not wealth. If the NHS is fragmented and consistency undermined by these proposals – and I can’t see how it won’t be – then there will be cause for complaint!

  229. Cllr Andrew Gravells says:

    Local authority health scrutiny

    Scrutiny done well can undoubtedly result in improved public services. The fresh independent thinking provided by locally elected councillors involved in the scrutiny process can make a real difference for local people.

    The key message is that scrutiny should make a difference in the areas that matter to local people – health services, crime and disorder, adult social care, schools, vulnerable people. It provides an opportunity to bring public agencies together to pick up important issues that might not otherwise be addressed.

    In common with all public services, local government is facing challenging times. There will be some tough decisions and through the scrutiny process non-executive councillors are well placed to identify priorities and ensure that services are provided in the most effective way. Councils will need to demonstrate to the public how well they are performing. There is a clear role here for non-executive councillors in holding public service providers to account, particularly as changes are proposed to the responsibilities of local authorities as well as healthcare providers.

    We would like to see the power to refer to the Secretary of State remain part of the scrutiny function. We do not want to see further watering-down of scrutiny powers, particularly in relation to acute trusts.
    The membership of the proposed Health and Wellbeing Boards includes GPs and members of the NHS Commissioning Boards. These are the decision makers; they cannot hold themselves to account. There should also be a statutory duty for commissioners to respond to scrutiny. The activity of the Health and Wellbeing Boards will also need monitoring to ensure that they are operating effectively.
    Community services, including social care, are being integrated more widely between the NHS and local authorities, and those services which are provided by the local authority will require scrutiny.

    The move to enable greater provider freedom could result in local communities not understanding why services are changing. Health scrutiny clearly has a role to play in raising concerns on behalf of communities, and ensuring that changes are made for the right reason, and at the right time.

    The strategy for health and well being will be developed based on the needs identified through the Joint Strategic Needs Assessment (JSNA), and will inform proposals for change. Health scrutiny has a clear role to play in ensuring that the JSNA captures the needs of localities. This role cannot be carried out by the Health and Wellbeing Board which undertook the work. The need for a separate scrutiny function is clear.

    Scrutiny should be impartial, independent and objective, therefore we believe that it is essential that the health scrutiny function and its role in the local authority should continue to remain separate from the proposed Health and Wellbeing Boards.

    In all of the changes proposed the one constant is health scrutiny and, whatever adjustments are made during the passage of the bill, we should ensure that it is retained and strengthened. The new arrangements should look to build on the successes and achievements of health scrutiny over recent years.

    • Michael Vidal says:

      I agree with Cllr. Gravels I would add that for crutiny to be effective then it shoulod be kept as it i and not as the bill suggests become a function of the authority as a whole. If scrutiny does become a function of the authoity as a whole it would not mprove matters it would make matters worse because you ill have less effective scrutiny. The reason for this is that in some scrutiny committees ordinary members of the public can challenge t statutory bodies and as they do not need to maintain a working relationship with them they can and sometimes do ask the most awkward questions.

      This feature of scrutiny would be lost under the current proposals

  230. Alan Kitson says:

    These are really 2 separate questions.

    Ensuring accountability for public expenditure needs to be the focus of the Secretary of State so she/he needs to have a primary responsibility to ensure that we have a comprehensive , national service and it follows from that the her/his department needs to be geared up to ensure adequate scrutiny of management decisions and public transparency in regards to expenditure

    Parliamnet also has a role to play through its public accounts committee. This is why it is important to keep ministerial responsibility for the NHS.

    The second question is about involving patients. Structures don’t involve patients, practitioners do. Reorganaising the structure is irrelevant as far as involving patients is concerned. I can go to 2 different docters in the same practice and get 2 different styles of treatment. One treats me like an adult and the other like an old dodderer. It is training, culture, attitudes towards patients that matter when trying to involve patients in their treatment.

    Getting feedback from patients on the quality of the service and thier suggestions for improvements can be done in many different ways and does not need a structural revolution to do it.

  231. Paul Haworth says:

    The Bill proposes giving commissioning decisions to unnaccountable Consortia who, unlike PCTs and SHAs, are not obliged to meet in public, admit the press or publish their accounts. Private companies brought in to deliver commissioning services, as well as private providers of services, will not be accountable and their activities will be deemed commercially sensitive and therefore not available for public scrutiny.
    We should retain the SHAs and PCTs which are publicly accountable to a democratically elected government, with mechanisms to increase input from a range of different clinicians (not just GPs), patients, carers and the community generally.

  232. Lindsey says:

    Keep the NHS in the public sector

  233. Paul Haworth says:

    On the subject of accountability.

    The Bill, if passed, will repeal the duty of the Secretary of State to provide or secure the provision of comprehensive care, and abolish the structures and mechanisms which follow from this duty. Commissioning consortia and providers (both of which may be privately owned and run) will be given freedom to:

    - charge for treatment and services which are currently free,
    - select out profitable patients and services,
    - generate and distribute surpluses (which may be created under the Bill through denial of care, and defining eligibility for care) to shareholders, investors, and employees.

    When my local GP consortium wants to charge me for a hip replacement, sell me health insurance, or refuses to provide my care because it’s too complex and expensive, who do I vote out?
    Not the NHS Comissioning Board or the board of the GP consortium, who will be completely unaccountable to me as a voter and a British citizen.

    The whole point of the NHS was that we, as a society, took responsibility for making sure we all received universal free health care by making the government, in the person of a democratically elected Secretary of State, accountable for providing it. He is divesting himself of that responsibilty and that accountability.

  234. Andrew says:

    This is all nonsense. The NHS should be accountable to people that understand health care, i.e. senior NHS medical staff, not to the public. How do you prevent corruption in commissioning? There’s only one way: keep health care within the NHS and don’t let the robber barons of the private sector near it.

  235. Carole Campbell says:

    Hear, Hear, Michael Shackleton, your post says it all. Drop these reforms now and re-think. The NHS is our most valued organisation and I sincerely want it to continue providing good healthcare. I have four children who have all needed it and it has been wonderful.

    Leave it alone.

  236. Patrick Jennings says:

    I agree – Keep the NHS in the Public Sector.

  237. Chris Mollan says:

    , I am concerned that new commissioning bodies will not be properly accountable and will not operate in a transparent way. GPs should not be able to take decisions behind closed doors, and other stakeholders including patient groups and other health professionals should also be involved.

  238. Joe Reynolds says:

    The NHS, like most modern health systems, faces huge financial pressures, and is probably bankrupt if looked at in commercial terms. Since demand is increasing, (demography, technical improvements, etc), it is critical that the decisions about how the money is spent are open to scrutiny at the time, not years later. If people do not have confidence in the processes followed by commissioners, the service will lose credibility, and will also get involved in more and more legal action over commissioning (and de-commissioning) decisions where they affect rationing and waiting-lists. The NHS cannot be drawn into the arguments about what is ‘commercial-in-confidence’ and market-sensitive, as some other ‘public’ services have been. The system also has to be fully open to scrutiny to make sure there is no scope for accusations of vested interests getting commercial advantage, and accusations about conflict of interest in decision making.

  239. Mark Bannister says:

    We can make the NHS properly accountable to the public, and make sure that patient involvement is at the heart of its decision making by keeping it entirely within the public sector.

    Why not ask the medical profession what they think? That’ll be because most of them disagree with you, right?

  240. Chris Bosley says:

    As a patient my prime concerns are with the quality of treatment and the ability of GPs to represent my interests impartially.

    I believe that my GP is currently acting on my behalf and in my best interests when referring me to a specialist for diagnosis or treatment. Under the new arrangements what assurances will I have that my GP will not allow the budgetary interests or the priorities of his consortium to influence or prevail?

    What firewalls are there going to be between the funds a consortium manages for procurement purposes and those for the administration or the consortium and CP practices? It is difficult to see how such firewalls can be effectively policed if the GP practices are providers of some of the services.

    It appears that by transferring 150 PCT’s role to 300 GP consortiums the government is replacing one tier of management with another. Is there any reason to believe that these new quangos will not acquire over time all the bureaucratic inefficiencies (branding, grandiose premises, PR officers etc) of the old ones?

    Do GPs have the information needed to refer patients? At present little is done to collect, analyse and feedback to GPs vital data on patient outcomes (the ‘end product’ of the service). Instead the NHS wastes time and money on superficial ‘customer service’ questionnaires.
    Questions of financial propriety and efficiency can be addressed by local democratic accountability and independent audit. The Bill at present seems weak on these points. Concerns about the patient centeredness of GP decisions may also be overseen by local accountability, but there should also be a simple and quick appeals procedure if patients do not think a GP or consortium has acted in their interests. In the Bill the only appeals referred to relate to contracts not to patients’ needs.

    Over recent years constant reorganisation, targets and top-down imposed systems seem to have directed the NHS management’s efforts away from the patients’ needs and more to organisational needs. The Bill also ignores the needs and interests of the patient as it is focused purely on re-structuring and contracting rather than addressing the questions of accountability and quality management directly.

    I think the listening exercise could be an opportunity to re-think from scratch, starting with patients’ interests and concluding with the changes needed to make existing structures accountable to patients and to instigate the cultural (rather than ‘structural’) revolution needed to make the service patient focused.

    A change of mindset amongst politician, civil servants, NHS managers and staff is required rather than yet another top-down imposed restructuring.

  241. sadie says:

    Hi Andrew & team,
    Please do not encourage competition within the NHS, there will be no one to price check and monitor and the contracts will be open to ANYONE with a company. There will be security breaches and protocols missed as you attempt to wedge the private sector into the very public serving NHS.
    S

  242. sadie says:

    Publish notifications to ensure decisions are made transparent to the public. You will never engage fully with patients, carers and communities if you continue with these bull headed reforms.

    The NHS budget needs to publish a tax return to show its allocations transparently for proper accountability to the public at local level, and Parliament at a national leave.

    Re-open my local hospital to ensure that the NHS at local level has the freedom it needs to take locally-based decisions.

  243. Nicole houghton says:

    Don’t get rid of NICE. They’re not perfect, but without a national body we end up with a postcode lottery.
    Don’t give the GPs the job of administering healthcare – this is an NHS manager’s job – let the doctors practice medicine and the trained managers manage. I’m sure PCTs could be improved but to abolish them is just nonsense. It will be expensive in the short term (lots of redundancy pay, reorganisation setting up costs) and in the long term will prove to be counter productive.
    The best way to ensure that patient involvement is at the heart of decision making is to listen to this consultation and scrap the proposed changes. Especially the ones about private companies involvement.
    I do think that generic patient involvement is a bit of a misnomer. Only those that have the time and inclination to get involved will, and that skews the information received from the group massively, such that it isn’t representative of the view of the general population anyway.

  244. Cathy Fowler says:

    Properly accountable? This can’t happen when profit is a driving factor? Health care should be kept in the realm of non profit – how can we trust the decisions and actions of those for whom profit is a motivating factor? Bringing in these type of organisations is the opposite of ensuring patient involvement is at the heart of NHS decision making.

    I want my GP (and other health care professionals) to concentrate on what they are trained to do, not be trying to be accountants at the same time. Let the accountants do what they are good at and the doctors do the healing.

    Proper patient choice in terms of health care means good, unbiassed information about options available – not in terms of where to go but in terms of treatment and the effects, beneficial or not on their health. More work – community and support on health promotion and information especially for people who have low access to affordable, healthy food.

  245. Alan Parker says:

    How do we “control” / monitor our GPs? We have limited choice in rural areas. Lots of words with very little substance. We still have 0844 numbers which are an expense when you are kept queuing. How will we be able to get a review over a GPs commissioning decisions? Who will control transport to various providers? Will we have a GP ombusman?

  246. Alan Parker says:

    When willl we get a system that deals with complaints in the NHS that is truly independant and easy to access?

  247. Ian says:

    GP’s must not be compromised in their relationship with their patients. They need to always be fully ‘on side’ with their patients, seeking the best for them. If they manage budgets they will be compromised as they make life and death decisions about what level of care to approve or reject in order to balance the books.

  248. Tony Hamilton says:

    Accountability to the Public.
    The public is NOT best placed to make decisions about how to manage limited resources. The public always demands more services for less taxation (that some mythical someone else should pay), which is totally unreasonable.
    The health service need to be run by dispassionate and caring professionals, who are able to make the hard decisions which are necessary in any resource limited situation. However the important word here is “CARING” we do not need obsessive accountant/managers interested only in the bottom line. We need people with the required subtle blend of financial and social awareness.
    It might make sense to involve ordinary members of the public in the appointment process, rather than confining this to the managerial class.

  249. Tony Hamilton says:

    Locally Based Decisions.
    Another largely nonsensical piece of political mumbo-jumbo correctness. What is local? – my street, my ward, my town, my county? Of course we need to manage our health service at all these different levels and sometimes one degree of locality will have to be deprived in the interests of the bigger picture.
    But again these breakdowns need to be managed appropriately. It does not make sense to organise ambulance services over such a large area that the staff do not understand the local geography. Any more than it makes sense to have British train information handled from India. Appropriateness means balancing management economies of scale with local information content.
    Again it comes back to appointing individuals who are caring and sensitive as well as financially aware.

  250. Dr Rebecca McLaren, Consultant Child Psychiatrist says:

    4. How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?

    Commissioning in its current and proposed guises is based on the premise that we have to have a purchaser provider split. Again there is little or no evidence to support this idea. If the government is truly interested in change for the good of the NHS they need to pursue other ideas for example integrated care (secondary, primary and social) and not the false god of the purchaser provider split as advocated by markets. This would be a form of integrated care based on social justice not the US Health Maintenance Organisation insurance based integrated care model.

    5. How can we best ensure that the NHS commissioning budget, held by the new NHS Commissioning Board, is allocated transparently and used with proper accountability to the public at local level, and Parliament at a national level?

    Allocate a budget based on population data from the census, local government and GP lists. GP lists are now very accurate and reflect true health need, the problem with “ghost patients” has been more or less eradicated. Make a proper allowance for areas with high population turnover (newly arrived patients tend to make higher use of the health system than settled populations) and high levels of immigrant influx. Ask for comments, advice and revision from front-line staff and publish the formulae used and the adjustment factors well before they are formally adopted. All members of the Board have to declare all their interests and to be open to challenge. Avoid political appointees.There is already disbelief at the appointment of Cynthia Bower as chief executive of the Care Quality Commission after having been one of the responsible officers (Chief Executive at the West Midlands SHA) for the Mid-Staffordshire debacle where 400 more than expected patients died. In whatever system we end up with publishing the minutes of all the meetings, documents, conflicts of interest etc will go some way to ensuring transparency. Having (true not single interest zealots) patient representatives at all levels even if only as observers in some cases would be a helpful step. However, we have to be realistic, if “transparency” becomes all important the difficult conversations will just be held elsewhere.

    6. Are we doing enough to make sure the NHS at local level has the freedom it needs to take locally-based decisions?

    We feel that this must not become an excuse for a post-code lottery. We need a good evidence-based national standard maintaining equity of care as the bedrock. There obviously needs to be some locally based decisions but we feel there is already provision for this. The problem has been excessively rigid interpretation of the rules by (usually) middle management.

  251. M CARTER says:

    having personal experience of this I would say that leaving comissioning to gps alone is a terrible mistake, my child was brain damaged before birth, the gp did notthing, it was down to me to show there were problems i e he did not want to suckle,would not grasp a finger,did not flinch or blink when one clapped hands right in front of his faceand no reflex when put down quickly. his head was very misshapen after birth with one ear at least 1inch out of line, no advice about this or possible advantages of cranial manipulation. it came down to a health visitor who acted on our concerns, and the information, we were referred, by the Health visitor directly to the local Paediatric team, which then started a raft of medical intervention and investigation, scans showing he had brain differences etc. basically if it had been left to our gp at what point would anything have happened. It came down to the brilliant Paediatrician who sat like the centre of a wheel, deciding what to do next, who contact, and surely in a situation like that the Paediatrician is more the expert than a GP anyway, much better placed to commission treatment and involvement, from the right people, the GP at the time, had no interation with the child, other than a cursory look for about 4 minutes, all fine and goodbye.
    GPs should not be comissioning, it failed in the past, plus how on earth do they have the time, or the knowledge to do so…..we get our five minutes, we hear about how the hospitals fail in care, what about the elderly lady who starves to death because the Gp told her repeatedley that she was overweight, and then did not help her to lose weight. Or the people presenting with syptoms that should have pointed to an investigation to see if the person had cancer, and they did, and it was too late! We are all human, but I think the system as it is now is better.
    Any comissioning body should be transparent, it public money, hence its accounts and actions should be available for all to see.
    How can we judge what quality of care is being received. I fear that once the GPs see the patient purely as a financial burden to his practise, profit will become the driver, we must not have any more involvement of private companies. Our NHS will cease to be, if there is too much private care, the competitions rules will come into play and the NHS will basically be destroyed.
    we should have less management, who have no medical understanding at all, panels, and comissioning bodies should have Surgeons, Consultants etc. all on board. I think that it is quite clear that there is alot of anti change amongst the professionals.
    Keep care local, if it is specialist care, that is not as often required, set up centres of excellence, where like pilots keeping their flying hours up, our surgeons etc, can keep practicising what they excel at.
    My GPs I have now are very good, they have open surgerys in the morning, they have a pharmacy on site, one has access to chiropodists etc on site, obviously not possible every where, but we are still rushed for time, with so many people to be seen.
    Private companies care for profit first and foremost….if a patients op costs 5000 to perform, and it still costs 5000 for a private company to perform, where is the profit starting to come in? All research shows that run for profit, the quality of care will decline, it is simple maths, private business does not act as a charity.

  252. The following views were submitted to NHS Stockport’s own listening exercise by staff and members of the local community:

    Locally, NHS Stockport’s GPCC Pathfinder has started to work up plans to ensure clear lines of accountability and transparency in the new organisation, including an oversight Board made up of local Practice, patient, Council, health board, hospital and public representatives.

    All GPCC should be transparent and open to the public. This should be included in the Bill, rather than leaving it up to local Consortia to arrange.

    Patients and representative groups should be represented on Boards and involved in sub-groups working on plans, to ensure that patient views are at the heart of decision making.

    Care must be taken to ensure that patient involvement casts as wide a net as possible, including all sectors of the community. Support should be given to ensure patient engagement is meaningful and representative, not tokenistic.

    Boards should also include nurses, Allied Health Professionals and Local Authority representatives. These members should have full voting rights and not just play a role of consultative representation.

    Concerns were raised about the removal of the Secretary of State for Health’s responsibility for NHS services. It was felt that rather than removing political interference, this would create a lack of accountability for the national health service.

    The Bill should be explicit about where responsibility rests if something goes wrong – with the commissioner or the provider – particularly when the provider is a small, private company.

    “Health Secretary should remain responsible for provision of a comprehensive health service.”

    “Who is liable when something goes wrong? The private provider or the NHS as the commissioner?”

    “What is the voice of the public? Every person is different and has different opinions. Often it’s the same people who let their voice be heard.”

    “How is the NHS Commissioning Board any more transparent than SHAs?”

    “Strengthen role and voice of patient representative organisations”

    “Representation of patients and their organisations in Boards and Structures supporting them”.

    “Ensure local commissioning boards fully open to public”.

    “Boards must include: nurse; AHP; Local Authority representative with a voice, not just a rep.”

    “Loss of role of Secretary of State:
    • Who will be accountable?
    • Different person for different issues?
    • Very confusing for patients
    • and local MP won’t be able to assist.”

    “The risk of a postcode lottery and widening inequalities is significant.”

    “Transparency of NHS Commissioning Board is non-existent.”

    “What support to ensure patient engagement is meaningful and representative, not tokenistic?”

    “NHS Commissioning Board is centralist in approach compared to the rest of the bill. Which is it – ‘Giant corporation’ or ‘localism’?”

    “Patients / patient representatives involved in contracting”.

    “Nolan principles. See select committee report.”

    “Require Consortium publish papers. Board meet in public.”

    “I think GP’s would listen, but how will the general public get their views across? Everyone has different priorities. Usually those that talk loudest get heard, what about the quiet people????”

    Feedback from survey of local people

    1. Would you like to have a say in how NHS money is spent?

    Yes No Don’t Know
    71% 11.6% 17.4%

    2. If you answered yes to the question above, have you ever done any of the following?

    Attended consultation events 37.0% 20
    Attended focus groups 31.5% 17
    Attended NHS workshops 38.9% 21
    Attended the Annual General Meeting (AGM) 18.5% 10
    Completed a survey 63.0% 34
    Read the PCT annual report on how local NHS money was spent 42.6% 23
    Written to the PCT 9.3% 5
    Made a complaint to the PCT about funding decisions 1.9% 1
    Other form of input / participation 29.6% 16
    None of the above 18.5% 10

    3. If you would like to take part in future engagement/consultation events please provide your contact details below

    17 people gave their contact details

    4. Do you think the local NHS listen to your views on how to prioritise spending?

    Yes No Don’t Know
    28.6% 45.7% 25.7%

    5. Do you think local GPs listen to your views?

    Yes No Don’t Know
    28.6% 52.9% 18.6%

  253. Jonathan White says:

    Please take on board my concerns about proposed changes to the NHS. I think these proposals have many fundamental flaws.

    For example, I cannot understand why the government is proposing to scrap its duty to provide a comprehensive health service. This duty has always been fundamental to the NHS, and it must be retained. The duty of care should be maintained, rather than a duty to outsource, increase profits and keep shareholders happy. The only duty for shareholders is to make a profit. Full stop. No mention of quality of care there. Self-regulation and market forces are a joke: Energy companies anyone? I believe a society can be measured by it’s treatment of the vulnerable.

    I appreciate that the Hippocratic oath has been altered within the countries where it is referred to when providing medical care. However I do not believe that it should be forgotten altogether. Health care professionals should not be checking credit card balances before patient’s pulses. My uncle, in the US, the richest country in the world can not afford to go to his doctors. I believe a society can be measured by it’s treatment of the vulnerable. Why should our NHS be run on the principle of the lowest bidder wins?

    I do believe that the patient, along with a multi-disciplinary team can provide a more holistic approach to care and therefore better than can be provided by one discipline on it’s own, such as doctors.

  254. kelly McLaughlin says:

    I’m making this submission to the NHS listening exercise because I have huge concerns about the proposed changes. I think it’s time to drop them and start again.

    For example, I am opposed to the proposal to scrap the Secretary of State’s duty to provide a comprehensive health service. This is a duty which has been fundamental to the operation of the NHS ever since its formation. It must be retained.

    “Cherry picking” by private companies must be fully ruled out, and the mechanism for preventing it must be clearly established. What happens to the provision of chronic care for people with no money??.. are people with no money always workshy slobs??.. with an aging population this is a travesty waiting to happen.

    Any new commissioning bodies should be transparent and accountable. They mustn’t be allowed to meet behind closed doors. Patients and other health professionals must be represented as well as GPs.

    The health service in the US is the worst in the world…. I don’t want to
    have a McOperation with a side of MRSA thrown in for free, to go with my McDegree and McHeart Attack. Super Size us, scrap these reforms.

  255. K Vines says:

    The general public is, on the whole, not able to make sensible decisions about the way resources are spent in the NHS or any other public service. The whole idea of the public services is that competent people are appointed to run the services on behalf of the rest of us. Those of us without any kind of medical expertise normally defer to the opinions of doctors and consultants, and I can’t see why there should be difference in the way we regard those put in charge. No organization is ever going to be perfect, so there needs to some kind of oversight to make sure things are running smoothly, but this should never become so onerous that it begins to eat significantly into the overall funding. Because people who work in the public sector are not usually in it for the money, this seems to work pretty well, provided politicians don’t keep putting their oars in. We had a decent education system when teachers ran it. Just look at the mess we have now. The trouble with senior politicians, when they return to government after a long period of absence, is that they like to be incontrol and to leave their mark on their office, and, it often seems, the bigger the mark, the better. Common sense goes out of the window and change is forced on public servants, most of whom know better than the secretary of state.

  256. PatR says:

    Being a patient doesn’t make one a patient representative.

    There seems to be dismissal of charities because they are only looking out for the concerns of their beneficiaries – but at least a representative of that charity represents all beneficiaries of that charity….

    There are quite a few people who represent me as a patient: my borough councillor, my county councillor, my MP, my MEP …. Any or all of these should be my representative.

    Or Patient Representatives should be democratically elected.

  257. Pam says:

    I’m ambivalent about localism: the downside of “local accountability” is “postcode lottery”. I don’t want my Mother’s Aricept to be suddenly withdrawn because of a local decision when her neighbour half a mile away can still get it. Nationally agreed standards have a place in the NHS. NICE eventually saw reason about Aricept – we don;t want to have to fight that battel separately in each local commissioning structure.

  258. George C.A. Talbot says:

    Well said, Tony Hamilton!

  259. Dave Waite says:

    The only way of ensuring accountability is to ensure that the NHS is run by the public sector. There is a clear chain of command from the hospital cleaner right up to the health minister. How can I trust my doctor when I know that he has one eye on practice profits.
    Private companies are accountable firstly to their shareholders, not their customers. The CEO’s of several American healthcare providers have stated that they put profit above patient numbers. If a private provider refuses to treat me because I am not profitable, who are they accountable to then?

    The NHS may have problems, eg Bristol heart surgery, but when they are uncovered the NHS has the opportunity to put them right. HBOS, Northern Rock, Railtrack, PPI mis-selling, Standard Life endowments… Where was the accountability when these went wrong? That’s not the model to follow. No more private providers in the NHS.

  260. Joel Arnstein says:

    GPs are specialized healthcare professionals. They are not managers, accountants or businessmen by training or by inclination in the majority of cases. Although their advice on commissioning services and budgets is of value, responsibility for administrating budgets compromises their prime role as advocates of each patient’s best interest. Over time this is destructive to the essential trust between patient and doctor.
    If the system is to be accountable to the public then those who appoint senior staff must be elected, ie politicians, and the politicians must accept responsibility and not try to push the responsiblity onto qangos, the ‘market’, private companies or charities.

  261. Sue says:

    As a mere patient, the arguments seem very complicated. I am concerned that GPs seem to have had difficulty this year ordering the correct amount of ‘flu vaccine, so do wonder how they are going to have time to see me when they are going to be involved in commissioning. I query if those who voted in this government actually knew they were voting for these changes? To my knowledge this government has no mandate for these proposals, which should be abandoned forthwith.

  262. Dr Charles Elliot says:

    The best person to choose my treatment is a highly trained, skilled and experienced doctor who has no other concern or motive than to see me receive the best possible treatment. Not someone with one eye on the budget and another on his bonus and another on the shareholder value and another on what perks he might get from a commercial provider competing with others to sell healthcare services. Or a doctor who is willing to work cheap because his skills and training are questionable.
    The government’s proposals see accountability as something to be bolted on try to prevent the worst effects of privatisation instead of building it in to the relationship between doctors and patients by removing financial motives from the equation completely.

  263. Vanessa says:

    The cynic in me says that the most vulnerable never have a voice, and that the free-marketeer is a most eloquent persuader. Putting ‘patient engagement at the heart of decision making’ is a cop-out, because this is about whose voice is heard, and there will be winners and losers. Many lobbies and companies already benefit from the tax-funded NHS health market, and they will continue to ensure those decisions on a self-interest basis. Localism will create even greater disparities in provision across the country.

    Bring back the humanitarian ideals of equal treatment rather than local versions of patient choice. Make the NHS accountable to this principal.

  264. J Salisbury says:

    A fully public, non-privatised NHS has the best chance of being publicly accountable. If private companies are allowed to take on sections of healthcare provision they will be looking to make profit and not to necessarily provide the best possible treatment journey.

    Services should be maintained within existing provision. They should be directed through dynamic and innovative involvement with user groups and the community- such as partnerships with local individuals, NHS employees, charities/groups and patient expert panels. Similarly to parent-governors working with schools teacher/heads to provide the best service, people outside and within the Trust should have valid input.

    Accountability can also currently be sought through the NHS through freedom of information. Complex out-sourcing contracts to Private companies may not be transparent, as the companies can claim commercial confidentiality. This would not help!

  265. Dr Trish Evans says:

    The current legal framework ensures the NHS is universal, comprehensive, free at the point of delivery and publicly accountable. This is dependent on the Secretary of State having the legal duty to provide health services in England. It is fundamental that this legal duty is not removed. This is the overarching accountability I want for my patients as a GP but also as a patient myself.
    The RCGP’s formal submissions have comprehensively represented my serious concerns about in more detail.

  266. W M Wong says:

    1. How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?

    Statutory obligation to consult on major commissioning changes eg to move a surgical contract form one provider to another. Final decision and supporting arguments to be be published.

    2. How can we best ensure that the NHS commissioning budget, held by the new NHS Commissioning Board, is allocated transparently and used with proper accountability to the public at local level, and Parliament at a national leave?

    National commissioning board decides what primary care services to commission from GPs, but Secretary of State to remain responsible and accountable for provision of a comprehensive health service.

    GP commissioning consortia to have full declarations of interest, and members of consortia, along with their families and financial associates, must be barred from tendering to provide any services they commission. Public / patients to have statutory presence on commissioning boards and to endorse commissioning corsortia annual reports, or produce their own report if dissenting.

    Published accounts for services commissioned, activity performed compared to contracts, quality of outcomes. Also to publish responses to any concerns raised by Care Quality Commission, Public Health, formal complaints, legal actions.

    Members of consortia to hold public meetings where they can be questioned about the accounts.

    Severe sanctions for those found guilty of corrupt practices.

    3. Are we doing enough to make sure the NHS at local level has the freedom it needs to take locally-based decisions?

    Local NHS services should not be free to opt out of some obligations eg to train the next generation of health workers or to provide local expensive services eg maternity care or health care for people with complex needs.

  267. Robert Reynolds says:

    The voyage is near at an end:

    Eerily quiet on the bridge. But glasses peer. Figures scurry behind.

    Out in the mist are there rocks, or just the icebergs of popular imagination?

    Suddenly, into view heaves the Marie Celeste. Her ghostly First Mate utters a cry!

    Encouragement, at last, for the ears of a listening Secretary of State.

    Follow! Follow! My Captain bids you follow!

    Even so spake the voice of New Labour last week.

    Heed not the panicky Swiss… Or the Germans!

    Nuclear Fission power… is as safe as…when our forebears thought…

    Nuclear Fusion soon would eat-up the waste… and set us free!

    And heed not the naysayers on New Labour IT! It could have worked!

    We did it for you… A boost for industry… A platform for real growth!

    The Prawn Cocktail Offensive, the Sun’s support, the price seemed small.

    Over the intercom comes Lord Warner. No longer at sea, in Consulting…

    Truly he tells, there’s a storm coming… I should know… I (muffled)…

    Short rations all? Yes… but, No! Blame the crew! Cowards on the rigging!

    Their families will thank us… when we deliver… our shareholder dividend!

    God Save Us! And allow us our sixth Sense, next time we set sail!

    Set against each other, we are played off against each other.

    Then they sold exciting Personal Pension Plans in place of the boring…

    Now they will sell the boring Stakeholder, just as inflation set to crush!

    When will we really be ‘in it together’?

    Anyone for equal shares, and solid commitment?

    How about liberation of conscience – for NHS and all?

    The issue has become… not the NHS… not even salvage of the wreck…

    But how did we steer here? How did our votes mean so much worse than little?

  268. David Mackie says:

    I don’t want commissioning consortia at all!

    I also would like NICE’s current role to remain. Evidence-based decision-making is very important.

  269. Helen Pinnock says:

    Patients like me don’t want choice – we just want the quickest and easiest possible route to the best experts and treatments available. Delivering this is the best way to be accountable to patients.

    We don’t want our GPs to be making decisions about cost, or managing our healthcare budgets; GPs should be there to refer on to the best available sources of expertise without having to worry about budget issues. Separating healthcare expertise from budget control functions is important for ensuring that the two key priorities of quality services to patients and cost effective management are fairly balanced. It is too much of a conflict of interest to combine these functions in a GP role.

    Accountability to patients would be better served by reinforcing the goverment’s role to be directly responsible for a high standard of healthcare through the NHS, and by protecting and publishing a strong budget for the NHS.

  270. Michael Meinen, GP says:

    We already have bodies in place that do commisioning, they are called Primary Care Trusts (PCTs). As public bodies, they are accountable to the public as well as to the government. Granted, I am not always happy with their decisions, but unfortunately I do not know any better how to balance the various needs and interests of the local population. So when we have people who have been doing it for a decade, why does commissioning has to change again? Why has it to be given to people who have no training, only very little experience and already a job to do? Where is the evidence that this works any better than what we have? Is it not just about keeping unpopular decisions away from the government? If so, can we abolish the health secretary along with the PCTs when the time comes?
    If commissioning is handed to GP consortia, it will be split further as there are usually more than one such consortia within the boundaries of any given PCT. This will make it more difficult to keep the decisions transparent than it is now.
    Patients will have to consider that commisioning is time consuming. Your doctor will spend a lot of time on this, which leaves less opportunity for you to discuss your problem in the surgery. Is that what you really want?
    The way the DH has set the questions and the format for answers shows clearly that this so-called ‘listening exercise’ will not change a thing. Mr Lansley seems set on breaking up and privatising the NHS, and will not budge.

  271. Liz Griffin says:

    Ensure accountability by publishing all decisions and debates online – and hold all meetings in public, encouraging the local press and BBC to attend.

  272. John Gowar says:

    Transparency, accountability and public (i.e. patient) involvement are essential at all levels of the National Health Service. They are inadequate in the present system and need to be strengthened in any changes to the management structure.

    You ask how we can be sure that commissioning decisions are made transparent and with the full engagement of patients, carers and communities. You ask how the commissioning budget can best be allocated transparently and accountably.

    The mere fact that you ask these questions implies that you don’t, at present, have answers.

    The Health Service Bill should not be allowed to progress unless and until you and we (the public) can be sure that systems and structures will result that do improve transparency, accountability and patient involvement.

    At present, Primary Care Trust Boards and Hospital Trusts are required to meet regularly in public to receive publicly available reports from their officers and managers. These bodies have appointed lay representation but this, in practice, is often perfunctory, the Boards acting as rubber stamps and not questioning the judgement of their officers or leading the formulation of policy.

    Significant variations of service provision have to be reported to local authority Health Overview and Scrutiny Panels, made up of elected councillors. Again, these meet regularly in public, their minutes and papers being open to public scrutiny. However, in my experience, these Panels are again ineffective in critical matters and allow reports containing known factual errors to be received without challenge or correction.

    In order to deal with these matters, the Bill (if a Bill is necessary) must contain explicit provision for stronger public representation on the boards of commissioning consortia and these representatives must themselves be more accountable to the patients they represent. Likewise, the body taking over the responsibilities of scrutiny should not be dominated by local councillors who are not (and indeed cannot in practice) be held accountable on a single issue. Those whom they represent must have the power to remove them from this role if they are perceived to be failing in their duties in this particular area.

    There is much opposition to the Bill for the fear that it will lead to increased privatisation of the secondary sector. What is not highlighted is that the primary sector is and always has been entirely privatised. Worse, individual private businesses are given a virtual monopoly to provide primary care in their local area. In general they are not fully accountable in that the public is not permitted to know what public funding is allocated to these private businesses for the services they provide. The Bill must ensure transparency in the allocation of funds to the commissioning consortia and in the allocation by the consortia to individual practices. It should also ensure that genuine competition for patients is encouraged. In particular, that no obstacles are placed to obstruct enterprising doctors from establishing surgeries wherever they believe they can attract patients.

  273. Dr Dorothea Kleine says:

    How can we make the NHS further accountable to the public?

    - commissioning decisions should be made as transparent as possible – use the Internet to display procurement decisions
    - If you use computer-assisted procurement systems, make sure they can handle qualitative aspects as well as quantitative aspects such as price – the cheapest offer is not always the best or most appropriate
    - Consult with key stakeholders, including patient representatives, on procurement criteria
    - any purchaser should declare conflicts of interest, including any links to private companies and third sector organizations (e.g. freebies or funded conference trips from pharmaceutical companies, directorships, board memberships, union links beyond ordinary membership etc.)
    - decentralize commissioning while not increasing the share of the private sector. Local control can be enhanced without turning healthcare into a market commodity.
    - “Give the NHS more freedom at local level” – yes, but make sure local Foundation Trusts remain accountable for the use of taxpayer’s money – they are on track to becoming so free that they become unaccountable to the public
    - increase participation of local stakeholders (esp. patients) in commissioning decisions. To ensure busy and competent people from different backgrounds can volunteer as patient representatives, pay an appropriate stipend for the time they can show to have spent preparing and attending

    • Michael Vidal says:

      While not disagreeing with Dr Kliene I would say that information should be published in forms other than on the internet. This is for the rather important reasons that a significant proportion of the population does not have internet access but might also be interested in seeing the information

  274. Sally-Ann Garrett says:

    G.P.s are not the only people who bring expertise to the commissioning of health services. They will receive value through engaging with other professional grouping including those outside of the NHS. We should trust to local good sense to pursue this approach and of local scrutiny arrangements to challenge when it is not evident. There is no reason why the GPC could not include AHPs.

  275. Gary Hughes says:

    GPs alone will not be accountable. Why invent a whole new system when we already have a democratically accountable system in place – Local Government. Hand over commissioning decisions to democratically elected Councillors who are elected by their communities.

  276. Dr S Anderson says:

    I am very concerned that the legislation proposes to remove the Secretary of State’s duty to provide a comprehensive health service. I think the duty to provide a comprehensive health service is crucial and should be retained. Dropping this duty would erode the foundations of the NHS and inevitably mean privatisation, which in turn means that some money for health care would end up as profits for private company’s rather than for its primary purpose of health care.

    Good quality healthcare should be available for all and locally. The NHS is revered worldwide. The proposals in the White paper will destroy it as a public service providing comprehensive care for all on the basis of need. Please don’t allow this to happen

    • B. Smith says:

      I agree with you and feel the Health & Social Care bill should be pulled and rewritten. My feeling there are too many problems with it and my biggest worry is that it will destroy the NHS.

  277. Louise Irvine says:

    GP commissioning consortia lack accountability. They will meet in secret and will not have to publish board papers or minutes. They are not obliged to have patient representatives on their boards but can do so if they wish. Some may choose not to or only have one token patient representative. The role of the health and wellbeing boards is just advisory, as is the role of the patient organisation called Healthwatch.

    It will be difficult to scrutinise the contracts that consortia enter into because of “commercial confidentiality”. This will make the process less transparent and less accountable.

    • B. Smith says:

      This is exactly why I feel the Health & Social Care bill should be stopped, rewritten, and then submitted to MPs for review.

  278. Alison Underwood says:

    Is struggling to understand how GP’s, commissioning and accountability fit comfortably all in the same sentence. GP’s are already highly over stressed and over worked, or so we are led to believe. With appointment slots consistently being booked up and being reduced constantly. We also already rely on GP’s to be the font of all knowledge with regards to our physical health, and now we want them to take on the additional responsibility of holding the purse strings for the services within our local community? In my opinion this could have distrous consequences. For instance, with regards to safeguarding procedures and interventions, there are alot of services who give their time and effort in supporting the safeguarding of children, unfortunately, due to their current work commitments GP’s are unable to support these interventions as much as they might like to. How, therefore, are they expected to provide commissioning to support such work? I work within the health visiting profession and it is within our public health role to assess the needs of the local community and the local service provision – surely it would make more sense to have a board of such professionals who specialise in such areas, in order to influence commissioning (Strategic Health Authorities)? Instead of wasting the vast amounts of money it must entail to change they way the NHS is formed and the commissioning process, surely it would make more sense to invest time and energy into the processes which are already present.

  279. Wendy Ross GP says:

    I think part of the way to keep the NHS accountable to the public is actually to keep the Secretary of State for Health accountable for the NHS. It is then very clear where the buck stops. By devolving the responsiblity to multiple other organisations it is much harder for anyone to be held accountable. I am a GP and note that many of the comments above address the issue of involving other health professionals in consortia, which is a fair point, but to some extent the issue is that consortia themselves are not a very accountable way of making decisions, regardless of who is on them. I think it will be very difficult for “the public” to have a meaningful voice, and under the current proposals less likely than at present, where at least PCTs have to meet in public – which consortia will not have to. I think there is little doubt that the NHS has improved greatly over recent years, with generous funding and clear standards set by NICE and also through QOF. At the very time when funding is set to stand still it seems crazy to set in motion a huge and expensive reorganisation.

  280. John Puntis says:

    The Secretary of State should continue to have a duty to provide a comprehensive health service. Delegating this to an unelected quango the National Commissioning Board and unelected GP consortia who may make their own decisions about which services should be provided is wrong. The proposed GP consortia should be responsible for providing services for a geographical area co-terminus with the local authority; include public health and hospital doctors, members of the public and local authority; meet in public and publish minutes of meetings; properly consult if changes to services are to be made; be entered into voluntarily by GPs.

    No further PCTs or SHAs .should be abolished. GPs who do not wish to join in consortia should work closely with PCTs or PCT clusters to plan services. Monitor should be abolished and hospitals regulated by the DH via the SHAs and CQC. Health and Wellbeing Boards should be given powers to monitor the proposed GP consortia

    The purchaser provider split should be abolished and collaborative working encouraged between primary, secondary and tertiary care. The NHS should be the preferred provider and should it be necessary to use private or voluntary organizations then there should be no commercial confidentiality. All transactions should be transparent and published for the taxpaying citizens to scrutinize.

  281. Angela Dunn says:

    * How can we ensure commissioning decisions are made transparent to the public, and that commissioning consortia engage fully with patients, carers and communities?

    Democratically nominated decision making committees spring to mind. Made up by a mix of a wide range of people from the medical professions whom are willing to do the research and pass on the results and also a wide range of Joe and Josephine public.

    Publish the decisions to be made on a website the public can access and in local press and allow people to contribute there opinions before the decision is made. Afterward publish the results again on a public accessible website and in local press.

    But it must be Jargon free. Most people are not going to grasp terms such as commissioning and consorta and how it works.

    * How can we best ensure that the NHS commissioning budget, held by the new NHS Commissioning Board, is allocated transparently and used with proper accountability to the public at local level, and Parliament at a national leave?

    See above. Publish the accounts yearly. Charities have to so why can it not work similar to the charity commission?

    * Are we doing enough to make sure the NHS at local level has the freedom it needs to take locally-based decisions?
    Nope, you have not made people aware that this is happening or the details of the changes let alone things such as this listening exercises.

    Ruth at the top of the page has hit the nail on the head perfectly though.

  282. Tim Cribb says:

    My GP works fine as far as commissioning goes. If s/he didn’t, then I can go to another practice. As long as I’m free to do that, then that, combined with national inspection regimes as are normal in education, should ensure GPs are kept up to standard.

  283. Dr Redwan El-khayat says:

    In my view DOH should have less control and intervention in how NHS should be run.
    We should have less politicisation of NHS. We should have more independent body,( like Bank of England setting interest rate independently) setting policies by experts, able to work on long term goals rather than the current system which is a political football. NHS employees should not be working on short goals, aiming to satisfy politicians, their primary aim is to be re-elected every 4-5 years. It is wrong for me, as NHS employee, to help politicians re-elected.
    NHS employees have been exhausted by continuous restructuring of NHS by politicians. We are diverting our energy away from care.
    Consecutive politicians thought that shaping and reshaping is the answer for NHS shortcomings. Not enough brave politicians dare to say that, as a Country, we cannot afford to have a full health cover through NHS.
    We should have slimmer NHS, more focussed. Patients visiting GPS should pay between £ 5 to 10, which will help to provide more income to NHS, and screen our unnecessary visits

    • B. Smith says:

      I disagree, by charging patients for care will start us down the path the US is facing with health care. Those who are elderly, unemployed, under-employed, and are struggling to pay their bills due to a variety of issues will forgo care in order to meet their obligations. This will lead to a two tier system and will lead to further problems whereby care becomes more expensive due to people waiting to see a GP. The best way to keep the cost of care down is by making sure people can access it when they need it and that means keeping the care free.

  284. Rob Gough says:

    Whilst I agree with the proposal to bring service delivery and development closer to the patient, or service user. It is erroneous to suggest that G.P.s by definition know their patients needs better than any one else. Some patients very rarely see their G.P.s, they actively avoid them for a variety of reasons. Furthermore, for those patients suffering from mental health problems, most G.P.s have very limited training in this major field. Certainly not the amount of training that reflects the prevalence of mental health problems in the population. Consortia could work, but the membership would need to be wider, and include those who are experienced in living with long term problems, such as mental health. There is a wealth of experience and knowledge in this field that could be very valuable to G.P. consortia.

  285. R G Mackie says:

    It is clear that the cost of the NHS should be allocated transparently and used with proper accountability to the public at local level, and Parliament at a national leave. But at the same time the service, taxed as it is nationally, should meet national standards of service. Quality of service should not be set locally; the example of NICE in setting national criteria should expanded not reduced.
    Commissioning should be based on a broad base of health professionals and not focussed on GPs. As GPs are the part of the NHS which has always been private focusing on them appears to be an ideological choice.
    Citizens need to be involved; it is too late if they are only involved when they become patients or carers. But the inclusion of citizens in commissioning is complicated. It is not clear that the participation of nominated local councillors is an effective solution.

  286. Dave Bryant says:

    We the public have a rather cosy, safe view of GPs which does a lot to sweeten the plans for the NHS into the future.

    In the real world things are slightly different. GP practices are currently small businesses and employ a large number of doctors who are not full members of the practice.

    Now what could happen to these practices in the course of time? We cosily think the reins are passed to junior ‘Dr Finlays’ such that continuity is assured. But what assurances do we have that super-practices can not arise, conglomerations of the existing smaller practices? Access to NHS funding will be a massive cash cow for these enterprises and its unclear that this will be of direct benefit to the patient.

    Control can become more concentrated into smaller group(s) of manager GPs and become de-facto the NHS. The NHS is now indirectly privatised in direct contradiction to the published aims.

    Legislation alone never seems a good way to prevent these sort of things occuring. A new industry in finding the loop holes will emerge and will take more effort and expense away from the patient.

  287. Celia says:

    Some ideas to really make providers accountable – currently my gps response to everything is I am not paid to do that – or it is not commercially viable!
    so for proper Patient involvement and public accountability
    o Outcomes based not target driven
    o Outcomes to include prevention and healthy community focus
    o Community empowerment – use models from other (resource limited) countries to motivate people to care about these services.
    o Need to make them about staying well not just about being ill and diagnosed

  288. Michael Simpkin says:

    Over the years it has been an enormous struggle to get any degree of transparency into the NHS. Things were improving – PCTs were making at least some more information available and trying to foment ‘engagement’ especially at neighbourhood level. Hospital Trusts on the other hand, especially as they neared Foundation Status, became more and more information shy. Meanwhile GP practices are mostly notorious for the poverty and inaccuracy of the information they provide. The replacement of CHCs (whatever their weaknesses) by the LINKs has been a disaster from the moment it started and there is no sign yet that Healthwatch will be any improvement. The proposed reforms will further damage accountability because they limit commissioning to a small group of professionals (for most of whom democratic accountability is at best unfamiliar and at worst a dangerous concept), they will be stuck with commercial confidentiality issues, and the information will be so fragmented that it would require an Assange to collect it together.

    I have worked with GPs in a number of settings and while a small number have the skills required, most clearly have not the skill, the time nor the motivation for this task. Furthermore the proposed set up (even if it involves more clinicians) will return the NHS to being an illness service (if it remains any sort of service at all). Commissioning a health service requires a much broader range of knowledge and expertise – some of which can, surprise surprise, be provided through local authorities especially if the new public health structure can be made to work.

    Finally to have services designed round the patient does not have to have a whole expensive panoply of formal patient involvement structures, it requires good organisational thinking informed by patient input and evaluation.

  289. Paul Hackett says:

    Governance dominated totally by GPs will produce courses of action which will reflect their frame of reference, missing opportunities for improvements. I saw a COPD pathway produced by clinicians (not just GPs) where the actions were focussed on medicines. Other more innovative care/treatments, such as telecare, were not in the model. Similarly, the clinically led Map of Medicine operates under the same paradigm – no telecare etc..

    Power should not be exclusively placed within the hands of GPs. AHPs & Nurses at least should have a formal place at the table, not just as optionally invited guests.

  290. B. Smith says:

    Time has come to stop coddling NHS senior management and hold them accountable for their decisions. If a NHS senior manager does not meet their targets or loose confidence of their staff then they should be dismissed. In senior level manager that has been dismissed for not meeting targets or loosing staff confidence should not allowed to work within the NHS in another senior NHS management role for a minimum period of two years.

    In addition, during a period when there are unprecedented cuts in the NHS and unprecedented changes being made, senior NHS managers must face the same conditions, which means their pay should be frozen with a view of cutting pay of those who make more than the Prime Minister.

    Third, I believe, local NHS budgets should be made public with the public being given the opportunity to comment on them. If a NHS Trust does not meet their budget targets then they should be made to publicly explain what has happened.

    Fourth, I believe each local Trust should be overseen by an elected board and whose meeting is open to the public. The board will be responsible for hiring senior managers, setting pay, setting targets, and approving any spending over £50,000. However, any targets would have to be set in accordance with national strategy. Without a national strategy the risk of post code lottery care increases and any change must strive for providing the same level of care throughout the UK.

  291. Martin Stanley says:

    This is a government smoke and mirrors trick.
    The government is accountable to the public and they are responsible for ensuring the NHS provide an adequate service to the country.
    The NHS should be responsive to the publics needs and their organisational executives are personally accountable for the running of their services, but the accountability to the public should always remain with the government as long as the NHS remains a public sector service.
    And at the point that the government turns all of the public sector services into private sector services will be the point we cease to need a government.

  292. Peter says:

    Re accountability.

    Who will ensure that accountability and performance monitoring is carried out without bias. The Government will want their reforms to succeed and will I suspect put pressure on any organisation monitoring outcomes to present the outcomes in the most positive light. Frankly, I do not trust the Government in this regard, any more than I would have trusted the previous administation. The Government’s links to private healthcare firms are well documented, and its own advisors have ben telling private healthcare firms that there are big profits to be made – I strongly suspect that the HGovernment will be more interested in delivering results for these companies, than acting in the public interest.
    I do not see how any failing provider will really lose a contract – the Government will not allow it, because any business failures will reflect upon the changes they introduced, which are based more on Right wing dogma than sound medical or business practice.
    Put simply, I do not trust the Government on this.

  293. Jane says:

    In my experience as an NHS Physiotherapist Commissioning has led to additional bureaucracy, and endless meetings for staff whose time would be better spent treating patients.

    Physiotherapists look at the whole person/picture when assessing and treating, I believe this approach would be beneficial when planning care, it’s not just about a fragment of what a particular condition requires but the whole care pathway and the whole person.

    I have concerns over the impact of the any willing/qualified provider model on delivering better patient care and do not feel this is the solution. I believe this would lead to a poor quality fragmented service.

  294. Mike Cooper says:

    Any reforms to the NHS must follow the key principle that decisions on all publicly funded commissioning and provision should be taken by publicly accountable and open bodies, and should be subject to local authority scrutiny.

    It is welcome that in their response to the consultation on the Health White Paper, the Government has confirmed that that health scrutiny should remain independent from the executive, and that both commissioning bodies and Health and Wellbeing Boards will be subject to scrutiny by local authority scrutiny committees.

    However for this commitment to be put into effect the current powers of health scrutiny and duties on NHS bodies need to be retained and explicitly applied to the proposed new bodies; this could be achieved most readily by the names of bodies in the current regulations etc – eg PCT – simply being changed to the give the names of the new bodies – eg GP Consortia.

    Commissioning bodies need to be subject to independent scrutiny, regardless of the composition of the boards themselves; and Health and Wellbeing Boards cannot provide that effective scrutiny – they are part of the executive function, and they themselves should be subject to independent scrutiny.

    There is a need for proper governance and transparency of commissioning consortia and of Health and Wellbeing Boards, with membership including elected councillors and representatives of local patients and the public; but regardless of who is made members of these bodies, there is still a need for separate and independent scrutiny of both commissioning consortia and Health and Wellbeing Boards, by local authority scrutiny bodies.

    It is a key strength and advantage of scrutiny that it is separate from the strategy and commissioning decisions, and is not responsible for taking the decisions or the delivery of services, so it does not need to be defensive of those decisions, and it does not have cover everything, but can focus on what it thinks is important for its local community.

    Health scrutiny’s power of referral to the Secretary of State needs to be retained as a power of the health scrutiny committee, not having to refer via the Council; and the power of referral should not be restricted by making it only apply to ‘designated services’, but should also be available for other services where the scrutiny committee believes that there will be a significant impact on the local community. This is an important and symbolic way in which scrutiny retains its independence from the local authority executive and retains a strong relationship with the NHS.

    I think that strategy, as proposed for Health and Wellbeing Boards, commissioning as proposed for commissioning consortia, scrutiny by local authority scrutiny committees, and engagement with the community through HealthWatch are all valid and distinct roles, and it is helpful to have different bodies with different members and perspectives undertaking them.

    The Health and Wellbeing Board does have an important and distinct role, in taking an overview across both health and social care, agreeing joint policies and strategies, integrating health and social care and raising the profile of public health; and in ensuring that commissioners are following the agreed assessments of needs and strategies.

    Health and Wellbeing Boards are in the direct line of executive accountability; they are distinct from and additional to the ‘parallel’ role of independent scrutiny and their role is not to provide ‘scrutiny’ of commissioning bodies. Health and Wellbeing Boards require some real power to ensure that commissioners do follow the agreed strategies, and that primarily policies and strategies are agreed, and disputes resolved, locally.

    I agree with the suggestion that Health and Wellbeing Boards should follow the local authority model, with ‘members’ of the Boards being appointed representatives of the decision-makers of the commissioning body(ies) and local (executive) Councillors; and officers of the council and commissioning professionals should act as officer support to the Board and not be ‘members’.

    The boards of commissioning bodies should have non-executive members, like PCTs have, and these should include elected councilors, but elected councillors need not make up the majority; and they should also have representatives of other health professions, not just GPs.

    There is concern about how Health and Wellbeing Boards will work with Commissioning Consortia that cross local authority / Health and Wellbeing Board boundaries, and in particular how commissioning consortia that cross boundaries will be held accountable for following the agreed strategies of different Health and Wellbeing Boards. It would be preferable if commissioning bodies / boards matched local authority areas.

    Distinctive engagement of patients and the public needs to take place at each level. And the simplistic approach of having a few councillors and a representative of HealthWatch as members of a board does not fully address the issue.

    The role of HealthWatch on behalf of the wider community, and in particular in commissioning and strategy, does not remove the need for individual commissioners and providers to establish effective engagement mechanisms, like ppi forums, that can inform decisions and service provision, and be a more effective way for those interested in particular services and for patients and carers groups to become involved.

    Further, by being a ‘member’ of the board a councilor or rep of HealthWatch may be compromised, by their duty as a ‘member’ to act in the interests of the board/body, or perceived to be compromised or complicit in the board’s final decision, and therefore unable to act in the interests of their constituents or of HealthWatch. The experience of some scrutiny committees and LINks is that they are better served retaining their independence by having access to papers and a ‘place at the table’ without being a ‘member’, being able more effectively to scrutinise and make representations to the board from ‘outside’.

  295. Genevieve Smyth says:

    I am not convinced that “hard to reach” groups such as people with learning disabilities or dementia will be included in local commissioning decisions. Accountability will be reduced with over reliance on afew professional groups for decision making. We should have Allied Health Professional representation at all levels of commissioining and providing. At a national level there is apotential to use “Clinical Cabinets” to ensure all voices can contribute to decision making. I think that the proposed changes to Monitors role to promoting competition rather than focus on patient care or value for money will lead to less accountability particularly at alocal level.

  296. Primary Care Trust Information Manager says:

    GPs have already commented on the conflict they may encounter when reconciling their professional role as the patient’s advocate with their commissioning role in this future model. The concept of ‘no decision about me without me’ will be watered down as not all GPs will be active members of the consortia and so some GPs will be able to turn to their patients and say that it was the consortia that makes the commissioning decisions, not themselves. In addition, the underlying philosophy that GPs know their patients has to be questioned. In any one practice a significant percentage of patients will not have had any interaction at all with their practice as they have no reason to visit the surgery. These ‘inactive’ patients will pretty much encompass the majority of registered patients over the age of 5 up to middle age. Hence most GPs will really only ‘know’ patients at either end of the age ranges. This calls into question the basic premise that GPs know their responsible populations.

  297. B Thornton says:

    The proposal to give GPs the main responsibility for commissioning services is misguided. GPs do an excellent job in making a first diagnosis, treating what is within their circle of influence, and referring to hospital or to other specialists the more complex cases. It is unrealistic to expect these GPs, who are already working extremely hard to carry out their valuable service, to become cutting edge experts in EVERY field they might wish to refer a patient on to.

    I am also concerned about the degree to which GP commissioning could lead to a ‘postcode lottery’. GPs can place different values on services such as physiotherapy and occupational therapy, counselling services, dementia care etc. We could end up with a system whereby a patient can get the healthcare they need in one area, but a patient a few miles down the road cannot. Even within a single practice, there are clear differences as to how each GP treats a patient; I would not like to see this magnified on a national scale.

  298. J Foster says:

    Any willing provider who is a private company will be ultimately accountable only to its shareholders.

  299. Neville Farmer says:

    GPs have never been adequately consulted on the structure of healthcare provision but that is not a reason to swing totally the other way. GPs themselves largely do not want that burden and the argument that many of them have endorsed the proposed bill by signing up to consortia is derisory. They have little choice, so they’re getting prepared, regardless of their personal opinion of the policy. This is more than evident from the BMA’s reaction to the bill.

    The biggest concern with the GP consortia issue is that we’ve learned nothing from previous privatisations (remember GPs are largely private businesses). If a consortium is offered sufficient “incentive” to be swallowed up by a slick and helpful corporate business such as, say, United Health, why wouldn’t it?

    If that happens again and again, as it undoubtedly will, we may end up with the business of health commissioning being left in entirely corporate hands. Government has already fallen foul of the “too big to fail” issue with the banks. The lobbying power of these huge companies drowns out the cries of the populace and to pretend otherwise is naive.

    Once this has happened, it will be impossible to reverse without great cost – as we discovered with the shambolic railways privatisation.
    Yes, let’s devolve commissioning powers but it would be far better to combine GP’s, hospital clinicians, care services, publicly elected boards and councils to create a truly accountable commissioning system.

  300. Mencap is one of the signatories to the ‘Listen Up’ statement, together with 39 other charities and coalitions representing patients, calling for significant changes to the Health and Social Care Bill. Mencap and the other signatories believe that while it is tempting to purely focus on issues of competition and structure the new NHS must truly put patients at its heart. Our view is that in key areas, such as GP consortia, data collection and local Healthwatch, this is currently not the reality- particularly for disabled patients or those in hard to reach groups. The Listen Up statement is in Appendix A.

    The body of this response builds on Appendix A and focuses on the issues of substantive concern to people with a learning disability. People with a learning disability continue to face substantial attitudinal, access and practice discrimination that lead to worse health outcomes and premature death. While progress has been made, the changes inherent in the bill hold significant risks for this group. Mencap’s view is that if the NHS can get it right for people with a learning disability, who often have the most complex needs, it is very likely that the NHS will improve for all.

    1) Changes Mencap would like to see on Health and Social Care Bill

    From the outset, Mencap has accepted the general direction of travel in the Bill and has been keen to ensure that new NHS structures are constructed in the fashion that best delivers improved health outcomes for people with a disability. This must include those with a learning disability without prejudice to other groups.

    Mencap were pleased to be asked to join the NHS Future Forum and have used this as an opportunity to both make points of wider significance and advance the learning disability perspective.

    Mencap believes this bill presents a number of opportunities to improve the healthcare offered to people with a disability, including the focus that comes from the NHS Outcomes Framework, the arrival of Healthwatch (both England and Local), NICE quality standards and the roles and duties of the NHS Commissioning Board and the GP Consortia. Mencap believe however that certain key changes must be made, if health outcomes are genuinely to improve for all, including those with a learning disability.

    a) All new NHS structures must have a duty to tackle discrimination and improve health outcomes for all people

    People with a learning disability still experience worse healthcare and get worse outcomes than the general population, being at disproportionate risk of premature death, epilepsy and mental health problems. Public health issues, such as obesity and smoking also disproportionately affect this group. Yet, despite improved clinical care (often driven by very some impressive individual staff and units) it is still the case that people with a learning disability are 58x more likely to die before their 50th birthday than the general population.

    Mencap believes that the redrafted Health and Social Care Bill must place explicit duties on all bodies within the new NHS structure to tackle discrimination and improve health outcomes for all patients, not just those that are easiest to reach. Without this, people with a learning disability will continue to be disproportionately affected by poor health.

    Without this, it would be perfectly possible for outcomes to improve but for inequalities to worsen, further leaving behind those who need the NHS most.

    b) For all health professionals and bodies to reinforce the duty to make reasonable adjustments in the way they deliver care

    Making reasonable adjustments makes good clinical sense for healthcare professionals, as well as having clear basis in law (Disability Discrimination Act, Equality Act) and the upholding of an individual’s right to dignity and life (supported by the Human Rights Act).

    Unfortunately despite this clear legal position, and the fact that getting it right first time will likely lead to better outcomes, people with a learning disability continue to die and to experience worse health outcomes. One part where patients with a learning disability have often told Mencap they feel short changed is at the GP surgery.

    In June 2010, Mencap surveyed over 1000 healthcare professionals. This revealed that:

    • Almost half of doctors (46%) and a third of nurses (37%) said that people with a learning disability received a poorer standard of healthcare than the rest of the population.
    • Nearly four out of ten doctors (39%) and a third of nurses (34%) said that people with a learning disability were discriminated against in the NHS.

    One such area where discrimination could easily continue is in the proposal that patients will be able to choose their GP. For families of a patient who may have profound physical and learning disabilities, which many GPs may not know how to deal with, the thought that there will be other GPs keen to take this patient on to their books is illusory. This would equally apply to patients whose behaviour may challenge services.

    The GPs, the consortia and the NHS Commissioning Board must be made aware that they may not discriminate, and the Bill should consider a mixture of guidance and annual audit, including engaging carers, to ensure that this problem is monitored and changes can be gradually effected.

    In the primary care setting, a key reasonable adjustment that can help build understanding and tackle underlying health conditions among people with a learning disability is the annual health check. This is offered by some GPs and is currently funded under the Direct Enhanced Scheme (DES) payment.

    Evidence from Australia has shown that the use of a health check with people with a learning disability led to a 6.6-fold increase in detection of vision impairment, inter alia. The use of annual health checks has also been reported to deliver positive gains in health outcomes over a 12-month period.

    In England, during 2008/09, only 41% of those eligible had a health check – this has meant that nearly 6/10 people are not getting a service that could be extremely helpful in realising the preventative health agenda.

    Mencap believes that GP Commissioners and the NHS
    Commissioning Board need to be given explicit guidance from the outset as to the legal necessity, in all clinical specialties, of making reasonable adjustments to include people with a learning disability. This should permeate training. Mencap would also like to see the Annual Health Check rolled in as part of the Standard GP contract, if, as expected, the DES payment ends at the end of 2012.

    c) GPs as commissioners

    The commissioning of services for people with Profound and Multiple Learning Disabilities (PMLD) by Primary Care Trusts (PCTs) has been patchy and it is questionable whether commissioning led by GP consortia will lead to improvements.

    In parts of the country, trials have been offered around the provision of personal health budgets, often pooled between local authority and health budgets.

    Mencap believes that the piloting of personal health budgets could bring a new era of choice and control for people with PMLD and their families, as it is rolled out. Mencap fully supports the trial of personal budgets and would like to see them extended to all who need them, with no upper limit on the amount that can be spent on packages.
    The Raising our Sights report (Department of Health, 2010) showed that for patients with the most complex needs joined up planning is essential if people are to live longer and healthier lives. This joined up planning needs to span both health and social care.

    Given the planned changes to commissioning, Mencap believes that there is a real risk of fragmentation and the possibility of a triple discrimination. A triple discrimination could occur if GPs fail to make reasonable adjustments in their work (see polling above). This could then be compounded as patients with a learning disability go into hospital—where they have often died prematurely and avoidably. If commissioning is then done by consortia of GP, without the right training, people with a learning disability may not be fully considered when designing services.

    When the comparatively high cost of the care packages given to people with PMLD are considered it is conceivable to see how GP consortia could, if not sufficiently overseen, make a purely financial consideration about the worth of a person with a learning disability – a consideration that Mencap would wholeheartedly oppose.

    Mencap would therefore like the commissioning of the high cost packages for those with PMLD to sit within the remit of the NHS Commissioning Board. If it is not possible for the commissioning of services for those with PMLD to sit within the remit of the NHS Commissioning Board, an alternative could be for the Board to have a duty to reassure itself that either the GP Consortia (or sub-regional) level commissioners are delivering health outcome improvements for people with PMLD, annually. Such oversight work should also include people with challenging behaviour or other complex needs, who may also need substantial packages of support.

    d) Ensuring all information from all new NHS bodies is fully accessible
    People with a learning disability, people with communication difficulties, older people, people with visual impairments and those with hearing difficulties are often more frequent users of NHS services than other groups. Given the Equalities Act stricture to ensure that public bodies must ensure that there is no “substantial discrimination”, it is vital that the workings of NHS Commissioning Board (along with all the other parts of the new NHS structure) be fully accessible to all these patients. Mencap would seek reassurances as to how these bodies will ensure that their decision making and communication processes are fully accessible to anyone who may struggle to communicate.

    e) A disability data plan should be pulled together to understand the health experience of people with a disability and so prevent premature death.

    People with a learning disability continue to die prematurely and avoidably, as the cluster of deaths at Royal Berkshire and Basildon and Thurrock NHS Trusts have attested. It is vital that data on the safety of services is made available to the widest constituency, in order to drive patient choice and patient safety and ensure that there is no hiding place for substandard performance.

    Without the breakdown of this data, by impairment type, age, condition and location of admission it is not obvious to see how the system will prevent a repeat of these clusters of deaths of people with a learning disability.

    Mencap believes this must be an urgent priority for the bill and associated guidance and is pleased that the Department of Health has instigated the Outcomes Framework competition, including a call for new indicators on Learning Disability. One such indicator that could be included would be an indicator on the premature deaths of people with a learning disability.

    Though helpful, this in and of itself, will not be enough to tackle the problem of a lack of data collection around both the number of people with a learning disability and their health experiences.

    Mencap have long lobbied for the creation of a Confidential Inquiry into learning disability deaths and were delighted when a three year contract was awarded for both this and the creation of a Public Health Observatory.

    The Confidential Inquiry is looking to understand why people with a learning disability continue to die prematurely and the Observatory at what interventions work to promote better health outcomes and prevent premature deaths.

    Both the Inquiry and Observatory provide invaluable data on the health experiences (often negative) of some people with a learning disability, which could answer some, but not all, of this question. This must be supplemented by other forms of data, and a comprehensive action plan on disability data be pulled together, as currently much of this data is fragmented.

    The aim of such a plan would be to ready and pull together all these diverse sources into a more cohesive whole ready for future inclusion in the NHS outcomes framework and to inform the commissioning plans of both the board and consortia. Data sources to be pulled together could include, but should not be limited to:

    • Local Learning Disability Registers
    • Data from the Confidential Inquiry and Public Health Observatory
    • Data on the take up of the Annual Health Check
    • for all health outcomes, across the NHS, to broken down by disability/impairment type as well as age

    f) Complaints advocacy must be provided for as long as needed
    The proposal for local Healthwatch to support people with complaints, through the provision of advocacy needs some key tweaks if it is to truly be a champion for patients.

    Mencap has supported a large number of families through the NHS complaints system, through both the local and ombudsman stage. Going through these stages can take many years. Mencap is aware of many cases where the complaints process has taken more than two years.

    With local HealthWatch either providing or commissioning advocacy support it is crucial that it should be extended for as long as it is needed. Starting and then stopping advocacy support to families could be deeply upsetting to these families and could also contribute to lessons not being learnt, particularly around patient safety.

    What Mencap wants from the Bill
    • An explicit duty on all NHS bodies to tackle discrimination for all patients, in addition to improving outcomes for all patients
    • For there to be clarity on how the need for reasonable adjustments will reiterated and reinforced for all healthcare professionals
    • For NICE to produce quality standards on learning disability
    • For the inclusion of the annual health check as part of standard GP contract, post 2012
    • For Health & Wellbeing boards to have to include expertise on learning disability/PMLD
    • Support for provision of personal budgets and their rollout across England and Wales.
    • For the NHS commissioning board to commission the high cost support packages for people with Profound and Multiple Learning Disabilities (PMLD) or, as an alternative, to reassure itself annually that services being delivered are delivering improvements in health outcomes to all
    • Need for collection of data on all health outcomes, broken down by impairment type
    • Ensuring all new NHS structures (Commissioning Board, Consortia, Healthwatch England and local as well as Health and Wellbeing Boards) have a duty to fully engage with all disabled people
    • Ensuring that complaints advocacy Local Healthwatch is for as long as is needed.

    For further information, please contact – Patrick.olszowski@mencap.org.uk – 0207 6965465

    Appendix A – Listen up
    (joint charity statement on Health and Social Care Bill)

    “Listen up” – charity statement

    This is a time of great uncertainty in the NHS. This uncertainty does not help anyone.

    The Government’s ‘Listening Exercise’ is therefore to be welcomed.

    The Department of Health needs to use this time to substantially improve the Health and Social Care Bill. -

    Although the upheaval in NHS is a considerable challenge to all of those involved in health and social care, it is also an opportunity to address long standing inequalities.

    Currently, the Health & Social Care Bill does not live up to the aspirations set out in the Government’s White Paper.

    In order to put patients at the heart of the NHS, improve health outcomes for all and empower clinicians, we believe the Government must:

    1) Ensure GP Consortia effectively engage with all patients and put them at the heart of their plans
    2) Improve integration across health and social care by strengthening the role of health and wellbeing boards and the NHS Commissioning Board
    3) Create a Healthwatch that is independent, well-resourced, transparent and able to act as an advocate for all patients
    4) Include measurements for outcomes of the most vulnerable
    5) Ensure children’s services are embedded in health and social care
    6) Improve access to specialised services for those with complex needs

    Signed by Mencap, Patients Association and National Autistic Society, as well as :
    Action Against Allergy
    Alzheimer’s Society
    The Anaphylaxis Campaign
    Arthritis Care
    The British Liver Trust
    British Red Cross
    The College of Optometrists
    Crohn’s and Colitis UK
    Every Disabled Child Matters
    Friends, Families and Travellers
    Guide Dogs
    The Lindsay Leg Club Foundation
    Learning Disability Coalition
    Lupus UK
    Macular Disease Society
    The Meningitis Trust
    The Mental Health Foundation
    Migraine Action
    The Migraine Trust
    Mind
    Muscular Dystrophy Campaign
    National Forum of People with Learning Disabilities
    National Rheumatoid Arthritis Society
    Organisation for the Understanding of Cluster Headache
    Ostomy Lifestyle
    Parkinson’s UK
    Pelvic Pain Support Network
    Primary Immunodeficiency Association
    RNIB
    RNID
    Royal College of General Practitioners (Learning Disability group)
    Scope
    SeeAbility
    Specialised Healthcare Alliance
    Thyroid UK
    United Response
    WellChild

    Detailed policy information on Listen Up statement

    • Ensure GP Consortia effectively engage with all patients and put them at the heart of their plans

    The Government has stated that there should be ‘no decision about me without me’ with regard to NHS treatment and services. We support this goal.

    Patient and public involvement has a long history of confusion and poor implementation in the NHS. Since the publication of The World Class Commissioning Framework, however, this was beginning to change.

    We believe that the current proposes do not do enough to guarantee that patients will be involved in all aspects of their care, most importantly in the commissioning process.

    The Health and Social Care Bill plans to introduce greater information and choice for patients in terms of their own individual treatment, and give commissioning powers to new GP Commissioning Consortia.

    We are yet to be convinced that the Government’s plans will improve patient involvement and support the Health Select Committee in their conclusion that it would not be “over-prescriptive” to require local commissioning bodies to adopt governance structures which meet basic standards of good governance.

    Our goal is to see GP Commissioning Consortia be proactive in seeking out the views and experiences of the public, patients, their carers and other stakeholders, especially those least able to act as advocates for themselves.

    Central to this would be the requirement for a GP commissioning consortia to include lay membership of non-Executive Directors on a board comprised broad range of clinical and non-clinical members. This would ensure that objective and independent voices are represented on consortia governance structures

    • Improve integration across health and social care by strengthening the role of health and wellbeing boards and the NHS Commissioning Board

    Integrated health and social care offers three benefits: better outcomes for service users and patients; making limited resources go further; improving people’s experience of health, care and support. These have been policy aspirations for more than 40 years, but patchy progress and a transformed policy and financial climate demand news way of achieving them.

    We do not question the Government’s commitment to improving integration between health and social care.

    The uncertainty around the NHS reforms, however, is putting a number of important projects at risk. Also, with the demise of the co-terminosity between local authorities and the NHS in some areas, we believe the Government’s plans needs to be strengthened to ensure that more, and not less, joint working takes place.

    One of the best ways to ensure integrated working continues is to ensure pooled budgets are retained and developed.

    To do this, it is important to strengthen the role of Health and Wellbeing Boards to make sure that where there are a number of consortia operating in the area the incentive for GP Commissioning Consortia is not to ‘free ride’ and not contribute to joint projects.

    Furthermore, it is essential that a key role of the NHS Commissioning Board must be to encourage the integration between health and social care and act as an arbiter if disputes emerge.

    • Create a Healthwatch that is independent, well-resourced, transparent and able to act as an advocate for all patients

    Patients, service users and the public need a capable, strong and trusted body to offer help and advice in every area. No such body has ever existed.

    The Government’s vision for HealthWatch being an independent consumer champion that will help the public and patients influence decision makers, signpost people to support, offer information and provide advocacy is ambitious. Even with the support of a national body – HealthWatch England – this is a daunting task.

    In order to live up to the Government’s ambition, HealthWatch must be independent, well-resourced, transparent and able to act as an advocate for all patients.

    Currently the Government’s plans lack clarity, with questions being raised about the independence of HealthWatch from the Care Quality Commission, how and how well Local HealthWatch will be funded, the openness of HealthWatch if it is not subject to Freedom of Information requests and its ability to advocate for patients and service users in the complex world of health and social care.

    There is no silver bullet that will instantly create an organisation that lives up to the Government’s laudable goal. Nevertheless, more work is needed to ensure that the HealthWatch turns into the institution we all want it to be.

    • Include measurements for outcomes of the most vulnerable

    Judging the outcomes of patients is an important step towards monitoring quality, improving accountability both locally and nationally, and benchmark NHS performance.

    The needs and outcomes of vulnerable people of different ages are very different from the general population and the Government’s Outcomes Framework fails to recognise this.

    We are aware that the Government has recognised this problem:

    “The Government is aware that current data and data collections cannot adequately identify certain groups at present…As the framework evolves over time, outcome indicators will be refined with a view to being able to more fully measure and record health outcomes for all groups wherever it makes sense to do so.”

    We welcome this recognition but believe that work needs to be done sooner rather than later to ensure that vulnerable groups are not left behind and the outcomes in general do not overshadow outcomes of vulnerable people of all ages.

    • Ensure children’s services are embedded in health and social care

    Services for children are distinct from those for adults. The Government wants children and young people and their families to be at the heart of everything that they do.

    Currently this is not the case, not least because the Government’s ambition of improving integration across services does not marry up with their education reforms.

    Professor Sir Ian Kennedy’s report ‘Getting it right for children and young people: Overcoming cultural barriers in the NHS so as to meet their needs’ concluded that services for children and young people could be made significantly better and that work was needed to make sure services for children are unified and co-ordinated at a local and national level.

    There is a clear need for close collaboration between professionals in health, social care and education to ensure that children, especially those with long-term or serious health needs, do not lose out.

    We believe that more work is needed to guarantee that services for children and young people continue to improve following the NHS reforms and that a closer examination is needed of how the Health and Social Care Bill meets the recommendations set out in the Kennedy Review.

    • Improve access to specialist services for those with complex needs

    Commissioning services for people with complex needs of all ages, disabilities or backgrounds has always been a challenge. This challenge has rarely been helped by the repeated reorganisations of the NHS.

    The Government’s goal of placing GP’s at the heart of the commissioning process is a considerable risk at a time of tightening budgets and increased demand for services. Although, as with other reorganisations, there is an opportunity improve the commissioning of services for people too often left behind.

    To do this, however, the Government must be clearer on which services will be commissioned by the NHS Commissioning Board and which will be commissioned by GP Commissioning Consortia.

    It is of great concern that GPs, who will often have very little experience of dealing with patients with rare or complex needs, will be asked to commission intricate and expensive services in a competitive market.

    Clear guidance, advice and support is needed if this is going to work and this work needs to be undertaken urgently.

    Appendix B – About Mencap
    Mencap supports the 1.5 million people with a learning disability in the UK and their families and carers. Mencap fights to change laws and improve services and access to education, employment and leisure facilities, supporting thousands of people with a learning disability to live their lives the way they want. We are also one of the largest providers of services, information and advice for people with a learning disability across England, Northern Ireland and Wales. See http://www.mencap.org.uk for more information.

    About learning disability
    A learning disability is caused by the way the brain develops before, during or shortly after birth. It is always lifelong and affects someone’s intellectual and social development. It used to be called mental handicap but this term is outdated and offensive. Learning disability is NOT a mental illness. The term learning difficulty is often incorrectly used interchangeably with learning disability.

    Mencap’s interest in health
    • Mencap have a long standing interest in the health of people with a learning disability
    • Research has shown that people with a learning disability still experience worse health outcomes and health inequalities than the general population
    • Mencap’s Death By Indifference report (2007) highlighted the 6 premature, avoidable deaths of people with a learning disability in the NHS
    • These shocking deaths led to a government ordered independent inquiry (Sir Jonathan Michael/Healthcare for all) as well as an investigation by the Health Service Ombudsman (6 Lives report)
    • Since these reports, progress has been made within the NHS, but performance is patchy
    • A recent progress update to the Ombudsman (the 6 Lives Progress Report, DH, 2010) showed that concerns remain around poor use of mental capacity legislation and lack of health services being reasonably adjusted
    • With the changes proposed in the bill, the challenge is to make sure that progress in driving better health outcomes for people with a learning disability is not lost
    • Mencap leads the Getting it Right campaign, which is a coalition of charities and Royal Colleges working together to realise better health outcomes for all disabled people (including those with learning disability), collaborating on this bill.

  301. P R Jardine says:

    In what way is the NHS currently not accountable? It is accountable through the minister — as it should be.
    Turning it over to consortia who outsource to corporate services or American healthcare companies as you envision doing will reduce accountability as these corporate entities hide behind contracts citing commercial sensititives.
    My experience with American style healthcare is that there is less not more accountability – patients make do with whatever level of service their insurance company is prepared to pay for and have little choice about it.
    The only way to ensure that the NHS remains accountable is to retain the health minister’s DUTY to provide healthcare and to ensure that the NHS remains a public service, not a kite mark behind which corporate bodies enrich themselves at the expense of taxpayers health.

  302. David Rodgers says:

    People close to the current administration have already let the cat out of the bag that there are huge profits to be made out of these reforms, therefore the involvement of “any willing provider”, i.e. private companies, gives me no confidence that any “accountability” will be transparent in any form. The whole Bill should be withdrawn and looked at afresh by stakeholders who believe in the philosophy of the NHS, not just the economics

  303. Leigh Boyton says:

    It is important GP Consortia hold regular meetings with local people to explain what they want to do, and take the views of local people into account fully and well, before they commit themselves. They should also take advice from providers, including Voluntary,Community and Faith sector groups, Public Health Professionals and Healthwatch groups before decisions are made.

    The money should stay with the PCT’s, as they already have all the controls needed, and they should commission the services on behalf of the GP Consortia.

  304. Linda Waters says:

    Accountability is meaningless unless we have a NATIONAL health SERVICE. Unless the duty of care to every citizen remains we will only be left with health, no SERVICE and it will not be NATIONAL.

    The duty of care must be kept or all other discussion is pointless.
    Other discussion is a smokescreen to cover the removal of the duty of care. This must not happen.

    Accountability is however the way to protect our NHS from the private health providers. Patients must remain at the heart of the NHS and to that end we need patient representatives to whom the health service must be accountable.

  305. Iain Stokes says:

    The accountability of the NHS should not be diluted.
    Multiple private profit bound companies would strive to deprive the public purse of direct oversight with shadow accounting.

    Public Health Assurance is the primary contract of Governance.
    Education, Defence and Infrastructure Planning are parallel secondary contracts for taxation.

    There should not be Public Taxation to Public Service profit, only Surplus Investiture. Providing ‘illness prevention’ and ‘health care’ by civil governance is a pole position service that places tactical marine warhead boats and private profit subsidisation as sub-ordinates.

    The Publicly Funded Hippocratic Oath is not a usury.

  306. Neil Barrett says:

    “You are posting comments too quickly – slow down” it says to me as I leave my first ever comment here. Poor listening skills!

    As I am sure has already been said before:

    * The NHS is not just a brand. Under current legislation, the Health Minister has a responsibility to the people to provide for their health needs. Dilute this in any way, and the walls come crashing down (as I’m sure you will know)
    * NICE provide the framework under which the government, the patients, the commissioners and the providers interact to create the NHS as we see it. Yes, affordability of services is a problem. Abolishing NICE (or whatever it is you are planning to do with it – I can’t work it out) is not going to help. Instead, it will have the effect of destabilising the NHS, and putting too much strain on the clinicians and their relationship with the patient.
    * ‘Any willing provider’ means every member of staff in the NHS will lose their pension rights within 5 years (what’s to stop the commissioners choosing a provider who does not have to pay these contributions – answer – nothing at all).
    * By changing the NHS from the top down (by tampering with commissioning and deleting NICE) and the bottom up (by forcing every provider to become a foundation trust / social enterprise) at the same time, you are making the NHS unrecognisable and totally unstable with a single hit.

    My conclusion – make the NHS unstable, and patients will get a patchy service. Which, I presume, is exactly what you are trying to do.

  307. Chris Essery says:

    I also don’t see the need for replacing the existing PCTs with an even larger number of GP consortia – how can increasing the number of bureaucratic bodies cost any less? Just a waste of already limited resources on an untried, unpiloted re-organisation

  308. ruth marsden says:

    Healthwatch – if properly funded, and made truly independent , will provide that most essential assurance of services’ quality and safety – or lack of!
    CQC cannot possibly get round to all health and adult social care providers with the frequency and commitment that LINks/LHW can offer. LHW will be made up of local people who depend upon the services in their area, hence are wholly motivated to monitor those services and head off another Staffs.

  309. JohnM says:

    GPs are often great, sometimes terrible and always too expensive to spend a substantial proportion of their time sitting in meetings about budgets and administration. One of our most expensive resources removed from the front line for an unknown quantity of time each week to take on a role that they have not been trained for.
    Everyone agrees that the NHS needs to continue to improve and most of us agree that there are lots of expensive posts that could be eliminated with some well thought through reform and restructuring. The plans at the moment seem to be scooping away a layer of ‘management’ without giving enough thought to what or who will replace the people and the roles that they engage in.
    These ideas are not evidence based. The Government have not conducted any detailed research or pilots. They are rushing in without giving thought or supplying details to guide competition and cooperation between NHS Trusts and private & voluntary sector organisations.
    There is a significant amount of evidence indicating that GPs are poorly trained in relation to mental health difficulties. What is going to happen to service users who experience serious mental health difficulties in each locality?
    The Government’s lack of enthuasism for supporting people with more severe mental health difficulties coupled with the excessive influence of pharmaceutical companies on Government policy and NHS practice fills me with dread about the coming changes.
    I hear politicians talk about putting service users and carers at the heart of decision making. How about we put them in the head and open these consortia up to include an even representation of service users, ‘carers’, physical/mental health professionals, finance experts, administration staff, elected representatives etc etc……..
    As much as the last government were wasteful and opened the door to privatisation slightly, this new Government are about to take the door off its hinges.

  310. Hildegard says:

    The single most objectionable part of the White Paper is that Mr Lansley proposes to absolve himself of the statutory duty to provide medical care free at the point of delivery to all citizens.

    The introduction of increasing “commercial confidentiality”, the loss of statutory obligation, the pursuit of profit for private providers, proposals to wind up public statisitical work that will enable us to asses the effectiveness of Mr Lanlsey’s proposals & the publics attitude to the, allied to the absence of accountability within the Lanlsey health model, will be a disaster for the NHS. The NHS itself will be nothing but a logo.

    Outcomes & patient satisfaction rates within the NHS have been improving steadily for some years. On present form, we will soon outperform France & Germany in many key areas, yet Mr Lansley has consistently used out-of-date, & misleading figures to support his case.

    The Colaition partners have been dishonest about their plans for the NHS & dishonest in seeking support from the public. I cannot support dishonesty, nor do I think it a good basis on which to provide medical care.

  311. Michael Vidal says:

    I am sure it is in there somewhere in the 400+ pages of the bill but I can not immediately find it. But who will be responsible for the other things the PCT does apart from commissioning. For instance there is in every PCT an Accountable Officer who has to make an annual report on the handling of controlled drugs who will take on this work. Also who will I complain to if I have a problem with my GP or Hospita?l

  312. tim says:

    What is commissioning? It is an attempt to deliver maximum health benefit for a finite financial resource.All previous attempts have failed, because the model has been centrally imposed, delegating the impossible job of demand management, without honestly engaging the providers and customers ( patients) with that process.The white paper defines structures to allow this engagement, particularly health and wellbeing boards that demand democratic legitimacy.THe pateint participation DES provides patients with a clear vopice.The future has no place for vested interests, of GPs, consultants, patient groups or politicians.We have to work corporately to make very difficult decisions about what our local NHS can and cannot afford.Yes, patient groups will have to step up to the mark and engage intelligently with decisions to cut, restrict and restructure.When demands are made by anyone, commensurate cost savings elsewhere will need to be described by them. GPs obviously will not succeed if they continue as centralists and try to impose their own agendas on this process.Providers , councillors and patient groups need to be round a single table, and accept their responsibilities to work for the common good, not their own.So leave the white paper as it is, and let those of us GP commissioners who understand the process, get on and get going in the only way that will work, through real engagement on both sides, with all parties stepping up to our responsibilities to make the NHS financially sustainable.

  313. Dominic Houghton says:

    I don’t see the need for any great change in accountability in the NHS. Trusts already have obligations to supply a lot of information under existing legislation, such as Freedom of Information. I fail to see that there is much more information that is needed, or could practically be supplied. There are already procedures in place to ensure accountability when errors are made, and these seem to work reasonably well.
    Forcing change simply to make it look like the health secretary and the government are doing something is a poor idea.

  314. S Cooper says:

    I wonder how more centrally commissioned treatments and care across a region come into this devolving of power to GPs? I have a chronic condition and receive from via my local hospital excellent holistic care with access to consultants, specialist nurses and physiotherapists, and a long term drug treatment provided through the Trust. I can self refer to any of the listed and do not see my GP to manage and treat my condition at all. They may not even know of the services I access so so do not see how they are best placed to commission the services on my behalf. My NHS Trust can do this because of the numbers with my condition across the borough, and they can integrate the skills need to provide benefit with other similar conditions.
    I also worry that in general the treatment of chronic conditions will not be suitably safeguarded from cuts as they could be seen very much as low hanging fruit that saves money today: but that won’t in the long term.

  315. web editor says:

    This page was closed to comments on 31 May, the last day of the listening exercise. Thanks for all your comments, which have been fed back to the NHS Future Forum to consider.

    The Forum will submit its report to the Prime Minister, Deputy Prime Minister and the Health Secretary in June. The government will consider the Forum’s findings and then publish its official response.

    Annelise@DH