NHS White Paper 2010

On 12th July 2010, the Department of Health published proposals for wide-reaching reform of the NHS in the White Paper, 'Equity and Excellence: Liberating the NHS'. These reforms are being consulted on until 11th October 2010.

To enable better understanding of the impact of the proposals, we've asked leading voluntary sector figures to discuss key aspects of the reform. Their comments open up some of the complex issues - and help you consider how the White Paper proposals will affect your work and the communities and individuals you work with:

• New Migrants and Excluded Communities (Northern Refugee Centre)
• Infrastructure and Social Value Commissioning (Voluntary Sector North West)
• Equity for the Deaf (RNID)
• Access to Drug and Alcohol Services (addaction)
• Mental Health (Mind)
• Personalising Health (National Care Forum)
• Commissioning and Structural Change (Stephen Strutt)

You can also read our summary explaining what's in the White Paper, and respond to the consultation. There's also a comment box at the bottom for you to share your thoughts. To contact any of the authors, please email fiona.sheil@ncvo-vol.org.uk.

 Thinkpieces

New Migrants and excluded communities

The concerns that I have from managing a migrant refugee and asylum service agency for the proposed health service reforms, are threefold:

Firstly, that the sheer disruption of further reforms at this stage will impact on those PCTs who have developed positive commissioning policies for new migrants. This is not universal across the country, but in some key areas PCTs have worked with local agencies to develop commissioning policies that address the specific needs of new migrant communities, and recognise where new migrant communities may be excluded from general health services.

Secondly, that there is no guarantee that the consortia of GP commissioners proposed will have any sense of the needs of those new migrant communities, particularly if those communities have not been on their own GP list before. This may be because they have not been present within their catchment area, or in some cases, may have been specifically avoided. This is very worrying in the context of trying to provide a comprehensive service across areas that PCTs would have previously covered.

Finally, the lack of thought-through policies re: primary and secondary health acre around new migrants, will have an impact on the wider public health agenda, both in communicable diseases and general wellbeing. This will ultimately have an impact on wider health services and will therefore be less cost effective in relation to those limited resources.

 

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Infrastructure and Social Value Commissioning

Having worked so hard to make sense of the structures of the NHS and the Department of Health over recent years, the prospect of wide spread reform fills me with dread.  However, it is incumbent upon me and others in third sector infrastructure organisations to see the positive, which I am trying hard to do, and influence the process where we can to make some of the changes better.

The first big opportunity I see for the sector, especially for infrastructure, is the need for ‘navigators’: The new GP commissioning consortia will need support in understanding the third sector offer and identifying potential deliverers of service.  Never has it been more important for local infrastructure organisations to understand their local sector, to do work such as that carried out by Halton and St Helens CVSs and many others like them in showcasing our offer and then provide the support to make organisations commission ready.

VSNW have already discussed the opportunity to contribute to training with emerging GP Consortia in the Region to explain how they can access the sector and engage with it effectively.  Both Department of Health in the region and NHS NW have committed to supporting that engagement which is a huge positive.

I also think there will be a role in helping both the sector and individuals ‘navigate’ the NHS – the systems and the choices are going to be ever more complex and those who are not IT savvy may be left behind: digital exclusion is a real threat to the community with some of the reforms and the sector can make an offer that prevents this becoming a reality.  Far too often when we talk about ‘choice’ it is, as Mr Cameron described recently ‘...the middle classes like my family with their sharp elbows knocking others out of the way...’.  For choice to be made a reality for the many not the few there will have to be intermediary organisations to support this – I guess that makes opportunity number two.

At this point I should pause.  I have stated two opportunities but have not yet stated who will or should pay – and like many things at the moment I can identify opportunities, I can identify services that seem sensible to provide in the new landscape, I can’t identify who will pay: not with a government unwilling to legislate and willing to ‘let the market decide’.

In terms of Commissioning I have often seen the use of Social Value commissioning as the ‘Holy Grail’ for the sector.  I also believe it is major steps forward in getting maximum public benefit from public spend.  The work done by NHS NW on behalf of the ten strategic health authorities provides a framework for Social Value Commissioning that could be adopted not just across the NHS but across all public sector commissioning.

VSNW will continue to push for the NHS to adopt Social Value Commissioning wholesale and we will be supporting the Private Members Bill of Chris White MP for Warwick and Leamington, calling for Social Value to be at the centre of all public sector commissioning.  We believe there is no reason we can’t push for cross party support on this and use the valuable work we have done on this issue over recent years to make a revolutionary change to public sector procurement for good.

I have now outlined opportunity number three and would be grateful for any support in lobbying local MP’s to support the private members bill.

One of my concerns about the white paper, linked to other policy developments is the emergence of new geographies.  Traditionally many smaller third sector organisations are wedded to specific geographic boundaries – as are those who co-ordinate and organise third sector representation.  We are all going to have to be ready to be flexible to respond to the changes: co-terminus Local Authorities, PCT’s and other public services made our ‘organising’ easier: a shift in this will cause a shift in thinking for us all and we must be ready to forge alliances and collaborate across new boundaries OR accept we may see competition and the survival of the fittest amongst organisations who have until now been happy partners sat either side of boundary fences.

My hopes are that the implementation of Equity and Excellence and the Public Health white paper, will deliver greater opportunities for smaller third sector organisations to engage with the NHS and local authorities in delivering improved services and most importantly improved outcomes for the communities we serve.  I hope the Government will be bold enough to put social value at the heart of the commissioning process and not leave it to the market to decide if it is appropriate and I hope the sector will respond quickly to provide voice for those who are seldom heard and ensure there is choice for many not the few. 

I fear what we may see is a re-defining of Social Enterprise to suit Government rhetoric rather than community need, I fear we may see a lack of innovation and risk taking that may crowd out the third sector along with funding arrangements such as payment by results which will kill off many vital small third sector organisations.  I fear the death of grants in the health sector, so important in stimulating the market, reduction in support for infrastructure to develop the market – and most of all I fear that the third sector will be the Trojan Horse for the privatisation of the NHS – that whilst we look at our sparkling new ‘astro-turf social enterprises’ we find the private sector have taken the service by stealth behind our backs.

I am going to spend the next few months working to make my hopes come true – but keeping an eye on my fears and ensuring the sector speaks up when it should and seeks to shape the new NHS into something that really delivers for our communities – after all, what more should we want from the NHS than Equity and Excellence?

 

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Equity for the Deaf

Equity and Excellence: Liberating the NHS, proposes some fundamental and wide ranging changes to the NHS that will certainly have implications for people who are deaf or hard of hearing accessing health services.

A central point that must be taken into account when analysing any of the content of the paper is the financial situation that it has been produced in, with productivity savings of £15-£20bn being required from the NHS. A cut of 45% in management costs is pledged, alongside further bureaucracy cuts and efficiency improvements. The paper highlights that this is a difficult time to be found lacking funds, with challenges on the way from changing demographics and the availability and increasing cost of new technologies and drugs. Both of these factors, particularly an ageing population, are relevant to deafness and hearing loss.

For the 9 million people in the UK who are deaf or hard of hearing, perhaps the most important thing that the Coalition Government must take into account  as they move forward with the implementation of the proposals contained within the White Paper is full access to the ‘information revolution’ that the proposals promise.  It is essential that this information is fully accessible to people who are deaf or hard of hearing, a group that has a diverse range of communication needs, ranging from better deaf awareness amongst NHS staff who deal with patients and the public over the telephone, including those with a mild hearing loss, to those with a more profound hearing loss who are unable to communicate over a traditional telephone.

We welcome proposals that patients will be able to communicate with their clinicians about their health status on-line. This could be a major advantage to some people with a more profound hearing loss, particularly if software such as TalkByText is utilised as part of this drive. It could also help alleviate the problems currently created by the shortage of interpreters working in the NHS, as the need for face to face consultations is reduced. We must be mindful though that not everyone who is deaf or hard of hearing will be capable or will want to use the internet as their primary means of communication with health professionals.

A major theme running through the paper that will have an impact on people accessing NHS audiology services is the replacement of targets with outcome measures. Audiology was an area where patients greatly benefited from the application of the 18 week referral to treatment target. A few years ago, waits were as high as 41 weeks in some parts of the country and by April this year nearly all audiology patients had been waiting for less than 18 weeks.

As with many conditions, ensuring that hearing loss is dealt with promptly is essential as the longer a hearing loss is allowed to develop the harder it is for someone to adapt to the use of a hearing aid, which has implications for both the individual and to the NHS as hearing aids can lie unused and people will seek fresh help further down the line when their hearing deteriorates further.

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Access to Drug and Alcohol Services

Our service-users tell us that they'd rather receive help from their local GP for their drug problems. In reality, many are denied this opportunity as not all GPs are qualified to prescribe substitute medication, and don't have the specialist qualifications required to offer drug-treatment.

With NHS reforms on the horizon, Addaction would call for all GPs to be qualified in drug-treatment as part of their mainstream training. It would mean every drug-user having the opportunity to receive treatment from their local GP, who could - in turn - be supported by organisations such as Addaction.

The education already exists in the GPSI modules for substance misuse which are currently available for GPs. This is what we would like to see as mandatory inclusion in their training.

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Mental Health

Attitudes to the health white paper seem to vary pretty depending on who you speak to, but you can’t deny that the changes being announced are pretty radical.  With £80bn being handed to GPs to commission services, I’ve heard one commentator describe these reforms as the most drastic since the NHS was created after World War 2. 

It’s pretty difficult to find fault with the lofty ambitions being articulated: establishing an NHS that focuses on delivering world-class outcomes, freed from top-down control, made more accountable to patients and providing meaningful choice.

But what does all this mean for mental health in the UK?  Well, Mind certainly welcomes the greater emphasis on outcomes, together with the specific aim of beginning to, “…introduce choice of treatment and provider in some mental health services from April 2011, and extend this wherever practicable”.  But, as with all major reforms like these, the devil is in the detail and, by the government’s own admission, the detail is somewhat lacking.  For example, greater emphasis on outcomes is great, but we’ll need to reach some kind of agreement as to how such outcomes are measured. 

One of the main question marks hangs over the move to GP-based commissioning.  On the face of it, this could bring real benefits.  Doctors are the people that work face-to-face with mental health service users, and should be in the best possible position to develop services that meet local needs and give patients the choice they want. 

However, how will it work in practice?  We know that a lot of GPs lack the specialist mental health knowledge and training to understand the complexities of mental health commissioning.  We are concerned that this could result in something of a postcode lottery.  In some areas, where the GPs happen to understand the complexities in mental health commissioning, the provision of services could be very good.  In others, where the GPs struggle to grasp these complexities, service availability could be poor.  This would have several negative consequences, one being  an ongoing reliance on the prescription of antidepressants. 

The next few months will be very important in ensuring that the government gets these changes right.  For Mind, it is vital that in making these changes mental health does not lose out, and we will be fighting to ensure that the needs of mental health service users are heard.  For too long, mental health has struggled to gain an equal footing with physical health in the NHS.  It is imperative that we grasp the opportunity presented by these reforms to dramatically improve the UK’s provision of mental health services.   

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Personalising Health

The speed at which the Coalition Government published a White Paper on the NHS caught many people by surprise. The fact that it contained such a radical agenda for change was even more of a surprise. Proposals to ensure that healthcare services follow the principle of “no decision about me without me” are of course entirely consistent with the approach of personalisation long since adopted within social care. In fact the transformation of adult social care programme, now in its third year, was designed with the intention of increasing choice, control and independence for people receiving services. So it is good that healthcare services are being put on a similar track.

Equity and excellence views the NHS as integral to the Big Society and therein having the potential for patient involvement at many different levels and in many different ways. It offers an opportunity for key stakeholder groups within social care to be engaged in shaping the way in which the White Paper proposals are translated into practice and how they may actually operate. The rhetoric is easy, action less certain!

The White Paper refers to an “information revolution” to improve accountability, quality and the delivery of care services. Whilst the intentions are positive, good quality is only a part of the equation. People often need assistance in how to make sense of information alongside advocacy and support. Informed choice is no easy matter and the transactions in healthcare are typically complex. There is a crucial role for professionals, especially within the voluntary and community sector, in using information to improve quality of services. There is, in addition, the question of communication especially for some vulnerable groups or for those without the necessary social support networks.

The interdependence between health and social care acknowledged by Equity and excellence is refreshing and welcome, particularly in anticipating the greater role that social care services could play in the preventative agenda. There is scope for this to be developed further and, in this respect, much that managers in the health sector could learn from social care.

Substantial structural changes will be required to fully implement the NHS White Paper. Some estimates suggest that as many as a 100,000 jobs will be affected within the NHS with a net loss of around 30,000 jobs. This is change on a major scale. There are questions about the time required to develop the necessary infrastructure to transfer commissioning responsibilities from PCTs to GP-led consortia. Furthermore, there are a few significant hurdles which form a part of the context. The first is the unprecedented demographic demands we face as the population ages and life expectancy continues to rise. The second is the crisis being caused by the severe and ongoing under-funding of the care sector and the need for a new long term funding arrangement which many assume means people paying more for care in the future. And finally, there is the economic situation we currently face and the impact that substantial reductions in public spending will have on services and the wider economy. Taken together they could represent the ‘perfect storm’ and will be a real test of leadership.

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Commissioning and Structural Change

A weakness of the proposed and previous structural reorganizations within health has been the lack of formal piloting, detailed financial evaluation and announcement of specific outcomes that changes can be measured against. 

I believe that a number of the proposals carry significant risk.

The abolition of  Strategic Health Authorities and Primary Care Trusts and the proposal to implement new NHS support arrangements within a management cost envelope that will be reduced by 45% over the next four years will significantly reduce commissioning capability.

The NHS in England is underpinned by excellence in General Practice. As independent contractors GPs will have knowledge of working to practice budgets; a number will have been involved in GP fundholding and more latterly practice based commissioning.
The reforms indicate that new GP consortia will be holding aggregate budgets valued at between £70bn- £80bn.
To take on this significant commitment those GPs leading the commissioning agenda for their consortia will need to compliment their extensive clinical skills by comprehensive training in:

• corporate leadership
• contracting for a significant portfolio of services
• analysing data on contract performance in relation to finance and quality.
• lead commissioning,
• financial management and risk assessment.
• controls assurance. 
• engaging a segment of GPs who may view the reforms as a distraction to their clinical practice [recognizing that not all professionals will be involved in detailed commissioning]
• engaging effectively with specialists where expertise is critical in modernized service design and delivery
• comparative information analysis & benchmarking
• establishing systems to retain corporate memory.

It is acknowledged that the Department of Health and Strategic Health Authorities are project managing the transition.

The ability for GP consortia to choose from primary care employees, their local authority or private sector to provide commissioning support could lead to a loss of current expertise and corporate memory that is available to the service unless this is project managed.

The development of accurate consortia budgets will be critical to maintaining financial control and providing confidence in the new system. Transitional pace of change arrangements may be required in relation to allocations to maintain stability while also ensuring consortia receive a fair share of resources for the needs of their population. 

GP consortia can be expected to be reluctant to accept budget allocations that are below their assessed fair weighted capitation share and those that are above target  may be reluctant to accept a reduction or nil increase in allocations while establishing their commissioning portfolio and also tackling the QIPP agenda

In the interim period there may be tensions as consortia require increasing support while Primary Care Trusts look to manage current arrangements with reducing numbers of staff.

The need to deliver on structural reforms at the same time as a QIPP agenda to improve performance and productivity by upwards of £20bn to self-finance demographic and other cost pressures could lead to a loss of financial control depending on how this is managed

Early and firm action is required to reduce transaction costs that will arise with an increase in the number of commissioners.

There is a significant risk of losing the advantages of critical mass in professional services including finance.

The rationale for the NHS Commissioning Board to Commission maternity services rather than GP consortia is unclear.

The movement to outcome targets from process targets is a welcome change, recognising that a portfolio of appropriate comparable indicators may take some time to develop.

Proposals to strengthen the links between the NHS and local authorities and give councils an enhanced role in improving public health are positive. It is important that the NHS continuous to focus on Public health and does not concentrate simply on treatment. The critical linkage of public health needs assessment to developing service strategies and service modernization needs to remain. The increased emphasis on the linking of health and social care budgets is welcomed. With significant cuts to social care budgets likely to follow the Spending Review in the autumn, stronger integration between health and social care services is increasingly important.

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What's in the White Paper?

Personalisation and the 'information revolution'

The White Paper wants to see an 'information revolution' which will enable greater personalisation of health services through greater access 'to the information patients want'. This 'information revolution' will be partnered by shared decision making - 'no decision about me without me' and patients will 'have choucie of any provider... and choice of treatment'. To make this happen, the system will encourage 'joint partnerships and local partnerships'.

Outcomes-led commissioning

The White Paper continues to talk of a 'world-class' NHS, led by 'active responsibility' and the abolision of 'targets with no clinical justification'.

Significantly, rather than money being allocated by service, it will 'follow the patient... across the NHS'.

Providers will be 'paid according to their performamce. Payment should reflect outcomes, not activity'.

Very clearly, the White Paper states that 'the government will devolve power and responsibility for commissining services to the healthcare professionals closest to patients: GPs and their practice teams working in consortia'. These will replace the commissioning responsibilities of Primary Care Trusts.

Governance

A 'NHS Commissioning Board' will govern commissioning, nationally. The Board will 'lead on the achievement of health outcomes, allocate and account for NHS resources, lead on quality improvement and promoting patient involvement and choice'.

Local authorities

Local authorities and the local NHS are to be greater integrated. It will be local authorities who 'promote the joining up of local NHS services, social care and health improvement'.

Public health and health inequalities

Public Health will become the responsibility of local authorities, and the public health budget will be ringfenced. It will be 'allocated to reflect relative population health outcomes, with a new health premium to promote action to reduce health inequalities. The new NHS Commissioning Board 'will have an explicit duty to promote equality and tackle inequalities in access to healthcare'.

Social enterprise

The White Paper aims 'to craete the largest social enterprise sector in the world' by making all NHS Trusts into Foundation Trusts and encouraging NHS staff to set-up independent social enterprises to deliver health services.

 Budget Cuts

'The Government will reduce NHS management costs by more than 45% over the next four years.' The overall aim is for '£20 billion of efficiency savings by 2014, which will be reinvested'.

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How to read and respond to the White Paper consultation

'Equity and Excellence: Liberating the NHS' along with four detailed consultation papers, a draft Structural Reform Plan and an initial Equalities Impact Assessment can all be found on the Department of Health website.

You can respond to the consultation through the Department of Health website until 11th October 2010, or at one of the regional consultation events organised for the voluntary sector by Regional Voices, on behalf of the Department of Health.

For more up-to-date information on health policy and services in England, see the NCVO health pages.

You can read 'Equity and Excellence: liberating the NHS' in full on the Department of Health website.

The consultation closes on 11th October 2010.

For any questions on the role of the voluntary sector in delivery health policy and services, contact fiona.sheil@ncvo-vol.org.uk.