NHS reforms

Department of Health sets out detailed new reform proposals

The Government’s full and detailed response to the NHS Future Forum’s recommendations on the new shape of the reforms is now available.

The full response is available at www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127444

A summary of the key changes, published by the Department of Health, is outlined below:

Overall accountability for NHS

Some have raised concerns that the Bill would weaken NHS principles or the Government’s overall responsibility for the NHS. To make clear that this is not the case, we are tabling amendments which will:

Require the NHS Commissioning Board and clinical commissioning groups to take active steps to promote the NHS Constitution, which enshrines the core principles and values of the NHS;
Make explicit that the Secretary of State remains fully accountable for the NHS;
Create explicit powers for the Secretary of State to oversee and assess the national NHS bodies, to ensure they are performing effectively, while respecting their operational independence.
Clinical advice and leadership

The Forum’s report shows there is universal agreement that patient care is better if it is based on input from those closest to patients – doctors, nurses and other health and social care professionals – in discussion with patients and carers, the voluntary sector, and other healthcare partners.

But we have also heard that, to do this well and really make a difference to patients and carers, we need to be more ambitious. So we will:

Make sure that a range of professionals play an integral part in the clinical commissioning of patient care, including through clinical networks and new clinical senates hosted by the NHS Commissioning Board and stronger duties on commissioners to obtain an appropriate range of clinical advice;
Ensure that at least one registered nurse and secondary care specialist doctor are appointed to clinical commissioning groups’ governing bodies;
Embed clinical leadership throughout the new arrangements and support leadership skills to develop;
Support clinical commissioning groups to make high quality, evidence-based decisions, with information joining up to support integrated care;
Provide more clarity around the proposed arrangements for supporting the development of clinical commissioning groups, authorising them to take on commissioning responsibilities and ensuring ongoing accountability for their role in improving the quality of care.
Public accountability and patient involvement

The Future Forum agrees with us that patients and carers should be at the heart of the NHS, through shared decision making about their care and meaningful involvement in how health services are organised. But the Future Forum also says that if this is to be achieved, more needs to be done to ensure that shared decision making becomes the norm and that new organisations are sufficiently accountable for the decisions they make.

In response to these recommendations, we will:

Strengthen the accountability of new organisations, including clinical commissioning groups;
Ensure more joined-up local services by strengthening requirements for close working between health and wellbeing boards and clinical commissioning groups;
Strengthen the duties of organisations across the system with regard to patient, carer and public involvement;
Strengthen the definition of involvement to reflect better the principle of ‘no decision about me without me’;
Ensure that commissioning groups receive a quality premium only where they can demonstrate good performance in terms of quality of patient care and reduced inequalities in healthcare outcomes.
Choice and competition

Nearly everyone who contributed to the listening exercise felt patients should be given more choice and control over their care. Some felt that the competition that accompanies increased choice brought benefits for patients, while others were concerned about its impact on existing NHS providers and integrated services.

The NHS Future Forum said that, while competition has a role to play, the Government should make its position clearer and guard against the dangers of competition being an end in itself. We have heard this message and will improve our plans as follows:

The Bill will rule out any deliberate policy to increase or maintain the market share of any particular sector of provider – private, voluntary or public;
Monitor’s core duties will be focused on protecting and promoting patients’ interests, not on promoting competition as though it were as an end in itself;
We will keep the existing rules on co-operation and competition in the NHS;
There will be additional safeguards against cherry-picking and price competition;
We will set limits on Monitor’s powers to take action against commissioners;
We will phase in the extension of Any Qualified Provider;
Monitor will be required to enable integration of services for patients;
We will strengthen the duties on commissioners to promote integrated services;
The NHS Commissioning Board will promote innovative ways of demonstrating how care can be made more integrated, including exploring opportunities to move towards single budgets for health and social care;
As recommended by the Forum, the Secretary of State’s mandate to the NHS Commissioning Board will set clear expectations about offering patients choice: a ‘choice mandate’;
We will extend personal health budgets as a priority, subject to evidence from the current pilots.
Developing the healthcare workforce

The NHS Future Forum highlighted that there was strong support for our proposals to improve arrangements for professional development. But they also said that further work is needed to develop detailed proposals following consultation.

We will further develop and revise our plans to make sure we get them right. In particular, we will:

Ensure that Health Education England is in place quickly to provide national leadership and strong accountability, a whole workforce and multi-professional approach, with strong relationships with health, care and education partners;
Ensure a safe and robust transition for the education and training system. During transition, deaneries will continue to oversee the training of junior doctors and dentists, and we will give them a clear home within the NHS family;
Put in place a phased transition for provider-led networks to take on their workforce development responsibilities when they can demonstrate their capacity and capability;
Further consider how best to ensure funding for education and training is protected and distributed fairly and transparently, and publish more detail in the autumn;
Ensure high quality management is valued across the NHS, with a commitment to retaining the best talent across the PCTs and SHAs.
Timetable for change

The NHS Future Forum emphasised the need to get the pace of change right, in the best interests of quality and safety. We aim to strike a balance between maintaining momentum and allowing more time to recognise that some organisations may not be ready to take on their full responsibilities on the current timetable. We will make a number of changes to our proposals:

Primary Care Trusts will cease to exist in April 2013. However, clinical commissioning groups will not be authorised to take on any part of the commissioning budget in their local area until they are ready and willing to do so;
By April 2013, GP practices will be members of either an authorised clinical commissioning group, or a ‘shadow’ commissioning group, i.e. one that is legally established but operating only in shadow form;
Where a commissioning group is ready and willing, it will be able to take on commissioning responsibility earlier. Where a group is not yet ready, the local arms of the NHS Commissioning Board will commission on its behalf;
The NHS Commissioning Board will be established by October 2012 to start to authorise clinical commissioning groups, but will only take on its full responsibilities from April 2013;
Choice of Any Qualified Provider will be phased in gradually from April 2012;
Our expectation is that the remaining NHS trusts will be authorised as foundation trusts by April 2014. But if any trust is not ready by then, it will continue to work towards foundation trust status under new management arrangements. We will further extend, to 2016, the transitional period where Monitor retains specific oversight powers over foundation trusts;
We will ensure a safe and robust transition for the education and training system, and will set out further details in the autumn.

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