The coalition government’s white paper on the NHS is expected to be published shortly. This will contain far-reaching proposals to increase choice and competition, strengthen the commissioning of health care, give NHS providers more autonomy, and establish an independent commissioning board. But the white paper will need to answer ten difficult questions if it is to offer a credible plan for the future.
1. How will patients be supported to take greater responsibility and to exercise informed choices?
The coalition government has signalled its intention to put patients at the centre of the NHS and to start an information revolution by publishing more information about quality and outcomes. While patients want to be more involved in decisions about their care and to be supported to make informed choices, professionals are often too busy to do this, do not see this as their role, and believe that patients want them to make decisions for them. How will professionals be motivated and supported to put patients first and involve patients more in decisions? Will patients and professionals be able to make use of the information to drive improvements in care?
2. How will provider competition work in future and what will be the role of the proposed economic regulator?
A mix of competition and co-operation is needed to support the goals of improved health outcomes and enhanced patient experience. Will ministers follow through the logic of competition and allow unsuccessful providers to fail? How will co-operation be supported, for example, to ensure that the providers of unscheduled care work together to reduce duplication and inefficiency? What will be the role of the economic regulator and how will it work with the Care Quality Commission?
3. How will difficult decisions about service reconfigurations and hospital closures be taken in future?
Major changes such as those being implemented in London to address the oversupply of acute hospital beds and duplication of specialist services have taken many years and elaborate processes of public consultation to get to the point of implementation. The impetus for changing services is even greater given the financial context. How will commissioners tackle complex issues like the reconfiguration of tertiary and acute hospital services and how will the views of patients, the public and clinicians be taken into account without them blocking decisions that need to be taken on financial and quality grounds?
4. Will the right incentives and support be in place to ensure enough GPs are motivated to lead the development of GP commissioning and have the competence to do so?
The white paper will place great emphasis on the devolution of budgets to groups of GPs to enable them to commission care. Previous experience in the NHS has shown that while some GPs are likely to be enthusiastic about this opportunity, many will not be. Will the incentives be strong enough to engage a critical mass of GPs and will they have the leadership and other skills required?
5. How will GP commissioners be held to account for their stewardship of public resources for health care?
If most of the NHS budget is devolved to GP commissioners, it will be essential to be clear who are the ‘accountable officers’ for the resources they control. The proposed independent commissioning board (see below) will not be able to hold to account 500–600 GP commissioning groups, and there will need to be a body sufficiently close to these groups in a position to ensure appropriate and effective use of resources. Who will take on this role? What will be the consequences of failure, and who will ensure continuity of care for registered populations?
6. Who will commission primary medical care and ensure that GPs as providers of care deliver good value for money?
GPs provide primary medical care services under the terms of contracts negotiated nationally and locally, and currently their performance in relation to these contracts is assessed by PCTs. We know that issues such as how well those with long-term conditions are supported by their GPs or the availability of out-of-hours care are not only important to patients but also have a crucial role in reducing avoidable and costly emergency admissions to hospital. Who will take on this responsibility in future? Will consortia of GPs be responsible for the performance of other practices and if so what leverage will they have?
7. What will happen to NHS providers?
The white paper will need to have a coherent plan for all NHS providers to become foundation trusts. It will also need to offer greater autonomy to high-performing foundation trusts and active encouragement of social enterprise and mutual models. Greater integration of providers should be encouraged where this offers benefits for patients. Will there be a clear vision for the future of NHS providers and how this will be delivered?
8. What will be the future role of PCTs and local authorities?
The coalition agreement signalled that the boards of PCTs will include people who are directly elected as well as members drawn from local authorities. This will help to strengthen local accountability as long as PCTs have a significant role in future. If most commissioning is devolved to GPs, what will be the role of PCTs, and how will they work with local authorities to ensure that cuts in social care do not impact adversely on patients and users?
9. How will the independent commissioning board relate to the Department of Health on the one hand and the NHS on the other?
Distancing ministers from the day-to-day running of the NHS is welcome in principle but how will it work in practice? In the face of any significant clinical failure and result in loss of public confidence in services or organisations, what mechanisms will ensure that politicians remain removed from operational intervention? In the absence of targets, can the board ensure quality is maintained through commissioning standards without reverting to the command and control of past years?
10. How will the government ensure that leaders remain focused on finding £15-20bn under the QIPP programme while at the same time making far-reaching changes to the organisation of the NHS?
The NHS faces the biggest challenge in its history in delivering financial savings under the QIPP (quality, innovation, productivity and prevention) programme. Work on the programme could be derailed by the organisational changes contained in the white paper and by the loss of experienced leaders as management costs are cut. What transition arrangements will be made to avoid this and to ensure delivery of both QIPP and the white paper?
Chris Ham is chief executive of the King’s Fund. This post can also be viewed on the King’s Fund blog. An interview with Chris Ham will be published in the 16 July issue of Public Finance
