News / Government response to the NHS Future Forum – a quick guide

Commissioning

The NHS Future Forum recommended commissioning consortia should be required to obtain appropriate advice on commissioning decisions from all health and care professionals. There should be a strong role for clinical and professional networks in the new system and multi-specialty clinical senates should be established to provide strategic advice to local commissioning consortia, health and wellbeing boards and the NHS Commissioning Board. The forum said that, following a full public consultation, the health secretary should hand the commissioning board a ‘choice mandate’, setting out the parameters for choice and competition across the NHS. It added better integration of commissioning across health and social care should be the ambition of all local areas. All commissioning consortia and ‘significant providers’ of NHS-funded services should be required to publish their board papers and minutes, and hold their board meetings in public.

• Though commissioning consortia will continue to be groups of GP practices, a wider range of clinicians, health and care professionals, carers and the public will be involved in commissioning. To reflect this, consortia will now be known as clinical commissioning groups.
• The groups will have a duty to promote integrated health and social care and – as the NHS Future Forum recommended – their boundaries should not normally cross those of local authorities.
• Those that wish to cross council boundaries must demonstrate to the NHS Commissioning Board that it will benefit patients.
• Commissioning groups must include the NHS brand and a link to their locality in their name.
• They must commission all urgent and emergency care within their boundaries, and they will also be responsible for unregistered patients who live in their area.
• Groups will not be allowed to delegate their statutory responsibility for commissioning decisions to private companies or contractors. However, they will have the flexibility to work with other groups, local authorities and the NHS Commissioning Board.
• The government will publish details of the authorisation process for commissioning groups, as well as the accountabilities and relationships between the groups, the commissioning board and health and wellbeing boards.
• Clinical networks will be retained and given a stronger role in commissioning; supporting the NHS Commissioning Board and local commissioning groups.
• Doctors, nurses and other professionals will be able to come together in clinical senates to give expert advice on making patient care fit seamlessly across the country. The government expects commissioning groups to follow their advice. They will have a formal role in authorising commissioning groups and will advise the NHS Commissioning Board on major service changes and whether commissioning plans are clinically robust.
• The NHS Commissioning Board will host both clinical senates and networks.
• The health secretary and clinical commissioning groups will have a new duty to promote research. In line with existing guidance, the commissioning board will ensure treatment costs for patients taking part in research funded by government and research charity partners are funded through normal arrangements for commissioning patient care.
• The NHS Commissioning Board will promote integrate care, for example by developing tariffs for integrated pathways of care and exploring single budgets for health and social care.

The NHS Future Forum said the pace of implementation should be varied, though the NHS Commissioning Board should be established as soon as possible.

Timetable

• Primary care trusts will cease to exist in April 2013, but commissioning groups will not be authorised to take on any part of the commissioning budget until they are ready. Local arms of the NHS Commissioning Board will commission on behalf of groups that are not ready at this point.
• The NHS Commissioning Board’s local arms will reflect the PCT cluster arrangements.
• GP practices must be part of an authorised commissioning group or a shadow group by April 2013.
• Commissioning groups could be authorised to take on full or part budgetary responsibility from April 2013.
• The NHS Commissioning Board will be established by October 2012, when it will begin authorising commissioning groups. However, it will not take on its full responsibilities until April 2013.
• Strategic health authorities will remain until April 2013, but they will be rearranged into a smaller number of clusters later this year.
• The government will take steps to boost the quality of management and leadership by retaining the best PCT and SHA talent and through a commitment to the ongoing training and development of managers.

Reaction

King’s Fund chief executive Chris Ham welcomed the emphasis on clinical commissioning and the evolutionary approach to implementation. However, he warned the number of changes risked confusion and additional bureaucracy. ‘The government will need to specify very clearly how these bodies will operate and work together,’ he added.

BMA council chairman Hamish Meldrum was pleased there would be significant revisions to the health and social care bill. ‘More detail is needed about the way clinical commissioning groups will operate in practice. While greater accountability and transparency around their decision-making processes are welcome, they should not be encumbered by bureaucracy,’ he added.

NHS Confederation chief executive Mike Farrar was happy the government had recognised the importance of integration, but added for some services competiton and choice was essential to delivering better patient care. ‘While we recognise and applaud the importance of stable transition we also need to make sure that the new system is not over centralising and there is real momentum towards the important goal of pushing power down to the local level. Localism means being able to take different approaches in different parts of the country according to local needs. We need the new clinical commissioning consortia to be in place as soon as possible to make this happen,’ he added.

Commissioning group governance

The NHS Future Forum recommended commissioning consortia should not be given freedom to determine their own governance arrangements – as a minimum it argued they should have a governing body with independent membership that holds meetings in public and consults widely on commissioning plans.

• Each group must have a governing body, with at least two lay members – one will champion patient and public involvement and the other will oversee audit, remuneration and managing conflict of interest. One of the lay members will be chair or deputy chair of the governing body.
• While the professional membership will not be prescribed, the governing body should have at least one registered nurse and one secondary care doctor. To avoid conflict of interest, they must not be employed by a local provider.
• Governing bodies must meet in public and publish their minutes. Contracts with health service providers must also be published.
• Commissioning groups’ compliance with the Nolan principles of good governance will be tested by the authorisation process, and on an ongoing basis by the NHS Commissioning Board.The quality premium will be revised – the bill will make clear its purpose is to reward commissioning groups that improve the quality of patient care. However, there will be some circumstances where a quality premium will not be paid – for example, if a group has achieved high-quality outcomes by spending more than their allocation. Rules governing when the premium is paid will be put before Parliament for approval and the bill will be changed to make provisions for how commissioning groups can use quality payments.

Reaction

BMA council chairman Hamish Meldrum said more detail was needed on how the commissioning groups would operate in practice.  Greater transparency was welcome but the groups should not be encumbered by bureaucracy.

Choice and competition

The drive for change should not be through a duty on Monitor to promote competition, the NHS Future Forum said. The regulator’s proposed duty to promote competition, together with the reference to Monitor as an economic regulator, should be removed from the health and social care bill. While competition should not be an end in itself, the forum said it could be used to secure greater choice and better value. But it said the bill contained insufficient safeguards against cherry picking of profitable services.

• Commissioners’ duty to promote choice will be strengthened and, as recommended by the NHS Future Forum, the health secretary’s mandate to the NHS Commissioning Board will include a choice mandate setting out expectations about offering patients choice.
• Subject to the outcome of the current pilots, the mandate will also make it a priority to extend personal health budgets, including integrated budgets across health and social care.
• The extension of choice through the any qualified provider scheme will be phased and delayed until April 2012. Choice under the scheme will be limited to services covered by national and local tariffs to ensure competition is based on quality.
• Monitor’s key role will be to promote and protect patients’ interests and its powers to promote competition as if it were an end in itself will be removed.
• Monitor will be restricted to tackling specific abuses and unjustifiable restrictions that act against patients’ interests.
• The regulator will be required to support the delivery of integrated care where this would improve quality or efficiency.
• The Principles and rules for co-operation and competition will be retained and given a statutory basis.
• To prevent cherry-picking, where practical services will be covered by a ‘system of prices that accurately reflect clinical complexity’. Commissioners will be required to follow best value principles when tendering for non-tariff services, rather than choosing the lowest price.
• Ministers, the NHS Commissioning Board and Monitor will be prevented from implementing a policy that encourages the growth of the private sector over state providers or vice versa.
• Foundation trusts will be required to produce separate accounts for NHS and private-funded services.

Reaction

Royal College of GPs chair Clare Gerada said: ‘We are pleased that the prime minister now seems to be addressing the concerns that the RCGP has been raising since the outset – competition, choice and the role of the private sector; ensuring that the secretary of state remains accountable for the health service and how we deliver improved and joined-up care for our patients as a result of the reforms.’

‘We welcome the shift in the role of Monitor away from promoting competition,’ said BMA council chairman Hamish Meldrum. ‘However, while we have always supported the principle of greater choice for patients, it has to be workable. There will need to be robust safeguards to ensure that vital services are not destabilised by unnecessary competition.

Foundation Trust Network chief executive Sue Slipman said foundations would be concerned the NHS Commissioning Board setting choice and competition rules will increase centralisation of decision making. ‘The competition rules need to be seen to be fair to everybody. Monitor will now police these rules, but this may not be enough to allay concerns, even if, over time case law may build up to offer providers more certainty about the way the system works in practice. The FTN will want to see strong provider and stakeholder involvement in the setting of the rules,’ she added.

NHS Partners Network director David Worskett said the independent sector was disappointed with the proposals. ‘The independent sector continues to believe that the NHS needs more innovation, diversity and robust, fair competition if it is to meet the challenges it faces, including achieving better integration, which we strongly support and which can be strengthened by a competitive market,’ he said.

Providers

The April 2014 date for trusts to gain foundation status should not be an absolute deadline, according to the NHS Future Forum. As a minimum, foundations should hold board meetings in public and publish the minutes of those meetings. Governors should be given appropriate training to ensure they can oversee their trust’s performance. Monitor should continue to have a compliance role in all foundations until governors have the skills necessary to hold their boards to account.

• Most of the remaining NHS trusts should gain foundation status by April 2014, but there will no longer be a deadline for the abolition of NHS trusts. However, remaining as an NHS trust will not be an option and all trusts should move to foundation status as soon as clinically feasible.
• Monitor’s oversight of foundations will be extended to 2016 to allow the trusts to build governors’ capability in holding their boards to account.
• The government has promised an ‘effective failure regime that ends the culture and practice of hidden bailouts and gets the right incentives into the NHS, whilst protecting essential services’. Amendments will be made to the health bill’s proposals for an up-front system of designating services for additional regulation.
• All foundation trusts will be required to hold their board meetings in public and a ‘duty of candour’ will be introduced – a new contractual requirement on providers to be open and transparent in admitting mistakes.

Reaction

Monitor chair David Bennett, Chair of Monitor said: ‘We welcome the government’s swift response to Future Forum’s recommendations, and the clarity it brings to the government’s intentions. The proposed changes make it clear that Monitor’s role will be to put patients first and to protect and promote their interests. In my view, this is absolutely right and we will do this with commitment and determination.’
Competition should remain one of the ‘tools in the regulatory toolbox’ to promote patient choice, said Foundation Trust Network chief executive Sue Slipman. She added the FTN was ‘apprehensive’ that the deadline for foundation status had been softened and the extension of Monitor’s role over all foundation trusts until 2016. ‘There is likely to be concern from other providers that Monitor might favour FTs because it has a special responsibility for their success and could give it a conflict of interest,’ she added.
Ms Slipman said the FTN was disappointed there were no further details on the failure regime and called for the new regime to be run independently of government. She added that the duty to hold board meetings in public should extend to any organisation in receipt of public funds.
On the call for separate accounts for NHS and private work, she said: ‘FTs have always been clear about the need for transparency about the way that they use any funder under the private patient income cap for the benefit of NHS patients. They will use the freedom afforded by the lifting of the cap to create value for NHS patients through developing new services and products with partners across all sectors.’

Education and training

The NHS Future Forum said the pace of change risked jeopardising NHS education and training. It recommended taking time over implementing the changes.  There should also be a substantial transition period for moving to a levy-based funding regime, where all providers that employ NHS-trained staff should contribute to the cost of training, to ensure unintended consequences are removed.

• Further details on the transition for the education and training system will be set out in the autumn. Deaneries will continue to oversee the training of junior doctors and dentists.
• Proposals to ensure all providers contribute to the cost of education and training will be introduced in a careful, phased manner to avoid instability. More details will be published in the autumn.
• The health secretary will be given an explicit duty to maintain a system of professional education and training as part of the comprehensive health service.

Reaction

‘It is reassuring that the government recognises there are still a number of issues to work through. It is particularly important that dialogue continues on education and training,’ said BMA council chairman Hamish Meldrum.

Accountability

The NHS Future Forum said there had to be ‘absolute clarity’ that the health secretary was ultimately responsible to Parliament for a comprehensive health service. The legislation should strengthen the role of the health and wellbeing boards in health and social care integration and they should be the focal point for ensuring the health needs of a local population are met.

• The NHS Constitution will be further embedded and the government will ensure rights patients currently hold under the constitution have the same legal force under the new legislation.
• The secretary of state for health will remain responsible for promoting a comprehensive health service and securing the provision of services. The government will make it clear that ministers are responsible for overseeing national bodies, including the NHS Commissioning Board, rather than operational management of NHS bodies.
• Health and wellbeing boards (HWBs) will have a new duty to involve users and the public.
• HWBs should be involved in the development of commissioning groups’ commissioning plans and there will be a ‘strong expectation’ that plans will be in line with the health and wellbeing strategy. Though they will not have a veto, HWBs will be able to refer plans back to the group or the NHS Commissioning Board.
• HWBs will have a stronger role in promoting joint commissioning and integrated provision between health, public health and social care.
• HWBs will have a formal role in authorising commissioning groups and in the NHS Commissioning Board’s annual assessment of commissioning groups.
• Monitor will have a new duty to involve patients and the public in its work.
• The duty of public, carer and patient involvement on the NHS Commissioning Board and commissioning groups in commissioning decisions will be further clarified. They must be consulted on annual plans and any changes that affect patient services, not just those with a significant impact.

Reaction

‘The confirmation of the prime minister’s pledge to keep waiting times low, and the emphasis placed on the 18-week maximum wait for hospital treatment enshrined in the NHS Constitution, leaves the NHS with a very significant challenge,’ said King’s Fund chief executive Chris Ham.
‘With the spending squeeze beginning to bite, the number of hospital inpatients waiting more than 18 weeks for treatment is already at its highest level for more than three years and waiting times for A&E and diagnostic services have also risen. As the government has said that it is opposed to targets, it now needs to be clear about how this pledge will be measured and enforced,’ he added.