Comment / News review

We now know how the government intends to revise its proposed reforms of England’s NHS. Talk of competition has been toned down and consortia (now clinical commissioning groups) will be influenced by a wider range of clinicians, including those in secondary care. A committee of MPs will examine more than 100 amendments to the health and social care bill before it moves on to the Lords.

David Cameron previewed the NHS?Future Forum’s recommendations at Guy’s and St Thomas’ NHS Foundation Trust (below) a few days before it published its report. But his message was overshadowed by an outburst from orthopaedic surgeon David Nunn when he saw that some of the prime minister’s entourage and journalists had not taken off their ties and rolled up their shirt sleeves, as is protocol when in contact with patients (the prime minister and deputy Nick Clegg had complied).

Following its eight-week listening exercise, the forum published a summary of recommendations and documents on choice and competition; clinical advice and leadership; education and training; and patient involvement and public accountability. It took a pragmatic approach to the reforms, insisting the pace of implementation should be varied, though the NHS Commissioning Board should be set up quickly to direct the service’s focus on quality, safety and finances. The government accepted the ‘core’ recommendations.

The forum expressed support for managers and its Professor Steve Field said the committee was ‘alarmed’ at how demoralised managers felt. Its summary said managers had a critical role in working with clinicians and clinical leaders. Experienced managers must be retained to ensure a smooth transition and support clinical leaders in tackling financial challenges.?

Future Forum: The report said Monitor should not be duty-bound to promote competition. Competition should not be an end in itself, but it could be used to secure choice and value. But there must be more safeguards against cherry picking profitable services.

Government response: The health secretary’s mandate to the NHS Commissioning Board will include a choice mandate; personal health budgets will be extended; any qualified provider scheme will be delayed and restricted to services with national or local tariffs; Monitor will promote patients’ interests and support delivery of integrated care; tariff will be used to prevent cherry picking; foundation trusts will produce separate accounts for NHS and private-funded services.

Future Forum: All trusts should work towards foundation status by 2014, but this should not be an absolute cut-off. FT governors must be given training and support to oversee their trust’s performance and Monitor should continue to have an ongoing compliance role until foundation trust governors have the necessary skills to hold their board to account. ?

Government response: Most trusts should become foundations by April 2014; this will no longer be an absolute deadline, but remaining an NHS trust will not be an option; Monitor’s oversight to be extended to 2016 to allow build-up of governors’ skills; an ‘effective’ failure regime will be brought forward; all foundation trusts will be required to hold board meetings in public.

Future Forum: Commissioning consortia should be required to gain appropriate advice on commissioning decisions from all health and care professionals. 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, including FTs, should be required to publish their board papers and minutes and hold board meetings in public. ?

Government response: Commissioning groups will still be based on GP practices but a wider range of clinicians – including clinical and professional networks and multi-speciality clinical senates – and the public will be involved in decision making; groups must promote integrated care; they will not be allowed to delegate their statutory responsibility for commissioning to private firms or contractors.

Future Forum: Authorisation and annual assessment of commissioning groups should include an assessment of their skills, capacity and capability – consortia that demonstrate they can take control of commissioning budgets should do so from April 2013, but the commissioning board could perform this on behalf of those that are not ready. Incentives must be aligned across health and social care, with joint outcomes and financial mechanisms to drive delivery of care to patients in a place to suit them at the time they need it.

Government response: The government will publish details of the authorisation process; clinical senates to have a role authorising commissioning groups and will advise the commissioning board on service changes and whether commissioning plans are clinically robust; quality premium will be revised and rules on when it is paid will be published.

Future Forum: Governance arrangements should be prescribed and should have as a minimum a governing body that includes independent members and which holds meetings its in public.

Government response: Each group should have a governing body, with at least two lay members; commissioning group governing bodies must meet in public; professional membership will not be prescribed, but include at least one registered nurse and secondary care doctor who must not be employed by a local provider.

Future Forum: There should be a substantial transition period for moving to a levy-based funding regime for education and training – while the proposed levy on all providers that employ NHS staff was considered good, the forum said there could be unintended consequences, such as voluntary organisations recruiting only from outside the UK. The postgraduate medical deaneries must be retained and a new home found for them within the NHS.

Government response: Details of the transition for education and training will be set out in the autumn; proposals to ensure that all providers contribute to the cost of training will be phased in to avoid instability; the health secretary will be given a duty to maintain a system of professional education and training as part of the comprehensive health service.

…and across the wider healthcare sector over the past month

Reform and change are in the air – not only was most health attention in England focused on revisions to the government’s reforms, but June also marked the official launch of the Foundation Trust Network as a stand-alone organisation. FTN chief executive Sue Slipman (right) said the organisation would concentrate on persuading the government to maintain its positive stance on foundation trusts and ensure they weather the financial storm.

GPs nearing retirement are also considering change. A British Medical Association survey found that more than half the GPs who plan to retire in the next two years give the government’s planned reforms as a factor in their departure. More than 18,000 family doctors across the UK responded to a BMA survey (39%), though these preliminary findings are based on the first 10,000 responses. The reforms were the second most common reason for retirement (56%), with age being the most common reason (71%).

Over at the Audit Commission, change has been happening for a year. With the government planning to start scrapping the commission from next year, local government minister Grant Shapps announced it was likely the body’s in-house audit practice will be outsourced to the private sector. A letter to councils said ministers’ initial view was that outsourcing offered the best value option and asked the commission to prepare to outsource the 2012/13 audits. This would leave the commission radically smaller by 2013.

Elsewhere, the need for a continued focus on improving quality and increasing efficiency remained. The King’s Fund said England’s poor performance in key areas of cancer care compared with other countries was due to a number of factors, including availability of drugs, later diagnosis, delays in accessing treatment and age bias. A report, How to improve cancer survival, said the gap in survival rates for lung cancer had widened in recent years, while rates for older and deprived patients was worse than in other countries. There was better news on breast cancer, for which survival rates appear to be catching up. ?

The Department of Health reported that mixed-sex accommodation breaches had declined by 83% since December 2010. Health minister Simon Burns (right) said the Department’s tough action – greater transparency and penalties – had paid off. According to the May figures, just over 2,000 patients were placed in mixed-sex accommodation without justification, a 24% drop on April.

There was a timely reminder of the demand pressures for the NHS. Statistics from the Department of Health show the number of GP referrals to outpatients rose by 4% between the final quarters of 2009/10 and 2010/11. First attendance at consultant clinics increased by 4.4%. Inpatient admissions rose by 7.1% compared with the equivalent quarter in 2009/10. ?

The Royal College of General Practitioners insisted high-quality general practice is the most cost-effective way of delivering care. In a report on continuity of care in general practice, the RCGP said one day’s GP care was equivalent in cost to a tenth of a day in hospital.

Efficiency was high in the National Audit Office’s priorities when it examined NHS ambulance services. It said the NHS would save up to £165m a year if all ambulance trusts responded more appropriately to patients’ needs. Transforming NHS ambulance services found inefficiencies, with the cost per incident varying from £176 to £251 between trusts. There was scope to make better use of different ways of responding to patients, such as giving clinical advice to callers over the phone and taking patients to minor injuries units, not A&E.

The Department launched a consultation on plans to introduce centralised procurement of seasonal flu vaccines. The total cost of the seasonal vaccine programme is about £180m and the government believes this could be cut by up to £40m by introducing central procurement of the vaccine. Up to £15m a year could be saved by eliminating the fees paid to GPs to recognise the work needed to secure stocks of vaccine. Bulk buying could save a further £20m-£25m. The consultation closes on 17 August. ?

In a more wide-ranging move on procurement, the Department has thrown its weight behind the use of the GS-1 bar code system in the NHS. It said this would reduce variation in the prices hospitals pay for products and save the NHS significant sums of money. The Department will run central procurement of bar coding systems to allow trusts to use GS-1. But it said the decision to invest in the systems will sit with each trust and the savings made will cover the cost of investment. The Department will encourage suppliers to label their products with GS-1 bar codes and it expects all products to be identifiable by or carry GS-1 bar codes by the end of 2012.

Policy makers and watchdogs in Scotland, Wales and Northern Ireland got back to the day job, following the May elections to local administrations. New Northern Ireland health minister Edwin Poots said he would be focusing on better quality services, greater productivity and more powerful local commissioning. He said difficult decisions would be necessary and ‘every penny’ should be spent effectively, but quality of patient care rather than finance was his overriding concern. ?

The Welsh government gave the green light to initial plans for the £77m redevelopment of Ysbyty Glan Clwyd. As well as remodelling the hospital to bring services together, the redevelopment aims to ensure it meets the latest fire and health and safety standards. ?

In Scotland, auditors called on the government, NHS and councils to give greater backing to community health partnerships (CHPs) to allow them to tackle long-standing health and social care issues. An Audit Scotland report, Community health partnerships, found few CHPs – which manage £3.2bn in health and social work spending each year – had the authority to influence how resources were used. It called for a review of the partnership agreements to ensure there was clarity about how the funds are currently spent and where they could be better targeted. ?

Reaction in quotes

‘We have listened, we have learned, and we are improving our plans for the NHS. Ten weeks ago we paused our legislation. Today we show how we are improving it. We are taking people with us and it is in this spirit of unity that we are going to carry on listening and working together for the good of the NHS.’

Prime minister David Cameron launches the government’s response to the NHS Future Forum’s recommendations

‘The government’s health reforms are the biggest car crash in NHS history. The temptation to elevate short-term politics above long-term policy proved too much for David Cameron and Nick Clegg.’

Writing in The Daily Telegraph, former Labour health secretary Alan Milburn says the changes are less reformist than Tony Blair and Gordon Brown’s stance. He said the government would have to bail out the NHS before the next election.

‘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.’

King’s Fund chief executive Chris Ham warns of financial difficulties ahead

‘If the changes to the reforms go ahead, they are in real danger of neutering clinical commissioning. It would be tragic to see it join the rubbish dump of previous similar initiatives.’

Commissioning groups must not be overshadowed by the NHS Commissioning Board or secondary care, says NHS Alliance chair Michael Dixon

‘Doctors are not afraid of competition – in fact, they thrive on it. They want to know that they are working as well as, if not better than, their colleagues. But that is quite different from the unfettered free market of the industrial world, because the NHS must never be like that.’

British Medical Association chairman Hamish Meldrum vows to continue fighting against the ‘divisive features of the healthcare market’ in England

‘We are pleased to see that the government has recognised the importance of promoting integration, but believe it is also important to recognise that for some services the use of choice and competition is also an essential route to deliver the best patient care.’

NHS Confederation chief executive Mike Farrar says the government has listened to concerns, but the NHS must make the plans work

‘The government is creating a Frankenstein bill that should be thrown out now. The fact that the government is accepting the bulk of the Future Forum's recommendations simply underlines just how damaging the health and social care bill was and is to the NHS.’

Unison general secretary Dave Prentis says the revised bill is a horror story

The HFMA has published a quick guide to the NHS Future Forum’s recommendations, the government’s response and reaction from health lobby groups and think-tanks, which can be downloaded here.