News / News review - white paper, consultation documents, consultants' bonus review

Government plans for the NHS in England have commanded attention this summer. Proposals in the white paper and consultation documents make it plain the coalition wants to overhaul commissioning and regulation, as well as phasing out strategic health authorities and primary care trusts.

Despite whispers that the white paper, Equality and excellence: liberating the NHS, was a work in progress, Unison believed it was a finished product. Its head of health, Karen Jennings (left), launched a judicial review of the paper on the basis that staff, patients and the public were not properly consulted. The Department of Health is to defend the action.

GP-led consortia will take over commissioning of most secondary services and will be overseen by a new NHS Commissioning Board. Every GP practice will be a member of a consortium as a consequence of holding a patient list. Consortia will commission most services, including elective hospital, emergency, mental health and most community services. The NHS Commissioning Board will commission primary medical care, national and regional specialised services, maternity services and prison healthcare.

The board will structure the payment system and calculate GP practice budgets. Monitor, as economic regulator, will oversee pricing, promoting competition and ensuring continuity of services. Monitor and the board will decide which services should be subject to national tariffs. The development of currencies for pricing and payment will also be a joint responsibility, though the board will have primary responsibility for determining currencies.

Each GP consortium will have an accountable officer and chief financial officer, though the latter could work across several consortia. The government will consult on removing the cap on foundation trusts’ non-NHS earnings, while all trusts should be FTs in three years.

The white paper listed developments including currencies for adult mental health from 2012/13. Currencies for adult and neonatal critical care will be mandated from 2011/12. Tariffs will be moved to a best practice basis with ‘an increasing number’ introduced each year. Commissioners will also be able to pay quality increments and impose contractual penalties.

GP consortia will be accountable to the commissioning board for their management of public funds. They will be given incentives for good performance and will be required to join risk pools. There will be no government bailouts for consortia and a failure regime will be laid out by the Department of Health. There is little detail on the management of underspends and overspends, including whether any planned and managed underspends may be carried over to future years to invest in services or whether overspends will be deducted from the following year’s allocation.

Consortia are to be in place in shadow form in 2011/12, taking responsibility for commissioning in 2012/13 and financial responsibility from April 2013. The NHS Commissioning Board will allocate budgets to consortia for the first time in late 2012 for the 2013/14 financial year. Consortia will be able to decide which activities they provide in-house and which they buy in from public or independent sectors.

QIPP (quality, innovation, productivity and prevention) will continue with a ‘stronger focus on general practice leadership’, the white paper said. SHAs and PCTs should devolve the leadership of QIPP to GP consortia and local authorities as soon as possible. SHAs and PCTs must have an increasing focus on financial control during the transition period. NHS chief executive Sir David Nicholson (below) said the Department will strengthen its assurance mechanisms to keep a tight grip on finances during the transition. He said this would include monitoring and accounting in areas including the ‘detailed application of the 2% non-recurring funds to support delivery of change’. These arrangements would also cover financial support for named organisations and the deployment of other regionally lodged funds. Sir David is reported as saying the Department could ‘take powers’ over the 2% non-recurring funds, which amount to some £1.7bn.

With the government saying the reforms would help cut £1bn from NHS management costs, the white paper led to inevitable manager bashing. Doctors sprung to managers’ defence – British Medical Association GP leader Laurence Buckman said the reforms could not be implemented without experienced managers.

The NHS Institute for Innovation and Improvement will be the biggest casualty if the Department’s consultation on the future of arm’s length bodies is implemented. Six will remain, including Monitor, the National Institute for Health and Clinical Excellence (NICE) and the Care Quality Commission, while the NHS Litigation Authority and NHS Business Services Authority will be subjected to commercial reviews.

White paper aside, July and August was a busy time for health. Monitor chief operating officer Stephen Hay (left) told the HFMA foundation trust finance conference FTs must take a robust approach to applying tariff rules for additional activity. Mr Hay said many foundations were providing additional activity at high cost to the trust, sometimes at a loss and in some cases the trusts were not being paid at all for the activity.

The Holtham Commission, set up to examine Welsh funding, reported to the Welsh Assembly. The report said the Assembly should pursue the introduction of a simple needs-based formula to determine the Welsh block grant, replacing the Barnett formula. It also recommended the Assembly acquire limited powers to vary income tax and devolve corporation tax.

Finally, hospital consultants briefly made the news when the four UK health departments announced a review of payments made to consultants under the clinical excellence and distinction awards schemes. The NHS paid £202m in 2009/10 to consultants under the schemes. English health secretary Andrew Lansley said outstanding care should continue to be recognised, but in the current climate the service must ensure the system was effective and affordable.

The month in quotes

‘We all have responsibility to maximise return for taxpayer investment in health and healthcare and there are no exceptions. Some will drive the train; everybody else must be on it with a clear destination – improved health, reduction in health inequalities and supporting self care. World class commissioning may be dead – striving for world class healthcare is everybody’s business in the future NHS.’

NHS Alliance chief executive Michael Sobanja gives his perspective on keeping the reforms on track

‘Management is critical for good healthcare. None of the white paper’s ideas will succeed without good management by clinicians and specialist managers working together on the ground.’

Managers in Partnership chief executive Jon Restell

‘We cannot rise to this challenge without the help and expertise currently found in the NHS. We are also going to need to work with the best managers if this is going to be successful. We will need all the skills possible to make it work.’

BMA GP leader Laurence Buckman

‘This white paper could amount to the denationalisation of healthcare services in England and is the most important redirection of the NHS in more than a generation. A cornerstone of the argument is the NHS’s comparatively poor outcomes. The old certainties are gone: the NHS cannot be protected from economic reality any longer.’

Tribal’s business development director for health, Kingsley Manning