News / Next steps and operating framework: responses

King’s Fund chief executive Chris Ham was pleased the government had recognised some of the risks inherent in its plans by testing some proposals and acknowledging the importance of ensuring that the skills and expertise of staff currently in primary care trusts should not be lost in the transition to the new structure.

However, he added: ‘We would disagree with the assertion that structural changes will help meet the productivity challenge and the ambitions of the government’s QIPP agenda. While proposals are being phased in more carefully over four years, we share the concerns set out by the health select committee, that they will still act as a distraction from delivering the enormous productivity improvements required across the system.’

The health service faces an immense challenge, according to NHS Confederation acting chief executive Nigel Edwards. It will grapple with the need for unprecedented efficiency savings, major management cuts and radical structural reforms. The reforms were high risk and may not deliver what is claimed for them.

‘There is a real squeeze on hospital budgets that will seriously effect their income. NHS leaders up and down the country are really worried about the prospects for the next two to three years,’ he said.

‘One danger of predicting major problems in the NHS is its ability, against the odds, to rescue the situation. But, much of the machinery the NHS has traditionally used to achieve such change is being dismantled, devalued or suffering from reductions in capacity,’ he added.

David Bennett, Monitor interim chief executive, said the government’s response to the white paper consultation had cleared up many of its concerns. The regulator was pleased it will be given a role in all aspects of price setting and this would be important in ensuring the efficiency challenge facing the NHS can be met.

‘The government has also accepted the need for a “safety net” during the transition period. This means that Monitor will temporarily continue some of its existing compliance measures for newly-authorised foundation trusts (authorised after April 2012) for two years after authorisation, and for some other foundation trusts until April 2014.

‘There is still some detail to be worked out to ensure an effective transition to the proposed new system, especially around how to support governors in providing the appropriate level of oversight and challenge to foundation trusts,’ he added.

The NHS Alliance welcomed the announcements on funding levels for consortia running costs from April 2013; the ‘backfill’ payments for GP time from April 2011 and the development of PCT clusters to support development of GP commissioning consortia.

It was also pleased GP commissioning consortia will not be responsible for PCT legacy debt at the point they assume financial control in April 2013.

NHS Alliance chair Michael Dixon said: ‘The reforms should not be seen as a condemnation of the hard, loyal work of many NHS managers who have played vital roles. Good management will be essential in the new system, as the secretary of state has repeatedly emphasised.’

Meeting the £20bn quality and productivity challenge required greater input from the clinical team, focusing relentlessly on patient outcomes and high-quality, safe and integrated care.

He added: ‘Those who fear this change or are too wedded to the old system should go now, as NHS chief executive Sir David Nicholson has emphasised. The structures and systems of NHS management must be the servants of good, safe patient care – and never its masters. We must not get spooked by scary noises and rattled chains from The ghosts of systems past.’

The British Medical Association was less pleased. BMA council chairman Hamish Meldrum said there was little evidence the government was prepared to engage in constructive criticism of its plans.

‘Most of the major concerns that doctors and many others have raised about the white paper seem, for the most part, to have been disregarded,’ he said. ‘The response completely fails to acknowledge that proposals to increase competition in the NHS will make it harder for staff to work more co-operatively. While we still believe that clinician-led commissioning can improve patient care, this document does not provide assurance that it will be implemented effectively.’

He added: ‘Given the latest inflation figures, we do not accept the government’s claim that it is increasing real terms funding for the NHS. The stated 3% “increase” in funding for primary care trusts includes £1bn already announced to cover additional social care responsibilities and masks the fact that hospitals will have to do a lot more work to achieve the same income. Patients across the country are already discovering that local services are being rationed to achieve efficiency savings, and there are likely to be further NHS cuts on a scale we have not seen for many years.

‘The BMA will consider the government’s response in detail, but our initial reaction is that they seem committed to charging forward with these changes despite the warnings and despite the risks.’

Royal College of General Practitioners (RCGP) chair Clare Gerada welcomed the government’s response to some concerns, but said questions remained.

‘These include the pace of change and how this sits alongside having to make unprecedented savings; how to balance patient choice with health inequalities (those with the greatest health needs are often those with the least ability to exercise choice); and how the policy of “any willing provider” may impede the development of effective coordinated services as well as drive up the cost,’ she continued.

‘Our starting point is what delivers the best outcomes for our patients.  We firmly believe putting GPs at the centre of commissioning is the right way forward and we will continue to engage with the Department to shape the policy so it is safe for patients, safe for GPs and safe for the NHS.’

The reforms remained risky, according to Royal College of Nursing (RCN) chief executive and general secretary Peter Carter.

‘While we note the increased funding for commissioning services, this comes as the NHS in England is being asked to save up to £20 billion in efficiency savings – a huge challenge – and the risks are still considerable. Furthermore as we have identified 27,000 NHS jobs earmarked to be cut to date, it is misleading to suggest that the NHS frontline is being protected.

He warned there was a risk that services will become fragmented as consortia could become reluctant to collaborate and share good practice.

Mr Lansley’s plans were a ‘big mistake’, according to Unison. Head of health Karen Jennings said the timing of the reforms could be worse, coming alongside the affirmation of the £20bn efficiency challenge in the operating framework.

‘The combination of this major reorganisation alongside the £20bn demanded by the government in efficiency savings, creates a lethal cocktail that is a danger to patients.?? Lansley’s so-called consultation was a sham and a foregone conclusion. By forging ahead with his plans in the teeth of fierce opposition from leading health experts, patient groups, staff, unions and GPs themselves, he is showing an utter disregard for the long term future of the NHS,’ she added.

Responding to the operating framework, NHS Employers director Dean Royles welcomed the government’s move to put employers at the front of new arrangements for workforce planning, education and training.

But he added: ‘The financial context for workforce decisions remains challenging and this is reflected in the framework. We have worked with the health trade unions through the Staff Council on proposals that are included in the framework. If agreed, these provide staff with significantly improved security of employment in return for foregoing pay increments for two years. Any saving made by these proposals would be kept by individual NHS organisations and help them to protect staff from avoidable compulsory redundancies.’