On 12 July 2010, the coalition government released a new white paper setting out the proposed direction for the NHS. This white paper is designed to build on the successes of previous governments whilst addressing some of the key problems which have plagued the NHS over the previous years. The key points of the new direction include:
- Giving patients greater choice and control, and equipping them to make decisions through the provision of a greater range of data.
- Focussing on clinical outcomes rather than targets, building on Lord Darzi’s review and particularly its focus on quality. The aim is to provide continuous improvement through reduced bureaucracy and greater focus on clinical outcomes.
- Empowering clinicians and other healthcare professionals to use their judgement and innovate. This bottom-up approach is designed to draw upon the strengths and knowledge of front-line staff, ridding the system of the top-down approach much criticised in the past, with decisions taken centrally by less-informed politicians.
The following paragraphs constitute a summary of the main points raised by the white paper:
Liberating the NHS
- Age discrimination to be abolished (e.g. patients above or below a certain age being entitled to certain drugs). Note that this is not so much a new policy of the government. It is imposed through a European Directive.
- More power devolved to local NHS institutions with less interference from Whitehall. “We will be clear about what the NHS should achieve; we will not prescribe how it should be achieved”.
- Greater powers to local clinicians. This will involve a radical simplification of the hierarchy and the removal of several layers of management. Monitor (which currently regulates Foundation Trusts and ISTCs)will become the regulator.
- A greater focus on reducing inequalities and improving public health, with the creation of a new Public Health Service.
- NHS spending to be increased in real terms every year over the lifetime of the parliament (i.e. until 2015), but accompanied by efficiency savings. It is expected that the headcount will be lower in 2015 than currently (though this will be most likely through the elimination of managerial posts).
Putting patients and the public first
Shared decision-making
- One of the key mottos of the white paper is “no decision about me without me”. The report therefore reinforces the idea of patient choice and patient involvement. This is to be supported by an increase in the amount of information being made available to patients on conditions, treatments, lifestyle choices and on how to look after their own and their family’s health. In essence, better informed patients are more likely to want an input in their own care, and less likely to defer to clinicians’ opinion blindly.
- It is planned to expand the Patient Reported Outcome Measures tool more widely.
Greater availability of information and more accountability
- Data collected on patient experience and real-time feedback will take more prominence and will also be made publicly available, as will all data relating to the quality of services delivered by the various clinical services and departments. It is expected that the use of quality account will be perfected and disseminated to ensure that the public is made fully aware of the quality of care provided by the various services.
- Greater control to be given to patients over their own health records. Patients will be able to decide who can access their records and to see changes whenever changes are made. This is expected to apply to GPs to start with, to be extended to other services later on.
Increased choice and control
- The paper quotes the 2009 British Attitudes Survey which states that 95% of patients think there should be some choice over which hospital they should attend and the treatment they should receive. In the interest of debate, note that this is not the same as saying that, once given the choice, patients would be prepared or happy to exercise it (in fact GPs often complain that patients end up either choosing on the basis of proximity or defer the choice to the GP).
- The paper complains of the fact that the Labour government’s attempt to introduce choice was too restricted to the choice of provider. The new government is aiming to:
- Increase the current offer of choice of any provider significantly.
- Create a presumption that all patients will have choice and control over their care and treatment, and choice of any willing provider wherever relevant
- Introduce choice of named consultant-led team for elective care by April 2011 where clinically appropriate, and maximise the use of Choose & Book. Note that the patient will not necessarily be seeing the consultant, but his/her team. A patient may still be seen by a trainee or a nurse for example.
- Extend maternity choice and help make safe, informed choices throughout pregnancy and in childbirth a reality – recognising that not all choices will be appropriate or safe for all women – by developing new provider networks.
- Begin to introduce choice of treatment and provider in some mental health services from April 2011, and extend this wherever practicable.
- Begin to introduce choice for diagnostic testing, and choice post-diagnosis, from 2011.
- Introduce choice in care for long-term conditions as part of personalised care planning. In end-of-life care, there will be a move towards a national choice offer to support people’s preferences about how to have a good death. The government will work with providers, including hospices, to ensure that people have the support they need.
- Give patients more information on research studies that are relevant to them, and more scope to join in if they wish.
- Give every patient a clear right to choose to register with any GP practice they want with an open list, without being restricted by where they live. People should be able to expect that they can change their GP quickly and straightforwardly if and when it is right for them, but equally that they can stay with their GP if they wish when they move house.
- Develop a coherent 24/7 urgent care service in every area of England that makes sense to patients when they have to make choices about their care. This will incorporate GP out-of-hours services and provide urgent medical care for people registered with a GP elsewhere.
Patient and public voice
A new consumer champion called HealthWatch England will be created within the Care Quality Commission to look after the interest of patients and ensure that patient views and feedback are taken into account.
Improving healthcare outcomes
The government is intent on building on the principles of quality set out in the Darzi report. Having already modified some of the key targets for the year 2010-2011, the government wants to ensure that targets with no clinical relevance are scrapped and replaced by evidence-based measures and targets.
The NHS outcome framework
The government will set out the key outcomes that need to be achieved and will leave it to local authorities to determine how those objectives are best achieved. This will target 3 distinct areas of quality:
- the effectiveness of the treatment and care provided to patients – measured by both clinical outcomes and patient-reported outcomes;
- the safety of the treatment and care provided to patients; and
- the broader experience patients have of the treatment and care they receive.
Quality standards and incentives for improvement
- NICE will develop 150 quality standards over the next 5 years.
- Quality is expected to be rewarded financially (an old idea formalized by Darzi but never really put into practice to date).
- Tariffs will be refined and the implementation of best-practice tariffs will be accelerated.
- The CQUINs payment framework will be extended and poor quality care may be penalised by fines (Note that this penalisation policy is one which was adopted by the Labour government for underperforming schools – this backfired, with underperforming schools having less money to invest to make improvements, causing them to underperform even further. Such policy will therefore need to be carefully implemented and managed).
- Payments to pharmaceuticals are expected to be reviewed to provide better value.
Autonomy, Accountability & Democratic Legitimacy
GP consortia
Commissioning powers will be devolved to GPs through the creation of GP consortia. They are expected to be responsible for 80% of the budget.
NHS Commissioning Board
This new independent board will oversee the commissioning process and issue guidelines. It will design the structure of the tariffs and other incentives, though actual tariff levels will be set by Monitor. The Board will also ensure full patient participation and involvement, and will overseas the GP consortia. In addition it will commission services not commissioned by consortia such as maternity services and very specialised services. This means that the commissioning function will be taken out of the PCTs’ hands and PCTs will therefore be abolished, saving £1 billion in administration costs alone.
Freeing existing NHS providers
All Foundation Trusts are to be freed of current constraints and it is expected that all trusts will become foundation trusts within 3 years (Note: the Labour government had set a deadline of December 2008, which was never met).
The Care Quality Commission will monitor the quality of healthcare provided whilst Monitor will act as an economic regulator from April 2012. Monitor’s role will be to promote competition and regulate prices.
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