• 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:  

1. Increase the current offer of choice of any provider significantly. 
2. Create a presumption that all patients will have choice and control over their care and treatment, and choice of any willing provider wherever relevant 
3. 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. 
4. 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. 
5. Begin to introduce choice of treatment and provider in some mental health services from April 2011, and extend this wherever practicable. 
6. Begin to introduce choice for diagnostic testing, and choice post-diagnosis, from 2011. 
7. 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. 
8. Give patients more information on research studies that are relevant to them, and more scope to join in if they wish. 
9. 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. 
10. 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.

1. Primary care trusts will be partially elected to give patients a strong voice locally, with the remainder of the board appointed by local authorities. But the chief executive and principal officers will be appointed by the secretary of state on the advice of the new commissioning board.
2. The board will allocate NHS resources and provide commissioning guidelines. The Conservatives’ original proposal was for a strong board that would oversee the whole of commissioning, a role that looked to be stronger than just appointing people and issuing guidelines. So that proposal has obviously been watered down as part of the coalition agreement.
3. GPs will be given a stronger role in commissioning, though for the moment it is not clear as to whether this will be simply be an advisory role or actually a budget-holding role. The government will “strengthen the power of GPs as partients’ expert guides through the health system by enabling them to commission care on their behalf.
4. Development of a 24-hour urgent care service in England, “including GP out-of-hours services”. The GP contract will be renegotiated and an incentive system will be implemented to improve primary care in disadvantaged areas.
5. Promise to fund some cancer drugs that Nice  has turned down.
6. Promise that patients will be free to register with any GP, not just their local one.
7. A number of health quangos will be cut (though it is not clear which).
8. “Give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices”.

In addition, the health secretary has put a halt to current plans to change the NHS in London and issued the following statements: 

“As I promised before the election, I am calling a halt to NHS London’s reconfiguration of NHS services.

“A top-down, one-size fits all approach will be replaced with the devolution of responsibility to clinicians and the public, with an improved focus on quality.

“It will be centred on a sound evidence base, support from GP commissioners and strengthened arrangements for public and patient engagement, including local authorities.”

Want to know more about NHS issues? Why not join our medical management course on NHS issues. One day, max 16 candidates to make it an interesting interactive course. Only £249.

1. How can we maintain quality of care whilst cutting costs at the same time?
2. If I told you that we needed to cut costs in your department by 15%, where would you find the cost savings?

In giving answers to such questions, the majority of candidates are having trouble distinguishing between cost savings and cost efficiency. Some then picked on by interviewers or get feedback that they had a poor graps of basic business concepts. I thought it would be useful to deal with this topic in an article in an attempt to remove any ambiguities.

Cost efficiency means that for a given cost, you are making the best use of the resources available. So for example, if a nurse costs the department £35,000 p.a. then she is cost efficient by being made to see as many patients as possible. In other words, you are getting the most out of the cost.

Cost cutting however refers to the fact that the cost of employing the nurse in the first place would be lowered. In other words, this would involve demoting her to a lower salary (tricky!) or making her redundant (tricky too, but far more feasible). 

Note that when you are making the nurse see more patients, you are actually cutting the cost of dealing with one patient (since her salary is spread over more patients than before but you are not cutting the cost of her employment.

When you get questions on cost-cuttings, they refer to cutting the overall cost and not the cost per patient. Overall, there are many ways in which costs can be cut in an NHS environment, which would include:

1. Making staff redundant (salaries are the biggest expense).
2. Using cheaper drugs (drugs are the second largest expense).
3. Moving to day-case surgery, thus enabling a cut in the number of ITU beds, lowering the number of infections and readmissions (thus enabling redundancy of staff)
4. Using cheaper staff to carry out tasks (e.g. replacing doctors by nurses, consultants by senior staff grades.
5. Using permanent staff instead of locums
6. Replacing one consultant by increased PAs for the other consultants in the team (the total cost to a Trust of paying 8 consultants £10,000 more is lower than paying one consultants £80,000)
7. Encouraging follow-ups to be done by GPs (thus enabling redundancy of staff)

So for example, in anaesthesia, implementing pre-operative assessment clinics would lower the number of cancellations because patients would be better assessed and any risks identified. This would result in a fuller utilisation of the resources available and therefore greater efficiency, but not in cost savings because the trust would have to pay the salaries, theatre time, etc just the same.

Hope this helps! Good luck to everyone!

Candidates applying for consultant posts are very good at scaring themselves about NHS issues during their preparation for the big day. Across the range of thousands of candidates that we coach every year for their consultant interview, it is common to hear comments of the type: “I heard they can ask you anything about NHS issues” or “I don’t understand anything to all this management stuff”.

In reality, although it is of course important to understand what is going on in the NHS, the emphasis is not so much on knowing a lot of facts, but on understanding at a more global level how this will affect your speciality in the forthcoming years and therefore your role as a consultant in the unit which you are aiming to join. Doctors have always been trained to learn information which is then tested at exams. At the interview, it is your awareness and analytical power which is being tested rather than your ability to regurgitate information.

As such, it is unlikely that you will be asked very factual consultant interview questions such as “What are the 8 ways in which the clock can stop for the 18-week target calculation?”; and you will only be asked questions of the type “Tell me what you know about Darzi.” in the 4 to 6 weeks or so following the publication of a report.  Instead, you are far more likely to be tested on the broader implications of those reports, which, by itself, does not require any detailed knowledge of those issues. For example, currently, consultant interview questions associated with the Darzi report are more likely to be of the type:

• “How can we improve quality of care in a cost-cutting  environment?”, a question which refers both to the emphasis on quality in the Darzi report and to the forthcoming cuts in NHS budgets, but requires no specific knowlegde of the Darzi report. Instead, it requires a good knowledge of the areas of inefficiencies in your speciality in general and in the department that you are aiming to join.
   
• “How would you measure quality of care in your specialty?”, a question which relates directly to the Darzi report, Patient-Reported Outcomes Measures (PROMs) and patient experience, thus linking to the auditing of key performance indicators and patient feedback, neither of which are fully developed in the Darzi report.
   
• “How can we improve the quality of training in the current environment?”, a question which relates not only to the diminishing hours of training imposed by the EWTD, but also to the fact that spending time on training juniors is not always compatible with a drive towards efficiency and cost-cutting. No report will give you the answer to this question.

Consequently, although it is of course important to read and understand the key reports published by various organisations, you should not fall into the trap of trying to learn their content with a view to regurgitate it. Instead, you should make note of the key issues and try to understand their practical implications.

One of the greatest difficulties in reading about NHS issues is that it seems like there is an endless supply of documents. So don’t make the mistake that many candidates at consultant interviews make, which is to start right back to 1948. No one really cares about the old issues, and even the Tooke report which dates back to 2008 is no longer talked about. Look at the key documents published in the last 18 months or so, both at a global governmental level (e.g. Darzi) and at speciality level (e.g. recent NICE guidelines, Royal College strategy documents, etc). You may start with one and find that it refers to 2 or 3 others, which in turn refer to 2 or 3 others. It is important that you follow the trail so that you can appreciate how they all interlink. This should take about 4 or 5 hours of your time. If you feel that you are spending excessively longer then you are probably spending too much time on the detail.

Then, once you have a rough idea of what it going on, think of the implications. Try to do this by yourself to start with because at the interview there will be no one to help you, so it is important that you forge your own opinions and ideas about the implications of what you read.

Some of those implications may be common sense (for example, if you are place an emphasis on productivity and cost saving then training may be affected) but others may be less obvious to you simply because you are not involved in the day-to-day management of their unit. For that reason, as a second step. it is useful to discuss issues with your educational supervisors as well as  clinicians in their team how this influences their speciality and their department in practice. If you are applying for a job as an external candidate, it is also extremely useful to raise those issues at pre-interview visits so that you can get the local point of view on all important matters (knowing you may well be quizzed on those at your consultant interview).

All those impostant NHS topics are also obviously discussed on our consultant interview courses.