© Nuffield Trust

Current state of NHS reforms

Dr Judith SmithHead of Policy

Canadian Masterclass

17 May 2011

May 2011

© Nuffield Trust

The NHS at the end of New Labour

• Unprecedented increases in health spending • Major reductions in waiting times• Choice of elective provider• Choice of date and time of outpatient appointment• New forms of access - NHS Direct helpline, walk-in centres• Investment in staff numbers and pay• Renewal of the infrastructure – hospitals, primary care,

diagnostic and treatment centres, IT

May 2011

© Nuffield TrustMay 2011

© Nuffield TrustMay 2011

© Nuffield Trust

The NHS at the end of New Labour (2)

•Improvement in clinical outcomes

•Ranking well in international comparisons (e.g. CWF)

•Public satisfaction at an all-time high

•Persisting and worsening inequalities in health

•NHS largely absent from election debate in 2010

•Conservative Party keen to ‘detoxify’ the NHS as an issue

•Liberal Democrats’ concerns mainly focused on local governance of commissioning, and integrated care

• But it was clear that the money was running out...

May 2011

© Nuffield Trust

© Nuffield Trust

The efficiency challenge

•Reversing the reduction in overall NHS productivity

•Addressing large and unaccountable variations in clinical practice

•Stemming the increase in emergency admissions

•Actually making the shift from hospital to community care

•Dealing with the duplication and fragmentation that occurs in care that crosses provider and budgetary boundaries

•£20billion of efficiency savings by 2015

May 2011

© Nuffield Trust

© Nuffield Trust

The White Paper Liberating the NHS

• Secretary of State for Health who had spent a long time in opposition, and had got carefully developed plans

•White Paper published two months after the Coalition Government was formed

•Key policy proposals reflected Conservative manifesto (GP commissioning, national board, focus on outcomes, changes to public health)

May 2011

© Nuffield Trust

The White Paper (2)

Main elements

• A national NHS Commissioning Board independent of the Department of Health – to allocate resources, set commissioning framework, buy specialised and primary care services, hold commissioners to account

• An NHS Outcomes Framework as the basis for system accountability

• GP commissioning consortia to become the main statutory health purchasers with 60-80% of NHS funding

• All primary care trusts and strategic health authorities to be abolished

© Nuffield Trust

The White Paper (3)

• Local health and wellbeing boards to oversee, scrutinise and co-ordinate commissioning plans for a local population

•Public health to move from the NHS into local government

• All providers to become foundation trusts

• A new economic regulator, licensing providers, promoting competition, setting and monitoring prices, safeguarding service continuity

• Strengthened role for the Care Quality Commission

© Nuffield Trust

Reaction to the White Paper

•Cautious welcome at first from national bodies re addressing weaknesses in commissioning, clinical involvement

•The abolition of PCTs and SHAs came as a surprise to many

• Plans to have GP commissioning as the ‘only game in town’ were also more extensive than anticipated

• Other elements, such as changes to competition, regulation, and public health, did not attract extensive discussion initially

•The summer intervened....

May 2011

© Nuffield Trust

© Nuffield Trust

A health system in transition

• Four consultation papers were published with more detail of the reforms

• By September, NHS management was doing what it arguably does best, planning and implementing a reorganisation

• As the formal consultation closed, national organisations declared their hand

• A range of criticism, some clearly oppositional to the reforms, other more focused on improvement of plans

• A lot of ‘too far too fast’ commentary

© Nuffield Trust

A health system in transition (2)

• Significant concern about proposals to extend competition in the NHS

- widespread call to remove plans for price competition- policy of ‘any willing provider’ seen as ‘privatisation’- concern that proposals would open the NHS up to EU competition law

• Concern about readiness of GPs to commission• Questions as to how the system could ‘stay safe’ in quality

terms during such major change• And anxiety that the NHS would be distracted from the

financial challenge and ‘lose its grip’

© Nuffield Trust

A ‘policy pause’

• Announced in early April• Health and Social Care Bill put on hold• NHS Future Forum of professionals and patient groups

May 2011

© Nuffield Trust

Where might this take us?

• Option 1 – proposals implemented much as in the White Paper, GP commissioning enthusiasts get stuck in, the others are corralled, NHSCB takes a firm grip, but is this politically possible?

• Option 2 – clinical (not just GP) commissioning, with less focus on competition and more on integration, but how different would this be from PCTs?

• Option 3 – local commissioning authorities with councillors, patients, professionals and others on statutory board, but would the clinicians walk away?

May 2011

© Nuffield Trust

Risks facing the NHS

• The known costs (financial, service, and human) of transition

• The transition being drawn out even further, and recourse to a lowest common denominator solution

• Taking the eye off the financial ball• Lacking governance and management arrgts (NHS and

LA) to deal with financial pain and change• Slash and burn as a panic response to lack of QIPP

progress• The NHS becoming a major political issue again

May 2011

© Nuffield Trust

Opportunities presented

• To think through implementation issues in more depth• To build and sustain PCT clusters as key elements of

stability and safety for the system• To craft new incentives for clinical and provider innovation

– GP commissioning doing what it does best• To work through the complex issues of conflicts of interest,

competition etc.• To refine legislation in a way that is more usually

associated with countries working in coalition• To shape implementation – for that is where the real devil

in the detail lies

March 2011

© Nuffield Trust

And what does this all mean for the financial challenge?

• Major challenge for NHS management and clinical leadership

• Time is being lost by the day – distraction of the transition, policy pause causing confusion and hiatus

• It could get bloody next winter• The reforms will be blamed for the problems arising from

financial challenge• These in turn will be harder to tackle when the reforms are

perceived as ‘the problem’• Some early wins by clinical/GP commissioners will be

essential

March 2011

© Nuffield Trust

To conclude

‘ This is an unprecedented programme of organisational change [...] made more challenging by the efficiency target applied to the health service, and the demand for a 45 per cent reduction in management costs. [...]

Policy-makers and officials are balancing the twin pressures of the urgency of reform with maintenance and improvement of financial and service stability.’

Smith and Charlesworth, 2011, p13

March 2011

© Nuffield TrustMarch 2011

www.nuffieldtrust.org.uk

Sign-up for our newsletterwww.nuffieldtrust.org.uk/newsletter

Follow us on Twitter(http://twitter.com/NuffieldTrust)

© Nuffield Trust