Assessing the NHS White Paper

There are many good things to take from the White Paper on NHS reform released yesterday. The general thrust behind it - patient choice and clinician led care - is a good one. For too long, politicians have bogged the system down, and healthcare staff conformed to targets set by Whitehall. Yesterday's paper saw the introduction of GP consortia to carry out commissioning, which will be free to buy services from willing providers who will compete to provide services. We've said before that the NHS was too closed off to competition. This story shows how practice-based commissioning could work in practice – and this White Paper goes further than the previous government’s plans.

More good news is that hospitals will all become Foundation Trusts, with the yoke of Strategic Health Authorities (SHAs) removed as they will be abolished. They should therefore have more independence than existing Foundation Trusts. Primary Care Trusts (PCTs) will be scrapped; the White Paper suggests that PCTs add £1 billion of administrative costs to the NHS each year so this is a positive move. So considering that SHAs enforce commissioning on local providers that often know better and PCTs tend to be subservient to the whims of SHAs, in theory two layers of bureaucracy have been removed.

In theory. Because when quangos are removed, their function is often passed off to another body. The PCTs' role in public health has been transferred to local authorities, who must now hire a director of public health; a post with statutory duties. The problem with this is how councils choose to enact the statutory functions - there are often interpretative differences between councils which mean they do drastically different things to perform the duty, often costing more money than is necessary.

Some functions of the SHAs will now be performed by a single body - the NHS Commissioning Board. This new body will be very powerful and it's important, crucial, vital that it will be properly and regularly accountable to parliament and taxpayers.

There will be other new quangos to get to know: HealthWatch England and local HealthWatch bodies will "ensure that the views and feedback from patients and carers are an integral part of local commissioning across health and social care". This is quango-making at its worst. It’s almost as if civil servants sat around a table said to themselves: “How can we prove we are all about patient power? Let’s just make a body to deal with it. And let’s put the words in the name of it together to form a single meaningless word. People like that.” This is an incredibly inadequate solution and no substitute for actual patient power. The Public Health Service will oversee local directors of public health from within the Department of Health – more top-down bureaucracy? Can the Care Quality Commission not perform this task in its revised role as a quality-only regulator?                                                           

On pay, the document says:

"Pay decisions should be led by healthcare employers rather than imposed by the Government. In future, all individual employers will have the right, as foundation trusts have now, to determine pay for their own staff. However, it is likely that many providers will want to continue to use national contracts as a basis for their local terms and conditions."

The first two sentences sound great; they are rendered useless by the third. If centralised pay bargaining is retained then the NHS will not be able to tackle its biggest expenditure. As well as being grossly unfair, despite what the unions say, it has serious consequences for patients too. Any reform should address this as a matter of priority and the White Paper fails here.

On IT, there was notable silence over the future of the National Programme for IT – otherwise known as the supercomputer. This expensive and failed project should be scrapped, but the White Paper's omission of it leads one to suspect that it may be sticking around for a while.

Over at the Burning Our Money blog, there are some sound cautionary notes on just how much patient choice there can actually be. It may be hindered as the patient still won’t be the one with the money, so choice could be more limited than we might hope.

Overall though, there are some positive aspects to this document. But transparency will be crucial in all areas and should be the watchword throughout. For example, GP consortia should not be allowed to enter cosy relationships with Providers; contracts between them should be transparent to ensure accountability. And this could even mean more genuine competition and lower costs. Also, as pointed out yesterday, GPs could have a financial incentive that distorts their decisions when advising patients, so transparency will be needed to help offset this risk. Sunlight is the best disinfectant - every doctor knows that.

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