The document summarizes the current state of NHS reforms in the UK. It describes the NHS under the previous Labour government, including increased spending, improved access and outcomes. It then outlines the efficiency challenges facing the NHS and key proposals in the new White Paper, including establishing independent commissioning bodies and transferring public health to local governments. It discusses the mixed reaction to the proposals and an announced "policy pause". It considers potential impacts and risks going forward, such as the challenges of transitioning to the new system while achieving major efficiency savings.

1. Current state of NHS reforms
Dr Judith Smith
Head of Policy
Canadian Masterclass
17 May 2011
May 2011 © Nuffield Trust

2. 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 Trust

3. May 2011 © Nuffield Trust

4. May 2011 © Nuffield Trust

5. 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

6. © Nuffield Trust

7. 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

8. © Nuffield Trust

9. 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

10. 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

11. 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

12. 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

13. © Nuffield Trust

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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
May 2011 © Nuffield Trust

20. 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
May 2011 © Nuffield Trust

21. 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
May 2011 © Nuffield Trust

22. www.nuffieldtrust.org.uk
Sign-up for our newsletter
www.nuffieldtrust.org.uk/newsletter
Follow us on Twitter
(http://twitter.com/NuffieldTrust)
May 2011 © Nuffield Trust