Despite pledging to stop top-down reorganisations, the Coalition Government announced its intention to undertake a large scale restructuring of the NHS in its July 2010 White Paper, Equity and Excellence: Liberating the NHS. The changes put forward by Andrew Lansley, then Secretary of State for Health, were described by Sir David Nicholson, NHS Chief Executive, as so big that they were ‘visible from space’.
The White Paper set out the proposed abolition of two whole tiers of NHS management, with GP Consortia taking charge of the bulk of the NHS budget. The scale of the reorganisation, its ambitious timelines and its promotion of competition as the driver for service improvement gave rise to considerable opposition within Parliament, as well as criticism from the clinical community and patient groups. Under pressure from stakeholders, the Government had to halt the Health and Social Care Bill’s passage through Parliament to conduct a ‘listening exercise’, which led to significant compromises on the White Paper’s original vision. It took the Government until March 2012 to pass the heavily amended Bill.
Despite the controversy generated by the reforms, the concerns voiced by its opponents largely failed to materialise as the new NHS system went live on 1 April 2013. Despite the Opposition’s effective campaign messaging prior to the completion of the passage of the Bill, the Government is still able to point to the fact that the NHS remains a tax-funded comprehensive service, free at the point of use and based on one’s clinical need rather than the ability to pay. However, whether the reforms will deliver the service improvements they promised remains to be seen.
When evaluating the Government’s progress on the NHS, one has to keep in mind that the pledges included in the Coalition’s Programme for Government do not always mirror the proposals outlined in the White Paper. Famously, a significant breakdown in communication is believed to have taken place, resulting in the authors of the Programme for Government being left unaware, or choosing to ignore, Andrew Lansley’s plan when drafting the document. Despite the inconsistencies between the two documents, they share three broad goals: to make the NHS more outcome-focussed, clinically led and patient-centred. It is against these goals that the Government would like its reforms to be judged.
The Government is making good progress against the first two of these objectives, while more evidence is needed to make a fair judgement on the third. Through the introduction of the NHS Outcomes Framework, health outcomes have been established as the central measure of performance in the NHS. Through its five domains, the NHS Outcomes Framework targets improvements in preventing people from dying prematurely; enhancing the quality of life for people with long-term conditions; helping people to recover from periods of ill health or injury; ensuring that people have a positive experience of care; and treating and caring for people in a safe environment.
With regard to putting clinicians in the driving seat, NHS England has overseen the authorisation process of 211 GP-led Clinical Commissioning Groups, which officially took over around 60 per cent of the total NHS budget on 1 April 2013. The reforms also established additional advisory bodies such as Clinical Senates, Strategic Clinical Networks and Clinical Reference Groups, which are intended to provide expert clinical advice to commissioners in the new NHS. Having scrapped the management-heavy Primary Care Trusts and Strategic Health Authorities, and replaced them with a set of more clinically focussed organisations, the Government made a significant step towards strengthening the role of clinical leaders in the NHS.
While considerable progress has been achieved with regards to making the NHS more outcome-focussed and clinically-led, the Government has so far enjoyed only limited success in terms of patient empowerment. Despite the ever-present mantra of ‘no decision about me, without me’, the voice of patients is still not as strong as it could be. Even though Healthwatch, the new consumer champion, has been established on both a national and local level to advise decision makers, patients themselves still have little control over their care. In many areas, patients are still not able to choose their GP and universal access to patients’ own medical records will not be granted until 2015. The easy-to-interpret comparative data that patients may wish to use to choose their healthcare provider is still not readily available. The Government still has not made it clear how it would ensure that greater access to patient data does not contribute towards the widening of health inequalities; putting people with limited computer literacy skills at a disadvantage.
The Health and Social Care Act came with significant political and practical implications for the Government, and these will become more pronounced as the General Election approaches. It was one of Andrew Lansley’s intentions to distance the Department of Health from the day-to-day running of the health service through putting the independent NHS England in charge. However, the Government could feel tempted to interfere with internal NHS decisions if it was perceived to perform sub-optimally before the election. Pointing out the fact that the Government is no longer directly responsible for the running of the NHS would probably be a vote loser, generating more negative coverage.
Even if the reforms generate their intended outcomes, it is possible that the evidence to prove this will not be available until after the next election. As a result, the Government would probably be happy if the NHS was not the focus of the electoral agenda prior to 2015. Indeed, given the Opposition’s association with the process culture blamed for the failures at Mid-Staffordshire, giving the NHS a lower profile in the election campaign could suit both parties.
Progress against the Coalition Agreement
Pledge: We will guarantee that health spending increases in real terms in each year of the Parliament, while recognising the impact this decision will have on other departments.
Status: Not achieved - While the Government says that it has delivered on this pledge, in December 2012 the UK Statistics Authority upheld Labour’s complaint about this claim. It concluded that health spending was actually lower in 2011-12 than in 2009-10. This plays into the Opposition’s line of argument that the NHS is not safe in David Cameron’s hands.
Pledge: We will stop the top-down reorganisations of the NHS that have got in the way of patient care. We are committed to reducing duplication and the resources spent on administration, and diverting these resources back to front-line care.
Status: Not achieved – The passage of the Health and Social Care Act 2012 signified a major reorganisation of the NHS. As part of the broader restructuring, Clinical Commissioning Groups took control of the bulk of the NHS budget in April 2013.
In October 2012 Jeremy Hunt, Secretary of State for Health, admitted that the implementation of the Health and Social Care Act was expected to cost the taxpayer between £1.5billion and £1.6 billion.
Pledge: We will significantly cut the number of health quangos.
Status: Not achieved – The delivery of this pledge is contestable. The judgement on whether the Government has been successful hinges on whether the 211 newly formed Clinical Commissioning Groups constitute quangos or not. The Government has also been forced, due to stakeholder opposition, to retain some health quangos that it had earmarked for abolition such as the Human Tissue Authority and the Human Fertilisation and Embryology Authority.
Pledge: We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line.
Status: In progress – The Government claims that the NHS delivered cumulative administration savings of £1.4 billion by the end of 2011/12, which is expected to rise to £2.7billion by the end of 2012/13. It is yet to be seen what resources will be diverted towards Commissioning Support Services, which will provide administrative support to Clinical Commissioning Groups.
Pledge: We will stop the centrally dictated closure of A&E and maternity wards, so that people have better access to local services.
Status: Not achieved – In July 2010, the Government set out four key tests for service change to make the process of closures more transparent and less centralised. However, A&E units continue to be closed and downgraded. In 2013, prominent downgrades affected the North West London area and Lewisham.
Pledge: We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf.
Status: Done - In April 2013, 211 GP-led Clinical Commissioning Groups assumed their statutory duties and took control of approximately 60 per cent of the NHS commissioning budget.
Pledge: We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT). The remainder of the PCT’s board will be appointed by the relevant local authority or authorities, and the Chief Executive and principal officers will be appointed by the Secretary of State on the advice of the new independent NHS board. This will ensure the right balance between locally accountable individuals and technical expertise.
Status: Not achieved – Primary Care Trusts have been abolished as part of the broader NHS restructuring. However, the reform has established Healthwatch, the independent patient champion which will be raising issues of concern with regard to consumer rights with the Secretary of State, Care Quality Commission, NHS England, Monitor and Local Authorities.
Pledge: The local PCT will act as a champion for patients and commission those residual services that are best undertaken at a wider level, rather than directly by GPs. It will also take responsibility for improving public health for people in their area, working closely with the local authority and other local organisations.
Status: Not achieved – Primary Care Trusts have been abolished as part of the broader NHS restructuring. The responsibility for commissioning public health has been assumed by the Local Authorities.
Pledge: If a local authority has concerns about a significant proposed closure of local services, for example an A&E department, it will have the right to challenge health organisations, and refer the case to the Independent Reconfiguration Panel. The Panel would then provide advice to the Secretary of State for Health.
Status: Done - The Health and Social Care Act 2012 amended regulation-making powers in the NHS Act 2006 in order to confer health scrutiny functions on the Local Authority itself.
Pledge: We will give every patient the right to choose to register with the GP they want, without being restricted by where they live.
Status: In progress - Several pilot projects aimed at giving patients the choice of which GP practice to register with are ongoing. An evaluation of the pilots is due in the summer of 2013.
Pledge: We will develop a 24/7 urgent care service in every area of England, including GP out-ofhours services, and ensure every patient can access a local GP. We will make care more accessible by introducing a single number for every kind of urgent care and by using technology to help people communicate with their doctors.
Status: In progress – The national roll-out of the NHS non-emergency 111 line has been delayed. At the time of intended launch on 1 April 2013, half of the lines were still inactive. The Government’s handling of this roll-out has been criticised by the Opposition and professional bodies alike as the full scale of the problems relating to the new helpline was revealed in a recently leaked report to Pulse magazine.
Pledge: We will renegotiate the GP contract and incentivise ways of improving access to primary care in disadvantaged areas.
Status: Done - Despite criticism of its proposals by the BMA, the Department of Health pressed ahead with its GP contract reform, which included the abolition of the minimum practice income guarantee. The contract changes took effect in April 2013.
Pledge: We will make the NHS work better by extending best practice on improving discharge from hospital, maximising the number of day care operations, reducing delays prior to operations, and where possible enabling community access to care and treatments.
Status: Done - The NHS Tariff has been used to promote better continued care for patients following their discharge from hospital. Nevertheless, more real life data is necessary to demonstrate these improvements.
Pledge: We will help elderly people live at home for longer through solutions such as home adaptations and community support programmes.
Status: Done - The Government established a new capital fund, worth up to £300 million over five years, to support the development of more specialised housing for older and disabled people. In 2011/12, an additional £20 million was added to the Disabled Facilities Grant with this funding rising to £40 million in 2012/13.
Pledge: We will prioritise dementia research within the health research and development budget.
Status: Done – As part of the Prime Minister’s Dementia Challenge introduced in March 2012, the funding available for dementia research was increased substantially. The Challenge more than doubled overall funding for dementia research to over £66 million by 2015.
Pledge: We will seek to stop foreign healthcare professionals working in the NHS unless they have passed robust language and competence tests.
Status: Done – In April 2013, the General Medical Council was given new powers to test language skills of doctors trained overseas in order to close a loophole opened by the EU rules allowing member states’ nationals to work freely in the UK.
Pledge: Doctors and nurses need to be able to use their professional judgement about what is right for patients and we will support this by giving front-line staff more control of their working environment.
Status: Done - Clinical Commissioning Groups, the institutions responsible for spending most of the NHS budget are clinically led. Clinical Senates, Strategic Clinical Networks and Clinical Reference Groups have also all been established to provide commissioners in the new NHS with expert clinical advice.
Pledge: We will strengthen the role of the Care Quality Commission so it becomes an effective quality inspectorate. We will develop Monitor into an economic regulator that will oversee aspects of access, competition and price-setting in the NHS.
Status: Done – The Care Quality Commission and Monitor have both been given more prominent roles by the Health and Social Care Act 2012. Whether the strengthened positions of both organisations will translate into service improvement remains to be seen.
Pledge: We will establish an independent NHS board to allocate resources and provide commissioning guidelines.
Status: Done - NHS England is established as an executive non-departmental body and assumed its full statutory powers in April 2013.
Pledge: We will enable patients to rate hospitals and doctors according to the quality of care they received, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong.
Status: In progress – All acute hospital and A&E patients have the opportunity to rate services through the Friends and Family Test. The aim is to extend the opportunity to leave real time feedback to all users of NHS funded services by 2015. Duty of candour, a legal duty to be honest about errors in patient care, has been introduced into the NHS following the publication of the Francis Report.
Pledge: We will measure our success on the health results that really matter – such as improving cancer and stroke survival rates or reducing hospital infections.
Status: Done – The NHS Outcomes Framework includes health outcomes indicators by which the performance of NHS organisations will be measured. Its five domains target improvements in: preventing people from dying prematurely; enhancing the quality of life for people with long-term conditions; helping people to recover from periods of ill health or injury; ensuring that people have a positive experience of care; and treating and caring for people in a safe environment.
Pledge: We will publish detailed data about the performance of healthcare providers online, so everyone will know who is providing a good service and who is falling behind.
Status: In progress – The Healthcare Quality Improvement Partnership in conjunction with NHS choices will publish data on activity, clinical quality measures and survival rates from national clinical audits by summer 2013.
Pledge: We will put patients in charge of making decisions about their care, including control of their health records.
Status: In progress – The mantra of ‘no decision about me without me’ was a central tenet of the NHS reform. Healthwatch was established on the national level to provide the service user perspective to inform decisions about patient care. NHS England aims to guarantee every patient the opportunity to access their own online primary care medical records by the spring of 2015.
Pledge: We will create a Cancer Drugs Fund to enable patients to access the cancer drugs their doctors think will help them, paid for using money saved by the NHS through our pledge to stop the rise in Employer National Insurance contributions from April 2011.
Status: Done – The Cancer Drugs Fund was introduced in April 2011 to enable cancer patients to access drugs not routinely available on the NHS.
Pledge: We will reform NICE and move to a system of value-based pricing, so that all patients can access the drugs and treatments their doctors think they need
Status: In progress – The negotiations on the introduction of value-based pricing of branded drugs from 2014 are ongoing. Concerns have been expressed about the lack of progress in these negotiations in light of the looming deadline.
Pledge: We will introduce a new dentistry contract that will focus on achieving good dental health and increasing access to NHS dentistry, with an additional focus on the oral health of schoolchildren.
Status: In progress – A new dentistry contract is being trialled as part of a major pilot scheme.
Pledge: We will provide £10 million a year beyond 2011 from within the budget of the Department of Health to support children’s hospices in their vital work. And so that proper support for the most sick children and adults can continue in the setting of their choice, we will introduce a new per-patient funding system for all hospices and providers of palliative care.
Status: Done – In 2012/13 the Department of Health continued its commitment to providing £10 million annually to 40 children’s hospices in England through the Children’s Hospice and Hospice-at-Home Grant.
Pledge: We will encourage NHS organisations to work better with their local police forces to clamp down on anyone who is aggressive and abusive to staff.
Status: Done - The Government has launched supporting resources for NHS staff including an e-learning toolkit for practitioners, case studies and guidance for Community Safety Partnerships. Funding for 2012/13 is being used to promote the Violence Reduction Nurse model across England.
Pledge: We are committed to the continuous improvement of the quality of services to patients, and to achieving this through much greater involvement of independent and voluntary providers.
Status: Done - The choice of providers is being extended by the application of the Any Qualified Provider policy. Monitor is charged with harnessing competition as the means of service improvement.
Pledge: We will give every patient the power to choose any healthcare provider that meets NHS standards, within NHS prices. This includes independent, voluntary and community sector providers.
Status: In progress – While a phased extension of patient choice through the Any Qualified Provider policy is ongoing, the level of choice offered to the users of NHS funded services does not yet meet the level stipulated by this pledge.