1. NHS White Paper 2010 – Update on Consultation Papers Council of Governors Briefing Paper December 2010

2. Background  NHS White Paper: Liberating the NHS (July 2010)  Further consultation papers (consultation closed 12 October 2010)  Transparency in Outcomes – A Framework  Regulatory Healthcare Providers  Local Democratic Legitimacy in Health  Commissioning for Patients

3. Transparency in Outcomes – A Framework for the NHS Reasons for change  Government targets over the last 10 years ‘did little to improve patients health’  Need to create an NHS that is transparent about outcomes it is achieving for patients What will the NHS Outcomes Framework do?  Help patients, the public and Parliament understand how well the NHS overall is doing  Allow the Secretary of State to hold the new NHS Commissioning Board to account  Help drive improvements in patients health outcomes

4. Transparency in Outcomes – A Framework for the NHS  What will be included in the NHS Outcomes Framework?  Five high level domains  Preventing people from dying prematurely  Enhancing the quality of life for people with long-term EFFECTIVENESS conditions  Helping people to recover from episodes of ill health or following injury PATIENT EXPERIENCE  Ensuring people have a positive experience of care  Treating and caring for people in a safe environment and SAFETY protecting them from avoidable harm

5. Transparency in Outcomes – A Framework for the NHS  Each of these five domains would have:  Overarching outcome indicator (or set of indicators)  Small number of specific improvement areas  Supporting Quality Standards (from NICE) pathways to deliver better care

6. Transparency in Outcomes – A Framework for the NHS NHS Confederation Response  Welcome the general principle  Concerns about the three Outcomes Frameworks (NHS/Social Care/Public Health) – They need to overlap and cannot be separate  Concerns about practical implementation  Are there reliable methods for measuring outcomes?  Substantial cost of data collection  Timeliness of information for use by patients  Difficulty of converting population-based outcome measures (e.g. national cancer mortality rates) into provider quality indicators (unable to assess the respective responsibility of different providers along the pathway)

7. Regulatory Healthcare Providers  Foundation Trusts – Increased freedoms:  Repeal arbitrary income cap  Remove statutory controls over FTs’ borrowing limits  FTs able to change their own constitutions to meet local needs (no longer require Monitor approval)  Easier for FTs to choose how to evolve and organise (Board approves merger etc)  Flexibility for governance arrangements e.g. employee-led FTs  Department of Health (or third party) to manage FT financial failures (not Monitor)  Monitor’s Revised Role:  Economic regulator for all health and adult social care in England  Independent of Government  Develop a stable, rule-based system  Monitor (and CQC) license providers – streamlines process  Regulate NHS prices – set efficient or maximum prices/set prices for individual providers if in the patient/public interest  Promote competition  Ensure continued access to key services  New cost for FTs:  Pay to be licensed – to finance new Monitor  Fines if license breached  Levies to create a ‘funding risk pool’ to allow for management of insolvent FTs

8. Regulatory Healthcare Providers NHS Confederation/FT Network Responses  Concerns:  Competition could cause issues for viability of specialist services, emergency care and complex services – Safety net of hospital  Public Consultation can no longer be as slow and commissioner-led if a dynamic market is to operate – providers need to lead and process needs to be streamlined  A banking facility is needed to provide long-term restructuring loans  Difficult to deliver major structural change and £20bn cost savings simultaneously  Concept of staff-led only organisations seems counter-intuitive to the NHS being accountable to the public  FTs need greater freedom to withdraw from the provision of loss making services  Review current incentive structures to encourage hospitals to create more integrated care between primary and secondary care  GPs are commissioners and providers – need to ensure they are not acting anti-competitively  Benefits  Removal of arbitrary limits – capital and working capital  Ability to change constitution  Mergers/Acquisitions – Local Board decisions

9. Local Democratic Legitimacy in Health  Reasons for change  Commissioning has been to remote from patients  GP-led commissioning will ensure decisions are underpinned by clinical insight and knowledge of local healthcare needs  Areas covered by the consultation  Responsibilities (GP Consortia/NHS Commissioning Board)  Commissioning  GP Consortia – Elective hospital care, rehab, urgent and emergency care (including out-of- hours), community services, mental health, learning disabilities plus prescribing  NHS Commissioning Board – Primary Care (GP practices), other family heath (e.g. dental), specialised services, maternity and prisons  Finance  Finance NHS Commissioning Board -  calculate practice-level budgets/allocate to consortia  Designing guidelines/contracts/tariff structures/data standards  Financial stability of commissioners

10. Local Democratic Legitimacy in Health  Establishment of GP Consortia  Statutory public bodies held to account for outcomes  Shadow form from 2010/11 (Pathfinders being sent)  Fully operational 2013/14  Freedoms, controls and accountabilities  GP Consortia :  Free to decide commissioning priorities  Maximum allowance to cover management costs  Manage resources to breakeven on commissioning budgets  Commission services using any willing provider (Choice)  Cannot provide services in their own right  NHS Commissioning Board  Significant role in managing financial risk  Intervention powers in the event of poor financial management  Develop a commissioning outcomes framework  Decide proportion of GP income linked to achieving commissioned outcomes and financial risk  Partnerships  GP Consortia to work with local authorities – potentially via health and wellbeing boards

11. Local Democratic Legitimacy in Health NHS Confederation Response  Key Areas of Concern:  Scale of change and resource implications  Loss of short term focus during transition (particularly money)  Potential loss of organisational memory  Risks around splitting-up current PCT functions  Likely running costs of GP Consortia  How the system will work in practice i.e. GP commissioning and the role of competition versus local political influence on services provided  Other issues:  Why is maternity not commissioned at local level?  Need to ensure consortia are not just GP-led but involve other professionals e.g. nurses, AHPs, etc  Potential for competition to destabilise core local secondary care services  How do consortia commission extended primary care from constituent practices ?

12. Democratic Legitimacy in Health  Strengthening public and patient involvement  A strong local voice for patients via local democratic representation  Patients/public have a clear route to influence services they receive  Individuals have greater say in decisions  Create local HealthWatch (replace LiNKS) – more like a ‘citizen’s advice bureau’ for health and social care – the local consumer champion  Improving Integrated Working  Local authorities have greater responsibility in: Leading joint strategic needs assessments Supporting local voice Promoting joined-up commissioning- NHS, social care and health improvement Leading on local health improvement and prevention activity  Above gives local authorities influence over NHS Commissioning  Local health and wellbeing boards (joint strategic needs assessments/promoting partnership working and integration)

13. Democratic Legitimacy in Health NHS Confederation Response  Supportive of many of the aspirations  Key areas of concern:  HealthWatch – Will it be properly resources and have relevant capacity?  Health and Wellbeing Boards – Don’t necessarily increase legitimacy or local accountability  Monitor – Unclear how it relates to health and well-being boards to ensure service continuity  Public health and health improvement – Which tiers of local government are responsible for which functions?  Scrutiny of major strategic changes – Inadequate attention to potential for provider- led service change