An Alternative Summary of the Coalition’s NHS White Paper

By Kathryn Rose

One good detail to come out of the coalition’s NHS white paper is that the NHS will remain free at the point of use . It is also a relief to hear they will abide by the Equality bill introduced whilst there was a Labour government and produce the report demanded by the 2009 Health Act. From there onwards it gets grimmer.

Instead of the NHS being controlled by the Department of Health and monitored by the relevant Secretary of State; the NHS will be controlled mainly by GPs consortia and its finances will be monitored by the inventively named organisation called ‘Monitor’ . Monitor already oversees Foundation Trusts and assesses other trusts eligibility to become Foundation Trusts on the basis of the following three criteria: ‘Is the trust well governed…is the trust financially viable…[and] is the trust legally constituted’. Monitor will become the economic regulator for health and social care.

There will be a separate, ring-fenced, local health budget. This will be added to the responsibilities for public health that the Primary Care Trusts currently hold. The two combined responsibilities, for each council area, will be given to a person with the new position of Director of Public Health for that area. That person will be appointed by two bodies hopefully working together: the local authority and the Public Health Service.

The relevant consortium of GPs will also have a say in how NHS money is spent; the money that they control will be practice-level budgets allocated for administration costs and commissioning of local services. The concern with these three parts of the plan is the following:

“Once [these reforms] are in place, it will not just be the responsibility of the government, but of every commissioner, every healthcare provider and every GP practice to ensure that taxpayers’ money is used to achieve the best possible outcome for patients.”

If all of these different groups of people who are responsible for NHS outcomes, which one is responsible if the outcomes are not reached? All of these people – and by the same rule none of them. By devolving accountability from the secretary of state the government is ensuring that no one person or body can be held to account for mistakes or failures, including themselves.

In order to ensure that this supposedly empowering strategy is adopted, the government is paradoxically forcing GPs and trusts to adopt their proposals in a move that can be best summarised as ‘we order you to be empowered’.

GPs are supposed to want all of the devolved powers that the government is foisting upon them; but they cannot want the powers that much when they are threatened with sanctions should they refuse to accept this apparently empowering offer:

“A fundamental principle of the new arrangements is that every GP practice will be a member of a consortium, as a corollary of having a registered list of patients…we envisage a reserve power for the NHS Commissioning Board to be able to assign practices to consortia if necessary.”

It is not only GPs who the coalition are concerned may not be enticed by supposed allure of their new strategy. NHS trusts are also ordered to be empowered:

“It will not be an option for organisations to decide to remain as an NHS trust rather than become or be part of a foundation trust and in due course, we will repeal the NHS trust legislative model.”

Apparently the government is worried by the lack of competition between similar institutions in the NHS. Their answer is to enforce the rule of competition upon the health profession. The government will start by inviting patients to rate their treatment so that others can use this rating as a basis for choosing where they want to be treated.

To ensure that trusts are suitably pressurised by worries about poor reviews the government will make them compete:

“To ensure that competition works effectively in the interests of patients and taxpayers. Monitor will have concurrent powers with the Office of Fair Trading to apply competition law to prevent anti-competitive behaviour.”

This implies that people are actually going to be employed to penalise hospitals or GPs surgeries that fail to try and compete with each other.

Creations and Casualties

• Primary Care Trusts are expected to be history by 2014: “we expect that PCTs will cease to exist from 2013, in light of the successful establishment of GP consortia”.
• Practice based commissioners are also ‘to be replaced by GP consortia’.
• A significant amount of the Department of Health “The Government will therefore impose the largest reduction in administrative costs in NHS history. Over the next four years we will reduce the NHS’s management costs by more than 45%” “The Department will radically reduce its own NHS functions”.
• Strategic health authorities are also on the line: “Strategic health authorities will be abolished.”
• Any part of the new health system that cannot balance its budget will be under fire:
  “Everyone in the system – from the Department to groups of GP practices – [will be] accountable for the best use of funding. We are very clear that there will be no bail-outs for organisations which overspend public budgets”.
• Pay levels? “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”.
• Foundation Trust numbers will increase dramatically as GPs will join consortia.
• A Public Health service will be formed that deals mainly with data.
• The National Institute for Health and Clinical Excellence’s role substantially increased.
• A new NHS Comissioning Board will be created.
• A new organisation called Health Watch will be created to inform patients of ratings and opinions.

The coalition government has decided that it will fundamentally change the structure of the NHS. For patients, as for staff – the government is determined to empower us to do exactly as they say.