NHS Future Forum right to highlight primacy of the efficiency challenge

Nuffield Trust Chief Executive Dr Jennifer Dixon responds to the report published by the NHS Future Forum, concluding that political focus needs to shift urgently to the difficult decisions facing the NHS.

Press Release

Published: 13/06/2011

Commenting on the report published today by the NHS Future Forum, Dr Jennifer Dixon, Chief Executive of the Nuffield Trust said:

‘On balance the report forms a good basis for taking the Bill forward. There will be a temptation among some to prolong the debate in the hope of further concessions but the time has come to amend the Bill, and move on. Political focus needs to shift urgently to the difficult decisions confronting the NHS. Further uncertainty would likely have a demoralising effect on clinicians and managers, and make the already difficult job of achieving unprecedented efficiency savings even harder.

‘It is also important to emphasise that this Bill never was and never will be the solution to all the main challenges facing the NHS. Presenting it as such was part of the original problem. To build confidence the Government should over the coming weeks and months also seek to outline a coherent and credible plan for how it intends to deal with the very real risk of operational failure in the places where finances are already weak.

‘In that sense the Future Forum’s insistence that the central efficiency drive should take priority is absolutely right. The next four years are going to be extremely challenging for the NHS. Handling this effectively means putting into place measures which will help the health service to make large savings while maintaining access and quality levels. Longer term it is about encouraging the use of whichever arrangements have the best chance of promoting greater quality, efficiency, equity and openness. These are not wholly separate tasks. 

‘For instance, in a more challenging climate, clear expectations around outcomes and tight and explicit financial controls, with transparent mechanisms for reporting progress will be crucial. The recommendation for consortia and foundation board meetings to be open to public scrutiny, in addition to just being good practice, helps take us closer to this reality. As does the acknowledgement that investment in good management is essential. We are also pleased to see the recommendation that Monitor’s compliance function be extended until Foundation Trust Boards are fully ready to oversee the performance of their respective hospitals.’ 

Dr Dixon continued:

‘Finding a way through the highly charged, polarised debates of the past few months was always going to be difficult. The Forum has done a good job of helping to clarify and suggest ways that the best intentions of the original legislation can be built upon, whether in terms of creating more patient choice or establishing the conditions for less political interference and more clinical leadership. As a set of principles, the recommendations provide a sound basis for consensus. The question is whether the Government’s proposed amendments will speak fully to the Forum’s recommendations. We urge the Government to ensure that they do so that the Bill can be passed without further delay.'

Notes to editors

The Nuffield Trust report: The Health and Social Care Bill: where next?, makes a number of key recommendations arranged around the major flashpoints in the legislation, including:

Concerns about competition and role of the economic regulator:

  • Competition has a role in health care, and proposals to encourage it are right. But there should be no big bang. Markets do not work well in health care and it would be better to proceed cautiously over the next few years, helped by an intelligent regulator;
  • Calls to scrap plans for an economic regulator for health care should be rejected. Applying the principles and right blend of competition alongside other tools that promote equity, access and efficiency to a complex field like health care will require significant analysis, evaluation and experience. This is more likely to come from a health care specific regulator;
  • Increasing collaboration between providers in health care may achieve as much or more benefit for patients than competition. The over-riding duty of Monitor should be amended to manage the health care system in the public interest by promoting competition and collaboration subject to a public interest test.

Concerns about the pace and implementation of reform:

  • Implementing a large scale reform programme as proposed in the Bill in this financial climate is a high-risk strategy. If managed poorly, organisational failure in parts of the health system are likely. Strong financial controls and effective quality surveillance will be required to reduce the risk of deteriorating quality and access to care (e.g. waiting times);
  • GP consortia should take on their new responsibilities gradually, depending on the extent of their capacity as judged by the authorisation process (for example for elective care only, or excluding mental health);
  • Some hospitals are unlikely to be financially viable as they are currently configured. For these, thoughtful, clinically led reconfiguration of care is needed. The Government should consider whether decisions on major service changes can be made more swiftly than in the past, perhaps by decoupling politicians from the decision-making process as has happened in, for example, Canada;
  • There is a strong case for assuring that PCT clusters have a longer-term future beyond 2013 to help consortia commission services not in the purview of specific consortia, and provide vital strategic leadership for service changes.

Concerns about GP-led commissioning:

  • The Government should publish the criteria proposed for authorisation, such as governance arrangements, how conflicts of interest will be handled and accountability, alongside the Bill;
  • Membership of a consortium by a practice should be mandatory (as outlined in the Bill), not voluntary. Otherwise commissioning the hospital care for the populations registered with practices which do not join consortia is likely to be far more difficult and fragmented;
  • The Bill should be amended to allow for the emergence of a diversity of integrated provider models which have the potential to align incentives across practices and hospitals and other providers to help a population stay well, and reduce the costs of care.