The Nuffield Trust’s response to the publication of the Health and Social Care Bill

The Government’s planned reforms are broadly in the right direction but they will have to be judged on the extent to which they deliver – with minimum disruption – sustained improvements to patient care during a period of major financial challenge for the NHS.

That is the view of the Nuffield Trust in response to the publication of the Government’s Health and Social Care Bill.

Dr Jennifer Dixon, Chief Executive of the Nuffield Trust, said:

‘The NHS is at a fork in the road. It embarks on this period of reform with much strength but the pressures it faces over the next four years will continue to rise. Given the reforms over the past 20 years the Government’s decision to devolve more responsibility to the front line is logical. However, this approach carries significant risks in today’s financial climate and needs to be managed very carefully.

‘GP commissioning consortia will need considerable support if they are to manage public funds on such a large scale effectively, as well as succeed in moving care into the community when faced with the vested interests of powerful hospital providers. Research evidence from the UK and overseas tells us that they will take several years to develop properly, in particular in relation to being able to make a significant impact on hospital services.

‘Furthermore the information we have on the quality of patient care is not yet strong enough to hold providers to account, although the reforms help. The role of patients in helping to shape care has not yet been articulated clearly. Competition policy and patient choice are also currently weak, and we do not yet know how much of either will be needed to encourage providers towards sufficiently better performance.

‘Finally, the Government’s reforms propose substantial changes and will require significant management expertise to implement smoothly. As our latest report into the American experience of GP commissioning concludes today, substantial investment in leadership, management and IT will be vital. There are clear risks of introducing GP commissioning in England when the Government has placed such a strong emphasis on reducing management costs.’

The Nuffield Trust’s new report: GP commissioning: insights from medical groups in the United States, by Ruth Thorlby, Dr Rebecca Rosen and Dr Judith Smith, published today, is available to download now. Further details are included in notes to editors.

Background information – Nuffield Trust Analysis

The original White Paper, Equity and Excellence: Liberating the NHS, outlined a number of key reforms, including:

• giving groups of GP practices ‘real’ budgets to buy care;
• abolishing all Primary Care Trusts and Strategic Health Authorities, and creating a new NHS Commissioning Board (now NHS England);
• scrapping performance targets, including for waiting times;
• transforming the foundation trust regulator Monitor into an economic regulator of all NHS providers.

These are substantial changes and will require significant management expertise to implement smoothly. We have identified five areas where further refining would help the policies enshrined in the Bill to meet their objectives:

• The formation of PCT clusters needs to be speeded up. Reinforcing this week’s recommendation by the Health Select Committee, we have suggested that the formation of the PCT ‘clusters’ (which will help manage the transition) needs to be speeded up, with assurances given about their longer term existence so that they can attract and retain the best talent. If allowed to, such clusters could perform a valuable long term role helping to manage financial risk, providing commissioning support to GP consortia as well as overseeing the contracts for local primary care providers on behalf of the NHS Commissioning Board.
• The bringing together of GP commissioners and secondary care providers should be encouraged. The evidence suggests that to be effective GP commissioners will need to work closely with their specialist colleagues in community, social care, mental health, and secondary care settings. There have been some radical and promising developments across England along these lines already, although these may now be at risk because of the fast pace of organisational reform.
• Shadow GP consortia should be expected to meet explicit performance markers before proceeding to fully fledged consortia status. Evidence from the last 20 years of various forms of GP commissioning, and from international experience suggests it will take years for GP consortia to become effective at commissioning across the full range of health services. We therefore suggest that akin to the authorisation regime for foundation trusts, GP consortia should have a similar explicit authorisation regime that enables them to commission good quality care across a progressively wider range of services, as well as handle increasing amounts of NHS funds effectively.
• The decision to allow maximum prices to be set and negotiated in key areas (in particular for services for mentally ill people) must be reversed. International evidence shows that price competition in hospital care is associated with a reduction in quality of care.
• More transparency in the way that financial risk is managed and resources allocated is needed. In Liberating the NHS: Legislative framework and next steps, the Government suggests that the NHS Commissioning Board ‘may establish a contingency fund to make payments to GP consortia to discharge commissioning functions. The NHS Commissioning Board will also have the power to adjust consortia allocations in future years to reflect previous underspends or overspends’. The principles of allocation to the NHS are on the basis of health needs and there is potential for allocations outside this process to be ‘regressive’ i.e. not based on need. It is vital that the principles and rules for sharing financial risk are made completely transparent to consortia if they are to be confident that there is a fair and predictable process.