Loads more news is out in response to Steve Field's report back after the listening exercise:
• 'Future Forum recommends dilution of Monitor role and public accountability for consortia', is the headline over at of Health Service Journal.
Their reporter Steve Ford writes:
The health secretary must remain "ultimately" accountable for the NHS, Monitor's proposed role in promoting competition should be "diluted" and consortia must have a governing body that meets in public, the Future Forum has recommended.
He goes on:
The most striking change recommended by the forum is the watering down of the powers proposed for Monitor in the bill. The forum says the proposal that Monitor promote competition should be removed and replaced by a requirement to "support choice, collaboration and integration.
But adds as as a qualifier:
However, it (the announcement) has stepped back from recommending that their boards must include hospital doctors and nurses, which had been strongly lobbied for by groups such as the Royal College of Nursing.
• The listening exercise has turned out to be a watering-down exercise, writes Andrew Haldenby is the director of the independent think tank Reform in the Telegraph.
He writes:
Simply put, the Government and the Forum have bowed to the unjustified criticisms and rejected the justified ones. Last week David Cameron said that the relevant NHS agency ("Monitor") would not, after all, oversee competition in the health service, confirmed by the Forum today. It will support "integration" which will mean the creation of even bigger NHS organisations that are extremely resistant to change. Worse, David Cameron said that the people spending the NHS budget on our behalf will now include the doctors and nurses who receive the money, and who, inevitably, will defend the existing service. He is reversing the basic idea, going back to Kenneth Clarke's reforms of 1991, that the people who buy our healthcare should be separate from those that carry it out (the "purchaser-provider split"). Far from looking to the future, the Government is turning the clock back. Meanwhile, the Government will keep its reforms to commissioning despite their flaws, and will keep a Secretary of State of Health responsible for every action of the NHS.
• Over at the BBC, Nick Triggle writes that Field's report back shows that "the health plans for England need a major re-write to ensure the best interests of patients are protected".
Here is some more reaction to Steve Field's speech earlier today:
• The Chief Executive & General Secretary of the Royal College of Nursing, Dr Peter Carter, said:
We are pleased that the NHS Future Forum has used the 'pause' period to listen and reflect on the concerns that the public and professionals have over the future of the NHS. We welcome the report's findings that Monitor must support the integration of care and that care must not become of secondary importance to cost. Equally, we fully support the report's conclusions regarding the importance of transparency within the new commissioning consortia as well as the recommendation that private firms must not be allowed to 'cherry pick' services.
However, it is disappointing that the Future Forum appears not to have accepted the view of thousands of our members, who are calling for a mandatory requirement for nurses to sit on the board of every commissioning consortia. Nurses follow the patient throughout their care and have a unique range of skills and experience. The Government should enshrine this requirement in legislation when it responds tomorrow as the reality on the ground is that new commissioning consortia are currently being established at pace without nursing representation.
What he says matters, because it was the RCN that delivered the damning blow of no confidence in Lansley some months ago.
• Royal College of GPs chair Dr Clare Gerada welcomed the chance to participate in the listening exercise and the change of role for Monitor, but said that some major questions still remained unanswered:
we still have a number of outstanding concerns about the potential risks and unexpected consequences of the proposals. We need the Government to reassure us that GPs will be given the freedom and autonomy to lead the decision-making and design of future integrated health systems drawing on the support of other health, social care and third sector services. We support clinician-led commissioning but continue to believe that GPs are best placed to lead this process.
We also need further guarantees that changes to geographic and practice boundaries, and the tendering for services will not disrupt the continuity of care that is so vitally important to patients. And we worry that the Future Forum's proposals may lead to additional levels of complexity and bureaucracy which will impede the ability of commissioners to develop appropriate services with, and for their patients.
• Charles Fraser, chief executive of the homeless charity St Mungo's, said:
We very much welcome the focus on patient care and the proposal that the NHS Commissioning Board look at developing pilots for integrated pathways for homeless people.
Turning this into sustained and practical action on the ground will, however, be the litmus test. This requires not just better structures, but also attitudinal and behaviour change within the NHS.
• The Right to Work campaign to resist the government cuts and the "privatisation agenda" said today it would 'hound' Andrew Lansley's from office as the Health and Social Care Bill turned into messy compromise and experiment that's nothing short of a 'dogs dinner' and 'barking mad'.
According to an email from the organisation:
A hound will seek out Andrew Lansley at Olympia as he gives a keynote address at 'Commisioning 2011 - The future of UK Health Care' ? a two day event at Olympia in London on the 15th June.
Watch this space!
Our sharp eyed leader writer Tom Clark has just sent this observation via email to the blog:
Amid all the obsession with competition, a big story about reorganisations could get lost (apologies if you've all spotted this already or still worse written up)
Field says (page 12 of his summary report) that boundaries of GP consortia should not normally cross those of councils. But the existing consortia and did not need to have contiguous borders at all, and indeed there could be several within a single neighbourhood.
One of Lansley's few boasts is that most GPs are already plugged into the new consortia, but now they are to be rearranged again. We've shifted from "no top down reorganisation" to reorganising a reorganisation before it is even complete.
JudithSmithNuffield writes:
I wonder how significant clinical senates will be in the long run, or are they a way of trying to keep everyone happy when GPs have been given particular profile in the proposed consortia arrangements? Surely the critical issue is, as the Future Forum report suggests, that consortia are able to demonstrate real and effective access to, and use of, appropriate clinical advice?
All good NHS managers know that, in order to make effective changes to services, you have to have the right mix of doctors, nurses and other health professionals involved, and whether they are actual 'commissioners' or not is in many senses so significant. What is more important is that there is proper clinical input to decisions about new services, or indeed about stopping or changing existing services.
The more important question is whether consortia will be robust enough to take difficult decisions about what is commissioned or not for a local population. They will need to be able to account for these decisions to the public, and to local NHS staff, and ultimately be able to stand up to judicial review. The proposals in the Future Forum report for consortia governance are encouraging in making such robustness of commissioning decisions a reality.
AnnaDixon offers more reaction to the Future Forum:
The Future Forum has recommended that there is stronger governance for commissioning consortia. given that these bodies will have responsiblity for spending public money it is really improtant that they have good financial and clinical governance and that they operate in teh public and patient interest. The Forum has not gone so far as recommending that there be a hospital doctor on the Board as some had speculated following the PM's speech or a patient rep. It seems that the Board composition will be a matter for local determination but clearer that some will be non execs including local lay people.
One issue that has been overlooked by the government and was highlighted in oru recent accountability report http://www.kingsfund.org.uk/publications/nhs_accountability.html is the changes to Foundation Trust governance. It is currently proposed that Monitor will no longer have oversight of FTs once authorised. It will be down to local governors to keep the Board in check. The Forum are proposing that Monitor's compliance function in relation to FTs continues. It is important that the government get the balance right between central oversight and local devolution on this and other aspects of the reforms.
zetadoc asks:
If the NHS needs to change so much why aren't the other countries following suit?
Iankirkpatrick replies:
This is a really good question, especially when one takes into account recent comparative research comparing the NHS with other health systems. In a recent report the Commonwealth Fund listed the NHS as the second best performing health system with in terms of efficiency, equity, quality of care and access to care. At the top of the list was the Netherlands, with the US (spending twice as much per capita on health care as all other countries) coming last on almost every measure. Given that the US is the nearest example of a fully market driven health system this is hardly a very upbeat recommendation! Perhaps this is why other countries are not following suit in the rush to privatise. The best evidence we have is that it doesn't work that well... (http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2010/Jun/1400_Davis_Mirror_Mirror_on_the_wall_2010.pdf
parrotkeeper asks:
How do these proposals save money & improve outcomes?
AnnaDixon answers:
This will be the ultimate test. If the government can't demonstrate that the changes have saved money and improved outcomes they will have to answer to the electorate.
What does the evidence suggest?
There is evidence that reorganisations cost money - see NHS Confederation report.
The government have cited evidence that in areas of higher competition there are improvements in quality.We have published summarised the evidence on the benefits of integrated care http://www.kingsfund.org.uk/publications/clinical_and_service.html
There is mixed evidence on the effects of delgating budgets to groups of GPs - see research on GP fundholding, total purchasing and more recently on practice based commissioning http://www.kingsfund.org.uk/publications/pbc.htmli could go on. It is difficult to weigh all this up and predict whether on balance the proposals will deliver the benefits that are claimed. The experience of the last set of reforms is that they are often not fully implemented and therefore the expected impacts are smaller in practice.
Our recent cancer paper also showed how difficult it is to disentangle what drives differences in cancer outcomes http://www.kingsfund.org.uk/publications/cancer_survival.html
Ultimately whether health and health care outcomes improve will largely depend on the extent to which clinicians and managers and those in social care and public health work together with patients and users to find ways of delivering better health care for less money. This is why it is vital the reforms support more collaborative and integrated ways of working as the Future Forum have called for today.
Commenter Timak asks:
How is the proposed system better than what we have?
All it seems to the untrained eye is that medical staff will be more involved in commissioning and that private providers will be able to offer services to the NHS at a fixed tariff.
Could the same not be achieved by getting medical staff more involved in PCTs?
Do private providers not already provide some services to the NHS? Is there any actual factual evidence from the work done already that outsourcing work benefits patients? Is there any evidence that keeping this extra capacity outside the NHS is better than the NHS investing in this extra capacity themselves?
JudithSmithNuffield responds:
One important factor to bear in mind is that the NHS has already changed significantly since last July when these reforms were first announced. Primary care trusts have already been bundled up into 'clusters', GP commissioning consortia are meeting in 'shadow form' and many former PCT managers have taken voluntary or compulsory redundancy. So the question to now be asked is 'how can the NHS as it currently is be enabled to tackle the huge financial and service challenge ahead?'
The mandating of strong clinician involvement in commissioning is to be welcomed. Whilst some PCTs were already doing this in the past, others were not, and doctors, nurses and others felt very 'done to' in many cases.
Another important, and not often talked about, element of the Bill is the focus on assessing performance based on health outcomes, and that is also a potentially very significant change.
The focus in today's report on stronger local governance of commissioning is also a really positive move.
However, the underlying point here, that many of the changes now being debated could, arguably, have taken place without primary legislation is well made. What is now crucial is that the NHS is able quickly to move forward and tackle the real problems faced, and that the talking about structures and organisation can stop, or at least ease up.
Managers and clinicians need to know who will be on consortia and what their main responsibilities will be. And the public and patients need to be clear about who they will hold to account for decisions made about funding and services.
Iankirkpatrick writes:
I'm not convinced it will be better than what we have. In theory getting clinical staff more involved in commissioning is a good idea and could ultimately improve the design and responsibility of services. However it is not clear exactly how this can be achieved given the limited success of previous efforts to involve GPs in commissioning (for example, under the previous government). Nor is it clear how clinicians will find the time to do this work when management support is being stripped out of the system. Ironically, what one might need to put all this right is an organisation such as a PCT - which of course is what we had before!
Yes private providers are involved in delivering some services - for example, treatment centres providing non emergency routine procedures. Research conducted on these organisations finds little conclusive evidence to suggest that they are either less expensive than the NHS or that the quality of services is much better.
JudithSmithNuffield responds to ShavedOrSpiked's earlier question (see 4.42pm update):
The NHS, as one of the largest organisations in Europe is of course always changing to some extent, as it needs to in order to keep pace with technological and other innovation.
However, to have proposed structural change of the extent suggested by the White Paper and the Bill, and at a time of a need for the NHS to make unprecedented efficiency savings, is, to my knowledge, unique.
In Nuffield's paper 'NHS reforms in England: managing the transition' http://www.nuffieldtrust.org.uk/publications/detail.aspx?id=145&PRid=760 we argued that there was an urgent need to steady the NHS ship by giving some assurance of job security to those managers charged with leading this huge transition, helping local commissioners work out how best to handle the difficult service reconfigurations that will be needed, and making sure local PCT clusters and NHS providers can get on with the job in hand - running safe and high quality services whilst becoming more productive and efficient.
ShavedOrSpiked responds to AnnaDixon's comment that the "NHS needs to change":
1) has the NHS at any point in its history not been changing?
2) can you name a single person who was suggesting it did not need carry on changing?
3) do you not think that arguing against the no-change straw-man is a waste of time?
AnnaDixon replies:
I agree the NHS is always changing. However, a lot of the change has been to the structures and organisations. We argued in the run up to the election that the NHS did not need further structural reorganisation. The NHS faces one of its toughest financial periods - the key priority is the need to find up to £20 billion in productivity improvements to maintain quality and avoid significant cuts. This will require a degree of change and transformation in where services are delivered, how they are delivered that it unprecendented. So the argument is not about change or no change but whether these are the right changes to support the transformation of services that are needed to meet the needs of an ageing population and to meet the productivity challenge.
Iankirkpatrick adds:
I think it is correct to say that the NHS has been changing throughout its history and that major re-organisations are nothing new. The mantra accepted by most politicians (and indeed the general public) is also that more change is needed. However, the question I would pose is how much change and for what purpose? Yes, the NHS is being placed under a lot of strain because of changing population demands and financial crisis, but how will opening up the service to competition and transferring responsibility for commissioning to GPs solve this problem? By international standards the NHS has relatively low administrative costs while in the US – also a free market for health care – administration costs are astronomical.
Our expert panellists Dr Anna Dixon, Dr Judith Smith and Ian Kirkpatrick are online answering your questions and giving their reaction to Steve Field's announcements.
AnnaDixon writes:
I am Director of Policy at The King's Fund. We have just played host to Steve Field, Chair of the Future Forum. He was presenting the recommendations following the listening exercise. Some of these messages were 'preempted' by the PM earlier this week so some of the recommendations were expected: other health care professional sto be involve in commissioning, consortia to be given responsibility when they can demonstrate they have right skills, capacity and capability, and Monitor's role to be modified. Overall the message is the right one, NHS needs to change, but need to improve the reform proposals but then move on and address the task at hand. Will give some more specific comment and reaction over the next hour.
Iankirkpatrick adds:
Professor Field's recommendations to slow down the pace of the reforms is certainly good news because the original plans were wildly optimistic and are already causing widespread disruption. Retaining accountability for the secretary of state is also good news. Unfortunately I am less sure about the promise to water down proposals relating to competition and opening up services to any willing provider. How exactly will this work? On the one hand we are told that co-operation is important (with secondary care clinicians involved in commissioning) and that competition will not be an end in itself. On the other patents are to be given more choice to secure better value for money from services – which presumably means opening them up to all providers. How these goals can be reconciled I'm not entirely sure.
JudithSmithNuffield comes online to say:
The report of the Future Forum forms a good basis on which to take forward the Bill, underlining the key principles of the reforms, and setting out helpful ways in which concerns might be addressed.
What is critical however is that the government now makes it clear to clinicians and managers in the NHS exactly what they now have to do to enact the reforms. For example, how will consortia work with clinical senates and local health and wellbeing boards in practice? How far will the NHS Commissioning Board call the shots about changes to service configuration locally, or will this fall to consortia?
The major challenge of how to extract £20billion of efficiency savings from the NHS remains, and this will mean difficult decisions for local commissioners and providers. Whether new consortia will be up to this task remains to be seen, and the detail of transitional arrangements will be critical.
Whilst the Q&A continues below the line, we are continuing to publish reaction to Steve Field's speech.
Commenting on the report published today by the NHS Future Forum, Dr Jennifer Dixon, Director 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.
Whilst the Q&A continues below the line, we are continuing to publish reaction to Steve Field's speech. Unite the union is not happy:
In a statement emailed to the blog, Unite said that Field's response "will do nothing to quell the concern of health professionals and patients" and repeated its call for the bill to be scrapped.
Unite national officer for health, Rachael Maskell said:
The problem with Monitor is that it will now promote choice, competition and collaboration - all of which are contradictory aims.
The hybrid mess that Monitor will become will do to the NHS what other botched regulatory bodies have done to other public services - from rail to social care. Unless patient care comes first, then Monitor will fail patients - and our politicians will have failed them too.
She added:
The Future Forum has come up with a series of placebos; suggesting tinkering with the timescale, playing down the involvement of private healthcare companies, and the health secretary remaining ultimately in charge of the NHS.
The way that David Cameron and Health Secretary, Andrew Lansley will interpret the Future Forum's recommendations is that the pace of the privatisation of the NHS will be slowed down, but not abandoned – that's the crux.
Whilst the Q&A continues below the line, we're continuing to publish a whole series of reactions to Steve Field's announcement.
• The Royal College of Physicians (RCP) President Sir Richard Thompson said:
We urge the government to grasp the opportunity to give hospital doctors a mandated place on the board of local commissioning bodies to guarantee integration of primary and secondary care. To encourage this, the RCP also wants GPs to sit on the boards of foundation trusts. In this way all doctors will work together to lead a health service in the best interests of patients
On competition:
The recommendation that Monitor's role should be altered from promoting competition to promoting collaboration and integration is a step in the right direction. The Health and Social Care Bill must clearly state that the primary focus of regulation is promoting integration, collaboration and quality – not promoting competition. The RCP now waits to see how the government will reconcile choice and patient safety through the regulators, Monitor and the Care Quality Commission (CQC).
On education and training, the RCP is pleased that the Future Forum acknowledges that 'Mistakes may be costly and the impact of mistakes on both the health service and the public will be long lasting.'
• Responding to the publication of the NHS Future Forum report Dr Chris Hanvey, Chief Executive of the Royal College of Paediatrics and Child Health said:
Our President Professor Terence Stephenson was a member of the Future Forum and we are encouraged that the final Future Forum report acknowledges the concerns he raised about the extent to which the impact of the Health and Social Care Bill on children's health had not been reflected
In terms of what needs to happen now, the RCP added:
There are of course some areas of uncertainty in the proposals which need continued examination such as the role and purpose of Clinical Senates. However, overall the recommendations in the report represent significant progress in recognising the specific needs of children and young people. The Government must now demonstrate it is prepared to accept and implement them as the Bill makes its way through Parliament
Whilst the Q&A continues below the line, we'll be publishing a whole series of reactions to Steve Field's announcement.
• The Chief Executive of the NHS Confederation, Mike Farrar, has just emailed the blog this statement:
The Forum has run an exemplary process and we are delighted that it has taken the lion's share of our recommendations on board.
It suggests clarity about who is accountable for what, as opposed to confusion for patients and the public. It suggests an intelligent approach to integration and competition, not a one-size-fits-all system that risks fragmenting services. It suggests a realistic timetable for transition, not a rushed approach that risks some parts of the NHS losing control of finances.
Mr Farrar added that the process has not been easy:
The NHS has been in limbo for about 15 months and we are now in one of the most difficult periods in its history. A clearer view about the way forward helps us face the enormous problems before us - issues such as the variability and integration of care, which really matter to patients.
Right now, we are determined to tackle the problems of the NHS finances and put to bed the issues of structural and institutional change. This is a forest fire that is already burning quickly and we need to be taking action.
• Meanwhile the King's Fund's Chief Executive, Chris Ham, said:
We strongly welcome the Future Forum's report. The recommendations it sets out – if accepted by the government – will significantly improve the Health and Social Care Bill.
The emphasis on integration is particularly significant and addresses a key weakness in the government's original proposals. By strengthening collaboration and improving the co-ordination of services, integrated care offers the most promising approach to meeting the challenges posed by demographic change and the increasing numbers of people with long term conditions.
The 'pause' has served the NHS, its staff and patients well by allowing time to reflect on how to deliver the reforms the health system needs. But it is now time to move on. The government must now move quickly to endorse today's report, put an end to the disagreements that have dominated recent months and provide the direction and stability the NHS desperately needs to navigate the challenging times ahead.
Despite the headlines generated by the reforms, the key priority facing the NHS remains the need to find up to £20 billion in productivity improvements to maintain quality and avoid significant cuts in services. Implementing the reforms while maintaining the focus needed to achieve this will be very challenging and will require leadership and management of the highest quality throughout the NHS.
Straight after Steve Field's speech, we now have a live Q&A with Anna Dixon, head of policy at the King's Fund, head of policy from the Nuffield Trust Dr Judith Smith and Prof Ian Kirkpatrick from Leeds University Business School. Please start posting your questions below the line now or email them to rowenna.davis@guardian.co.uk.
Q: Michael Crick says you have only 8 weeks and only realised some things a few days ago? Would you not need a little more time?
A: We gave up our day jobs. We gave a rough draft to PM and DPM on the basis it won't leak. It really did not.
Q: Shouldn't private industry have to have open board meetings if foundation trusts are going to?
A: Field says yes, if it is taxpayers money then the answer's yes. Not sure how the government would enforce that. He says patients won't know which is the better GP surgery for one-year cancer outcomes. Field says it's up to the government to take this forward.
Randeep is still reporting on the questions to Steve Field GP.
Q: On reconfiguration - how about hospital services being reshaped?
A Field: Trying to get decisions made locally when you started to look at reconfigurations. Patients don't have the information to make decisions. Need more patient involvement.
Bubb: 70% of NHS budget is spent on long-term conditions. But the debate is all about hospitals. Part of what we are suggesting is to move to integrated care. Raises questions about where resources go. One of things emerged out of this... how we need better working between doctors, hospitals, private providers.
Paul Waugh, editor of PoliticsHome, has just tweeted this reaction from the health secretary:
Lansley's 1st reaction to #futureforum: "The Forum's approach is one on which we can build a strong NHS for the future."
You can read more of his updates on his Twitter feed.
High profile Lib Dem Evan Harris tweeted back:
Shock horror!
A little sarcasm from the Lib Dem doctor?
There's a tricky question from the floor: where are the signatures of the 250,000 people who signed the anti-health reform petitions? Steve Field says he has been listening. He then name drops the Guardian blog daily! So the official opposition is now here.
Field says Andrew Lansley should be responsible for the NHS - but the commissioning board needs to be in charge day to day. Surely the secretary of state is only responding to public pressure. We have seen this over the Bristol baby debacle; the Mid Staffs mess where there was political pressure and just about every local reconfiguration. Is it realistic to expect this?
Julie Moore says that she has a concern that good people will not want to join hospital management because they have been berated as pen pushers and bureaucrats. Not appropriate to slag them off. Should have said thank you for what you have done - but we have found other ways of doing things. Julie gets a little emotional while speaking. It's touched a raw nerve.
Field says we cannot afford to lose our best managers.
NHS reforms review recommends major changes to bill, writes our health correspondent Denis Campbell:
Experts recruited by David Cameron after the outcry over coalition plans to reform the NHS have recommended a series of key changes that will see the health and social care bill extensively rewritten.
Professor Steve Field, chairman of the NHS Future Forum, said a major overhaul of the plans was necessary after health secretary Andrew Lansley's original blueprint to improve the NHS in England alarmed health professionals, patients and the public.
Denis quotes Steve Field saying:
the principles underlying the bill – devolving control to clinicians, giving patients real choices and control, and focusing on outcomes – are well supported
But in remarks that underline the fear and confusion aroused by Lansley's original bill, Field added:
During our listening we heard genuine and deep-seated concerns from NHS staff, patients and the public which must be addressed if the reforms are to be progressed. Our recommendations represent important changes in future policy, crystallising those thousands of voices, as well as our own views.
You can read his full story here.
Nick Timmins asks whether consortia will still be GP-led? We spent five minutes going round and round and Nick's none the wiser.
Sam Lister of the Times asks: what will the PM reject?
Field has a chuckle but does not really go beyond saying the PM and DPM spent an hour going through the report in detail.
Steve Field continues his answer on competition:
I have been looking at the idea that private companies will be able to cherry pick services from the NHS. Monitor, say the Forum, should be tasked with preventing cherry picking. How? By making sure that providers are not trying to out spend rivals. Also private companies will not be able to turn away patients because they are too expensive.
Randeep comments:
It's going to be a huge bureaucracy or a lawyers feast...
Steve Field is taking more questions.
Q: How can the NHS compete and collaborate?
A: Geoff Alltimes says we can have both. Who is going to provide a service - and use that to up the quality and choice. Sir Stephen says government got it wrong over competition by suggesting Monitor should promote it. Strong evidence that competition drives choice and diversity of providers. What we are suggesting is how to give citizens the chance to challenge the government where providers fall down. Field suggests:
• citizens panel
• bottom up right to challenge
• need to move the debate to maximize the benefits and minimize the risks
Now Steve Field GP, head of the government's listening exercise, is taking questions. The first comes from the Daily Mail:
Q: Will the bill will have to be recommitted?
A: Not my call says Field.
Field ends with a plea that politicians should work together now. I.e. this punch up over the NHS has to be over now. We clinicians have spoken.
• To integrate NHS, public health and social care "the boundaries of local commissioning consortia should not normally cross those of local authorities". So GP consortia will have to be within a borough. Seems to be a big concession to the Lib Dems who raise the issue of "coterminosity".
• Training and education reforms need to be slowed down. This really riled the medical profession with budgets being put into hospitals. There seems to be a move to retain the present system. An attempt to buy off medical establishment opposition.
• Public Health England should be an independent body - taken out of government control. Not what Andrew Lansley wanted but important.
Randeep has just sent another update:
• Field says that the 2013 deadline for all GPs to be part of consortia will have to be relaxed. Some like in Cambridge might make it, but not everybody.
• Now the choice bit. If you are in a rural area and you are not getting the choice of services from a hospital then patients could challenge commissioners (ie GPs) to provide these services. An interesting point that Stephen Bubb has made before to the blog.
• Monitor, the health regulator, looks like its going to be stripped of its competition role. What will they all do in that regulator? Promote integration? What does it mean? Does that mean that parts of England will end up like Scotland with an integrated healthcare system? They were called Regional Health Authorities I believe.
Randeep has just sent this summary of Steve Field's announcements, that are still ongoing at the King's Fund:
• There's a very wooly bit about "no decision for me without me". Cannot see what this means for the NHS when patients and carers are told they will be equal partners with doctors.
• Commissioning Consortia need to be open. Foundation Trusts need to hold their board meeting in public. That is a big step.
• Alarmed and very concerned about managers becoming demoralised. They are fleeing the health service says Field. He says something must be done very quickly to get a smooth transfer to a new system and we need them to manage the financial situation. This is a question of whether you have the staff to make £20bn of cuts in the next few years without experienced managers.
High profile Lib Dem MP Evan Harris is also at Steve Field's announcement in central London and is tweeting here.
Here are a few of his updates:
1st specific recommendation at #futureforum - Nat Comm Board, and Comm Groups will have to promote rights in the NHS Constitution
2nd recommendantion at #futureforum - make the accountability of sec of state clear in the bill. He said it was misunderstood before! Hardly
3rd recommendation at #futureforum #healthbill Commissioning Consortia to be open, transparent, & governed. Yes see LD conf motion in March
Steve Field says the government's stated aim to improve outcomes and quality in the NHS is not questioned. But says he has had 25,000 emails and met with 6,500 people and "thousands of meetings". The idea is to stress just how much feedback there has been.
He makes a pitch for prevention: to keep people healthy rather than just patching them up. Prevention is better than a cure.
Field says it is right that GPs do take responsibility for large populations, multi-ethnic big cities. Field comes out as a fan of competition to back choice and integration. But he says Monitor's primary duty to promote competition should be removed. That was the overwhelming view of patients, doctors, nurses.
What Field is trying to do is to make the case that competition has to serve the patient interest. At the moment that's not in the bill.
Steve Field says the government's stated aim to improve outcomes and quality in the NHS is not questioned. But says he has had 25,000 emails and met with 6,500 people and "thousands of meetings". The idea is to stress just how much feedback there has been.
He makes a pitch for prevention: to keep people healthy rather than just patching them up. Prevention is better than a cure.
Field says it is right that GPs do take responsibility for large populations, multi-ethnic big cities. Field comes out as a fan of competition to back choice and integration. But he says Monitor's primary duty to promote competition should be removed. That was the overwhelming view of patients, doctors, nurses.
What Field is trying to do is to make the case that competition has to serve the patient interest. At the moment that's not in the bill.
My colleague Denis Campbell has sent through his quick summary of the report:
The forum's 16 recommendations include findings that:
* The pace of the reforms -- which had alarmed many critics in the NHS
-- should be varied so that the NHS carries them through only when it
is able to do so
* The health secretary should retain ultimate accountability for the
NHS in England, a responsibility that Lansley sought to abandon in his
original Bill
* Nurses, specialist doctors and other clinicians should be involved
in making local decisions about the commissioning of care, and not
just GPs -- another rejection of another key element of the Bill as
drafted
* "Competition should be used to secure greater choice and better
value for patients. It should be used not as an end it itself, but to
improve quality, promote integration and increase citizens' rights"
* In addition, the restructuring of the NHS should be based not on the
regulator Monitor's duty to 'promote' competition, which should be
removed, but on citizens' power to challenge the local health service
where they do not feel their service offers meaningful choice or good
quality
Steve Field is here with Sir Stephen Bubb of Acevo, Julie Moore, CEO of Birmingham NHS Foundation Trust, Kathy McLean, Medical director for the East Midlands SHA and Geoff Alltimes, CEO of Hammersmith and Fulham. These four are the key leaders of the NHS Future Forum report.
Field says he wants to provide care to the highest possible quality. But it cannot stand still. It does need to move forward.
Right the Future Forum report has been handed out. But we cannot tell you what's in it. The hack pack has been locked into a room deep in the bowels of the King' Fund in central London. I am sandwiched between the BBC's serried ranks (there are four reporters furiously poring and typing their way through the report) and Nick Timmins of the FT. Steve Field and his team of experts are nowehere to be seen. The coffee's getting cold...
Commenter MarshallStack writes:
Does Labour have its own narrative for the future of the NHS in light of rising costs, rising demand and expectations, but limited scope for large real terms increases in funding?
DianeAbbottMP answers:
Everyone understands the need for the NHS to make savings in the face of an aging population, increasing demands etc. But one of the main problems with Lansley's beloved "re-organisation" was that it represents a colossal waste of money. Three billion pounds and rising at some estimates. Remember most of those redundant PCT staff were entitled to redundancy pay.
We are committed to making necessary savings. Not wasting money on a re-organisation like this one.
She also comes back to petercs and RichardBlogger (see 1.56pm update):
Commissioning may do not much for you, an educated, computor literate individual who is registered with your GP. But in London there are hundreds and thousands of people who are not registered with their GP, who are potentially resevoirs of diseases like TB, HIV or even malaria. Good commissioning plans for the entire population, not just for people who are registered with their GP.
FirstTimePoster comments:
Remember Andrew Lansley said "I could have done most of this without the legislation" and it looks like that is now the plan.
RichardBlogger replies:
Too true. On Thursday I attended a public meeting given by the chair of the PCT in my area. He was exasperated that he has lost half of his executive board in the last few months because they feel that they had no future in their position. Yet the PCT *still* has to deliver healthcare for the area until 2013 (the local Pathfinders were third wave, so only recently announced). He asked: how can any organisation with a budget of £800m work when half of the executive board have left? In the private sector such an organisation would have had a crisis shareholders meeting before now.
It is sheer incompetence for a secretary of state for health to have put the NHS into so much disarray. In fact, it is quite amazing that Lansley could have done so much damage in just one year!
petercs asks:
Do we need commissioning at all? From my view as a patient I need my GP and specialist treatment units for referral. What does this intermediary, the commissioner, the PTC, actually do for me?
RichardBlogger responds:
Good point! When the NHS confederation listed the responsibilities of PCTs it came to 211 items and it took 14 pages just to list them. This may sound like bureaucracy, but when you look closer you see that these responsibilities include making sure that money is spent in a cost-effective way, that healthcare is equitable, that strategic planning is done to ensure that facilities are available for expected population changes.
They have to make sure that healthcare provision is compliant to laws including: NHS Constitution, European Convention on Human Rights, Race Relations Act, Equality Act, Sex Discrimination Act, Disability Discrimination Act, Equality Act (Sexual Orientation) Regulations, Mental Health Act, Coroners and Justice Act.
Can GP consortia do this with regards to Any Qualified Provider (which appears to be aimed at small companies, not large healthcare groups)? I doubt it.
Responding to Shemarch:
It is obvious that the overwhelming majority is against the proposed changes to the NHS. But will the Tories listen?
And Radleyman:
The NHS Bill should be withdrawn. Work on a new bill should be started with full consultation of the public and the NHS staff.
DanielPoulter writes:
I think we're likely to have two key things coming out of the listening exercise. The first is the integration of services. Second is making sure that as part of the process of integration we have clinically led commissioning by professionals - but not just GPs. We also need to get hospital doctors and other medical professionals involved. I think there will also be a focus on cutting back on unnecessarily bureaucracy in the NHS. Wherever there is wasteful spending on management and form filling that doesn't improve patient care. We have to look at how this money could be better directed into frontline care.
I was at a meeting with the prime minister and MPs earlier on today and there is a consensus that we are now bringing professionals with us - the Royal College of GPs, the Royal College of Nurses and the Royal College of Physicians have all recently released statements saying that the reforms are going in the right direction now.
Our panellists are answering your questions below the line. Dr Evan Harris, Daniel Poulter MP and Richard Blogger have now been joined by Diane Abbott MP, to share their views and predictions for the Future Forum report and respond to your comments.
LauraOliver asked:
What, in your view, is going to be the political reaction to this? Can you foresee Conservative or Lib Dem rebellions?
DanielPoulter replies:
The feeling I had with the PM today was that there is a lot of support for what Cameron is doing. The Coalition stands and falls together on this. There is a recognition on behalf of Conservative and Lib Dem MPs that we have to work together. It's silly to let petty party politics get in the way of the reforms. The PM and Nick Clegg have both been very clear on that. I don't see this as a Lib Dem or Conservative issue - it's one for the Coalition. Of course it's very easy for people to be quoted out of context. But Conservative and Lib Dem colleagues want the right things for the NHS and for the country. We have a strong medical challenge ahead and we have to work together. It would be wrong for anyone to look at things in narrow party political terms.
Certainly having spoken to colleagues there will always be one or two Lib dem or Tories that have some concerns. But the Lib Dems do understand that we have had three months of reflection to consider how we go about this the right way. Lots of concerns from medical and patient groups have been addressed. We've come through with a much stronger set of proposals as a result that I believe everyone will buy into across the Coalition.
RichardBlogger answers:
We have heard a lot of rumbling from de Bois about competition. Earlier today I said I think that the competition pledges the LibDems have "secured" will not please those Conservatives that favour a healthcare market.
I am interested in hearing what Dr Harris has to say about whether the LibDems will be satisfied - in particular, are these concessions enough for Lord Owen?
I agree with Nick. Nick Robinson and Nick Timmins that is. The BBC's political editor and the FT's policy guru have both hit on the same point. Timmins blogs it best - and highlights a key insight into the change here behind a paywall:
At the highest level, what Andrew Lansley wanted was an NHS shorn of at least some of its day to day politics.
A system in which the secretary of state essentially did nothing much except raise the money for the NHS from the Treasury. He or she would then set a few high level targets for the service (better cancer outcomes, improved mental health care).
These were to be delivered by a statutorily independent NHS Commissioning Board who in turn would oversee a bunch of GPs, working in consortia, who would buy the care locally.
They would do so following guidelines on the best way to commissioning care provided by Nice, the National Institute for Health and Clinical Excellence, while a new regulator would ensure patients got the services they needed at best value for money by using a mix of competition where appropriate, and regulation where necessary.
The design was pristine in its purity, allowing politicians to stand back from the day to day running of the service.
Instead, by producing such an enormous and detailed bill – when most of this could have done with minimal legislation – and by explaining it so badly, Mr Lansley opened his every flank to attack by the sceptics. Far from removing the NHS from politics, his bill has injected more politics in to how the NHS should be run than at almost any time since 1946.
Coming up at 1pm we have a live Q&A with high profile Lib Dem Dr Evan Harris, Conservative MP Daniel Poulter and Richard Blogger, health specialist who blogs at the left wing site False Economy and Tory Lies. They will be giving us their analysis and prediction
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