John Kell
Head of Policy

The laws that underpin the NHS have been controversial since at least the reforms instigated by Andrew Lansley in the early part of this decade, and possibly going back to the initial creation of an internal market in the NHS in 1991.

As part of its Long Term Plan, NHS England is consulting on proposals to change this legislation once again. It is not, however, proposing another ‘big bang’ reorganisation to sweep away the old institutions and replace them as Andrew Lansley did. Instead, it is mainly proposing to keep the current institutions (such as clinical commissioning groups) but give them new duties and powers. The idea is to make them work collaboratively, as the Ten Year Plan envisages, and not ‘compete’ in a ‘market’.

The proposals are inevitably technical. NHS England has published a survey that allows you to comment on their proposals item-by-item (they can be read in full in this consultation document). To try to gather opinions in a more accessible way, we will outline the main proposals in this blog post, and invite views on key points and themes, rather than technical specifics, in a short survey. We will use these views to develop a response by the Patients Association to NHS England’s consultation.

1. Promoting collaboration
Several of the new proposals are about making NHS bodies, including hospitals and CCGs, work together in a collaborative way, rather than rely on competitive commercial contracts. To this end, it proposes to remove the function of the Competition and Markets Authority to review mergers between NHS foundation trusts, and to remove NHS Improvement’s competition powers and duties.

2. Getting better value for the NHS
The rules around letting NHS contracts are currently subject to strict rules around process and competition. NHS England proposes replacing these with a ‘best value’ test that the NHS should base its procurement decisions on. This will involve assessing whether the NHS has obtained ‘best value’ from its resources in terms of the likely impact of decisions on care quality and health outcomes, whether they are in the best interests of patients, and whether they considered all relevant issues.

3. Increasing the flexibility of national NHS payment systems (the ‘tariff')
The tariff is the system under which funding is distributed in the NHS to the provider organisations, including hospitals, that provide healthcare. It is well established, but known for being inflexible, which can sometimes make it hard for doctors to secure the right treatments for their patients. NHS England’s proposals include setting ‘tariff’ prices under a formula rather than fixed value (for instance, to take account of local factors), and to allow adjustments to the tariff or variation from it in particular circumstances (for instance, to pay for a new treatment or cover out-of-area care).

4. Integrating care provision
Integration is a major theme of the Long Term Plan, in terms of both joining up care within the NHS, and integrating with social care and public health. One way of doing this will be to award a contract to a single Integrated Care Provider (ICP) to deliver a range of care that would currently be provided by multiple different organisations. NHS England proposes to enable the Secretary of State to create new trusts to take on this role, so that it is done by a public, NHS organisation that has been set up specifically for the task.

5. Managing the NHS’s resources better
Mergers between NHS organisations, or major changes in their governance, take place quite regularly when having two or more separate organisations no longer makes sense. Done well, they can help the NHS to run itself more efficiently, with less duplication of roles across different organisations. NHS England proposes to give NHS Improvement powers to direct mergers and acquisitions among foundation trusts when this is appropriate (this will change the governance of the organisations, but not directly change the patient care they deliver).

6. Every part of the NHS working together
There are numerous proposals that would have the effect of bridging the purchaser-provider split, and therefore dissolving the internal market to a large extent. One major proposal is to allow CCGs (currently ‘commissioners’, ie purchasers of services) and NHS trusts (currently providers of services) to form joint committees to plan and operate services. This reflects many important dynamics that often hindered the internal market, such as the fact that the clinical expertise and manpower that will actually deliver the care resides almost entirely on one side of the divide (ie in the provider organisations). Providers will also be empowered to form joint committees, without CCGs.

7. Shared responsibility for the NHS
Current legislation places many key duties on the NHS and the organisations within it. Currently they do not clearly require NHS organisations to think about what’s best for the NHS as a whole, or the ‘health economy’ in a particular area. NHS England proposes to put a new duty on NHS bodies to promote the ‘triple aim’ of better health for everyone, better care for all patients and more efficient use of NHS resources, in respect of the local care system and the NHS as a whole.

8. Planning our services together
Currently, local authorities are responsible for social care and public health, while the NHS is responsible for healthcare. NHS England proposes a new power, enabling NHS bodies and local authorities to take decisions jointly about planning the full range of health and care services.

CCGs will also be given powers to plan and arrange services for their combined populations, so in theory one CCG could (by agreement) plan a particular service for its neighbouring CCG. In practice this might mean CCGs sharing out responsibility for services among themselves, with one CCG specialising in one service area and its neighbour in another. This should make it easier to plan at larger, more efficient population levels, and also spread good practice more effectively.

9. Joined-up national leadership
The national bodies that currently regulate the NHS are NHS England (technically the NHS Commissioning Board) and NHS Improvement (really a ‘cut-and-shut’ combination of Monitor and the NHS Trust Development Authority). The proposal is either for the two to be formally merged, or for them to be given more scope to exercise their powers jointly.

Over to you
Now you’ve read a bit about the proposals, let us know what you think in this short survey. It should take you about four minutes to complete.