White Paper - reaction from the Kings Fund

If the proposals set out in White Paper 'Equity and Excellence' are implemented in full, the changes will have far-reaching and significant consequences for the NHS. The result will be a health care system, unique internationally, that gives groups of general practitioners unprecedented control over public funding. But will the proposals actually be realised in the way the Secretary of State hopes?

The White paper is littered with references to consultations. Many detailed questions remain to be answered in further documentation, which is expected to follow. Some of the proposals will need legislative change. The parliamentary process under the coalition government is as yet untested. The Bill is likely to be subject to close scrutiny both within the House of Commons and by the Lords. Some aspects will require renegotiation of contracts with trade unions. At a time when public sector pay is likely to be frozen these negotiations could be protracted. Andrew Lansley is said to be a man in a hurry, yet these issues suggest implementation could be slow.

There is a real danger that the financial squeeze on the NHS, which will start to show within 12 months, could derail implementation of the White Paper. Many providers will become financially challenged, making their ability to go it alone as a social enterprise organisation difficult if not impossible. And any appetite that does exist among GPs to take on commissioning (with support from other organisations, including the private sector) is likely to be dampened by the challenges of having to deliver huge productivity savings.

The other factor likely to make implementation more challenging is that the reform proposals themselves dismantle the very apparatus used in the past to get things done in the NHS – targets and performance management by strategic health authorities and primary care trusts. A reliance on choice and competition and the motivations of professionals and clinicians to drive the changes is a gamble. Our research on patient choice has shown that after several years, it was still having only a limited impact on providers.

If the proposals are to succeed, the government needs to engage and motivate clinicians and managers to work effectively together. They ultimately will lead change across local health economies and deliver improvements in quality and productivity. It is unlikely that managers, who face potential redundancy, and clinicians, who are being given new responsibilities without any increase in pay, will feel ‘liberated’ by the government’s plans. Instead, the government runs the real risk that these structural and organisational changes will distract from the real task of clinically led service change.

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