Ten Key Questions about the White paper

In July of last year, The King’s Fund set out ten key questions to ask about the health White Paper. Now, as the Health and Social Care Bill is about to be published to enact the proposed reforms, we look ahead to see what key issues need to be resolved.


1. Will the authorisation process for consortia be flexible enough to ensure that they take on commissioning responsibilities only when they are able to do so?
We welcome the establishment of pathfinder consortia to take forward general practice commissioning. But if general practices are to be more successful than primary care trusts (PCTs) in undertaking commissioning, it will be important to balance the speed of implementation with the readiness of practices to take on their major new responsibilities. While some consortia will be able to assume their functions quickly, others may not be ready by April 2013, the date set for the full transfer of commissioning to consortia.

2. Will steps be taken to ensure that the NHS Commissioning Board really is the ‘lean and expert’ body described in the White Paper?
The establishment of the NHS Commissioning Board – at arm’s length from the Department of Health – has the potential to reduce political micro-management of the NHS. This represents a major shift in NHS governance and could help to devolve power to frontline clinical teams and give greater autonomy to providers and commissioners. As the Board is established, its relationship with ministers needs to be clarified, as does its accountability for performance within the NHS. It will also be important that the Board does not expand its staff to the point where it becomes the Department of Health by another name.

3. Will the NHS Commissioning Board be required to work with consortia in the commissioning of primary medical care and to report annually on how consortia have discharged their responsibilities?
The NHS Commissioning Board will be responsible for the commissioning of primary medical care services, although it may delegate part of this responsibility to consortia. Experience shows that quality improvement in primary care is best undertaken at a local level based on a thorough understanding of the work of practices and the use of performance data to bring about improvements. The NHS Commissioning Board will not be able to take this task on alone because it will lack the expertise and be too remote from the provision of care on the ground.

4. Who will be responsible for local system leadership and where can consortia get support in commissioning specialist services that do not fall within the ambit of the NHS Commissioning Board?
There are some aspects of commissioning that individual consortia are unlikely to be able to undertake without support – for example, the reconfiguration of acute services across a county or a city, or the concentration of specialist services such as stroke, trauma and vascular surgery in fewer centres in order to deliver better outcomes. There is a need for ‘local system leadership’ to address these issues and to complement the expertise that consortia can bring to bear in commissioning other services. This is particularly the case in London, where there are major challenges in reducing duplication between hospitals.

Provider reform

5. Will the government support the Provider Development Agency in working with the most challenged NHS trusts to change service provision even at the risk of political unpopularity?
The proposals for provider reform are in many ways even more challenging than the ambitious plans for commissioning. Here at the Fund, we have always thought it highly unlikely that all NHS trusts can become foundation trusts by 2014 or that all existing foundation trusts will remain financially viable as NHS finances tighten. Establishing a Provider Development Agency to oversee provider reform is a step in the right direction, but it will need to act decisively to change service provision ahead of the new economic regulator taking on its full responsibilities.

6. Will the ‘any willing provider’ policy be implemented in a way that avoids fragmentation and supports efforts to improve the co-ordination of care?
The government wishes to support choice and competition by allowing any willing provider to deliver care to NHS patients. This could help to stimulate innovation and to develop new models of care, which in turn may help with the requirement to find up to £20 billion in efficiency savings by 2015. The benefits are likely to be felt in areas of planned care, where patients can use information about providers’ performance to decide where to seek treatment. In the case of unplanned care, especially for people with complex needs, there is a risk that services could become more fragmented if more providers enter the market.

7. Will practical advice and support be made available to NHS organisations that wish to become employee-owned mutuals to make a reality of the stated aim of creating ‘the largest and most vibrant social enterprise sector in the world’?
Provider reform includes support for new organisational forms including social enterprises and employee-owned mutuals as part of a government-wide programme to increase diversity in service provision. The previous government was equally enthusiastic about social enterprises and mutuals, but progress has been slow, not least because of concerns among NHS staff about pensions and job security. We welcome the emphasis on provider diversity and the exploration of these new organisational forms, and hope that more support will be given to NHS organisations wishing to become employee owned.


8. How will regulation work in the case of provider failure and what exit strategy will be used?
Previous attempts to apply market principles in the NHS have foundered on the weakness of regulation. While much is made of the argument that the innovation offered by new market entrants will help to drive improvements in performance, this will only happen if unsuccessful providers are allowed to fail and ultimately exit the market. Politicians need to have the courage of their convictions and accept failure is inevitable when providers compete for a limited budget.

9. Will the regulator adopt a nuanced approach and ensure that collaboration and integration are not harder to achieve?
Market regulation must help to promote collaboration, as well as competition, where appropriate. Ministers have put much more emphasis on the importance of expanding choice and competition than on the need for collaboration and integrated care. If the economic regulator acts as a competition commission for health care and fails to recognise the importance of providers working together to improve outcomes, this may work against the stated aims of the White Paper.

10. Will the government create a framework for the economic regulator and the NHS Commissioning Board that prevents price competition having adverse consequences for quality?The market-based reforms developed by the previous government were founded on a national tariff that removed price as an issue in negotiation between providers and commissioners. Ministers have suggested recently that the prices in the national tariff may in future be seen as a maximum, with providers being allowedto deliver services at lower cost. International evidence has shown the risk that quality of care may suffer if providers compete on price.

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