Labour Final Year Document – Response from Socialist Health Association

We set out our response within the context that there will be a restoration of support for public services and an end to the era of emphasis on privatisation, marketisation and market competition.  The social and economic value of good quality public services should be emphasised as should the dedication and contribution made by the care workforce.

We support a comprehensive universal system for care free at the point of need, paid for out of general taxation and contributing directly to the redistribution of income and power.  Entitlements to care must be clearly defined nationally and with a Secretary of State legally and politically responsible for the provision.

We strongly support the vision of a care system which begins from understanding and dealing with the social determinants of poor health and which has as a founding value the need to demonstrably reduce inequalities of all kinds, especially in health.

We believe there is a wide consensus about what a good care system would be like and a shared desire to achieve that objective.  But it will be very difficult to make the transition to what will be a different system, designed to meet current needs and far more work is required to map out how such a transition might be achieved.  We believe that Labour should:-

• Share a new vision for what a whole person care system should be like – viewed through the eyes of those who will be using it.
•  Publish a 10 year plan to move decisively from where we are to where we wish to be.
•  Set out how to accelerate the pace of change as economic conditions improve with quality services ranking ahead of any tax cuts
• Ensure an emphasis on quality – of outcomes, safety and experience of care
• Support those who work in the care system, including those who manage it, giving a clear sense of direction
• Ensure that those who work within the care system have decent terms and conditions within a national framework
• Support measures that help to bring beneficial changes to the way services are provided; accepting setbacks and mistakes along the way without knee jerk reaction
• Shift planning for wellbeing onto a population basis with a key role for local authorities in bringing public services together; at different rates in different localities  (Labour councils can take the lead on this)
• Promote removing legal, structural and financial obstacles to cooperation, collaboration and partnership working 
• Encourage and incentivise innovation in how services are delivered but within a clear national framework which sets out entitlement.
• Propose a few immediate changes, but without any kind of whole system top down reorganisation. Keeping to an absolute minimum changes that are imposed by directives from the centre.

We also believe that radical change is most needed within social care.  We support moving progressively to a system where all care is approached on the free at the point of need principle. Even within current funding arrangements it is essential to professionalize the social care workforce and to ensure consistently higher standards of care and more equitable access to care for all with moderate needs.  We would argue for the case to be made to fund the cost of such changes by increases in redistributive taxation – with tax on forms of wealth as a candidate.

At the earliest opportunity we need to:-

• Remove from the NHS the whole paraphernalia of markets and competition; restore the powers and duties of the Secretary of State to ensure we have a universal comprehensive NHS.
• Increase the funding for social care; moving the workforce onto a proper set of terms and conditions; setting an appropriate national level for entitlement to care; set out a long term approach to social care funding.
• Shift from commissioning that is used to support a market with competing providers to planning how best to use all the public resources to get the greatest health gains for defined populations.

“The NHS is not just a whole set of separate organisations with their own autonomous responsibilities but a group bound by “values and principles” which transcend that. Because of those values and principles “you have to take our people with you.”  Well said – David Nicholson – NHS Chief Executive.

1)        Whole Person Care/ Integration of health and social care and mental health

1.1       Whole Person Care (See Appendix A)

• We need a care system rather than separate systems with a vision for whole person care as viewed from the personal perspective and as described by Patient Voices..
• We need integration within the NHS to remove barriers between for example primary and secondary care.
• An integrated approach with individual care plans should greatly improve the support and treatment of people with long term conditions.
• We would extend the concept especially to include housing.  Locally this should also reinforce the requirement on local authorities to ensure the wellbeing of its population through integrated public services.
• We do not accept that integration of itself automatically produces significant savings.

1.1A     Moving to free personal social care funded from taxation

•  A barrier to whole person care is that social care is funded differently, structured differently and means tested. 
• The case for free personal social care is exactly the same as the case for free health care, and in other parts of the UK this has been recognised.  The risk of high costs which are not predictable and which cannot be insured requires a form of social protection.
• There will be savings from moving to free care (especially through reduced bureaucracy and administration) and outcome improvements through easier integration of services.  Over time better social care reduces healthcare costs, but the net cost has to be met – probably through progressive general taxes as with healthcare. 
•  Issues of inter-generational fairness obviously arise and a lengthy transitional period will be necessary.
•  A start can be made by the state meeting all costs above a certain limit and making care free for some such as those who have disabilities. 

1.2       Social care system

• The most important change is to fund social care properly so the quality of care is everywhere appropriate.
•  The NHS Constitution should be widened to cover all care. 
• We support the need for a properly skilled, motivated, well managed and properly remunerated workforce is essential with those employed as care providers on some system like Agenda for Change.
• We support structural integration as part of the move towards cultural and behavioural change; and where this will deliver economies of scale and more rational investment incentives. 
• Assessment of needs is complicated and requires safeguards, but we support the principle of a single national portable assessment process suitably informed by shared decision making and advocacy. Care planning must cover housing and environmental needs.
•  We support the general principle that standards and basic entitlements are set nationally, and this is monitored and enforced.  We support the principles around NICE and see that as extending into social care. 
• The principle that entitlement is set nationally but the delivery is determined locally must be tempered by the need for some genuine local autonomy, to make local democracy have greater meaning. 
• Structures and systems for provision should be decided locally and we may see different approaches in different settings.  Local authorities are not generally subject to top down enforcement as NHS bodies are. 
•  We support the principle that a personal budget may be suitable for some – but there can be no compulsion or even direction.  There can be no prohibition of top ups but the quality of care should be such as to make this less attractive and unnecessary.

1.3       Mental Health

1A)  Making our NHS a genuinely national system

• The N in NHS requires national standards, national service frameworks, national outcomes frameworks and inspection and regulation on a national basis. 
• What defines the “comprehensive” nature of the NHS is defined nationally and guaranteed by the Secretary of State.  The SoS can intervene if there are serious departures from what the NHS should be delivering.
• The rules which determine how the NHS approaches issues around cooperation, procurement and competition (which reflect domestic and EU law) should be binding throughout the NHS, but the rules should be there to protect commissioners (or planners) from external intervention if they act reasonably.
• National terms and conditions for staff should apply so staff can move within the NHS, although there can be the kind of flexibilities Agenda for Change already provides within the same overarching national framework agreement.
• Revenue funding should derive from a national formula based on weighted capitation; we need to go back to a geographical basis.  Programme funding which is aimed at specific outcomes rather than at organisations can, as now, be controlled at the appropriate level, most usually national or regional.
• There are strong arguments for national shared services and some national procurement framework to lever in economies of scale.
• We already have national systems for collection of data and we must have an obligation on all providers to supply that information with proper sanctions – we need high quality comprehensive data. 
•  This national service must however be tempered by patient and public involvement and if we are genuine about being responsive to local population need, then there will of necessity be differences in local planning. So long as the differences in area provision are properly explained and seen to be logical, it is no longer a lottery, but evidence of responsiveness to local need.
• This balancing act requires the SoS to have ultimate responsibility for securing the provision of services and power to intervene in any part of the NHS and to issue binding directions – although they would only rarely ever use such powers.

2)        Repealing the Health and Social Care Act 2013

2.1       Competition and the internal market 

• A model for the NHS based on regulated markets and economic competition between providers is rejected. The apparatus of the internal market should be progressively dismantled.
• We support the NHS as a single national system founded on the basis of social solidarity and all relationships between commissions and providers should be within the NHS and not the subject of legally enforceable contracts. 
• It should be a matter for commissioners to decide how best to secure the provision of the necessary services but only within a very clear national framework. 
• Nothing in domestic or EU law should be able to compel a commissioner to end an existing relationship with an NHS provider or force competitive tendering of clinical services. 
•  Where a commissioner is unable to secure provision of the necessary service from an NHS provider to the required level of quality then they would be expected to look beyond the NHS and run a competitive process. 
• Commissioners would be expected to test the quality and efficiency of all services on a regular basis to be able to demonstrate value for money and “best value”.
• The Competition Commission should not have any remit over NHS services and NHS providers would be free to merge or otherwise make strategic arrangements without external interference (subject to agreement from relevant Health and Wellbeing Boards). 
• Many of the functions included within commissioning around needs assessment,  pathway design, planning of services, setting of required standards, ensuring continuity of provision,  and the monitoring of performance and quality are important and have to be done somewhere.  These functions should be carried out separated from provision because:-
  • Planning for improving care should cover more than just the providers
  • There has to be some strategic layer than allows resolution of the wicked issues like reconfiguration where there will be winners and losers
  • Acute providers are always dominant and Community Care, Mental Health and other “Cinderella” services lose out
  • Too many “providers” have vested interests (especially GPs).
• The expertise which resides within providers needs to be captured to help inform service design, pathways and specifications but they should inform the decision making processes not take part directly in them. 
• Care resource allocation at every level is based on judgement and supported by evidence and professional advice and must balance what will often be competing priorities and even local politics. Those who make the key decisions about how resources are allocated and about how priorities are set within a tax funded, cash limited, system should be elected.
•  There must be one single democratic body which oversees the whole of the commissioning of publicly funded services for a locality – usually a tier one local authority or a grouping – for example a pan London body. 
• Clinicians, especially GPs (who have greatest contact with patients), must be closely involved in pathway design, service specification, monitoring quality and outcomes, but generally on a part time basis or as required. 
• The more transactional aspects of commissioning around data gathering, procurement, contract management, invoicing, and other back office functions which are continuous need to be carried out by others. 
• The longer term goal is for integrated commissioning undertaken by the local authority which looks across the whole public sector, driven by the local strategic needs assessment and set out in a wellbeing strategy and commissioning policies, all of which are informed by public health.
•  We support making the environment conducive for integrated provision where this can be evolved without major structural upheaval through incentives for joint appointments, joint budgets, collocation, information sharing, and shared services across the NHS and local authorities.  Initiatives such as “year of care” and “programme budgets” must be encouraged and coupled to incentives for joint working. 

2.2       Commissioning (See Appendix C)

Commissioning as we use the word does not mean activity put in place to support a market, internal or external.  In all state funded health systems there is commissioning of some kind as decisions have to be made about funding flows, priorities and quality.  This can be achieved within a single organisation (as in Wales) but requires functional separation and open and transparent systems.

2.2A     Public Health

• The political narrative on public health and the NHS should centre on the health and well-being benefits of tackling social inequalities, linking to the practical vision of economic development with productive jobs, real innovation and locally-based investment.
• We should support and strengthen the move of public health to local authorities. The key test of public health devolution will be ability of local authorities and local NHS to manage change, working across institutional boundaries. Public health funding needs to continue to be ring-fenced, at least until the habits of collaboration are well bedded in.
• Each Local Authority must have a qualified Director of Public Health reporting directly to the Chief Executive and with protection of the sort offered to Section 151 Officers.  They should be professionally responsible to the Chief Medical Officer who must also approve all appointments and terminations.
• Over time all public health staff and budgets should be independent and managed through a strengthened Public Health England, whilst professionals would continue to work within both local authorities and health bodies.
• CCGs with boundaries that do not correspond to the other agencies involved in public health are not sustainable. Uniting health and social care around the local authority platform will give planning for health real muscle.

2.3       Patient voice

• We strongly support complete openness in the provision of information to support patient voice; no NHS funded service or body should be exempt in any way from FOIA and commercial confidentiality should not be used to block access to information.
• Communities should be involved in the planning and commissioning of their services with a major say in how to improve the health of their locality. Decision makers must be obliged to make this a reality and should be monitored on the effectiveness of doing so.
• We should firmly embrace the importance of community development which works with communities as assets not as problems.  Asset-based community development approaches need to be highlighted and promoted. We need communities to take more control of their environments and work closely with statutory agencies through residents-based partnerships.
• We should make involvement in our individual care a reality by embracing shared decision-making and self-care.  In general patients want greater involvement in their care and they should be offered informed choice about the treatment options open to them.
• Patients should have the right to see whatever information is held about them and should have access to independent, but quality controlled information about their condition and their options.  But some will not want to be proactive and just wish to be guided, advised and supported; they should not be coerced into anything.
•  In many cases, once their care plan is determined, patients should be able to choose which NHS venue they attend and should be able to select the appointment that best suits their needs.  These are not market choices and the likelihood is that the vast majority will be guided by professional advice and also are likely to choose facilities in the locality.

2.4       Providers, Regulation and Francis Report

• There is no need for an economic regulator as the market system will have been abolished.
• There remains a need for some form of registration and authorisation. Monitor should be abolished along with the market structures. Any residual roles should move either to the CQC or to sub regional teams.
• All Trusts should move to the Foundation Trust (FT) governance structure. 
• FTs that do not effectively embrace stakeholder governance should be encouraged to do so; some minor changes to FT governance rules should be made for example giving governors rights over attendance at all meetings and access to information.
• All barriers to integration through structural change (such as mergers or strategic alliances) should be removed although, in the short term, there would be some authorisation step. 
• Integrated providers would require a very different funding approach – probably a single block payment based on population.  This would save a significant proportion of the overheads compared with the quasi market with its multiplicity of transactions between commissioners and multiple providers.
•  We support the progressive development of broader based integrated NHS providers; a trust as a structure just for a single hospital or a narrow set of services ensures fragmentation, complexity and bureaucratic costs.
• In some localities integration of provision may be achieved without structural integration.
• Integrated providers should be supported and incentivised in the short term by a sub regional structure under NHS England (build on current Area Teams)
• We should bring back the best features of Community Health Councils and embed within Local Health Watch bodies with adequate support and guaranteed funding.
• We do not believe that more regulation will avoid future problems, and the CQC is largely a waste of money. 
• Local monitoring of standards based on much better transparency is a more productive way forward.  Commissioners should take more responsibility for the quality of services they are paying for. 
• Royal Colleges should publish quality standards, which set benchmarks which are very useful for lay assessors. Lay people need some support in understanding what they are looking at, and if such standards are comprehensible they are useful for patients too. 
• Peer review is also needed as is increased use of clinical audit within and across providers. 

The most effective monitoring of services is that provided by the people at the receiving end.

2.5       Reinvigorating professionalism

• The clinical professional bodies should collectively agree on how they can adapt their practices, training and professional development to meet the new challenges posed by revalidation, appraisals, Community Development and Shared Decision Making and the information revolution. 
• They have also to confront some of the messages from the various enquiries which show that their role in ensuring high standards and enforcing best practice is inadequate.
• We should revive the National Service Framework approach. This emphasised clinical collaboration and evidence-based practice and was well respected by the public, clinicians and organisations such as NICE. 

2.6       Enhancing the status and role of primary and community care

• Moving care closer to home and reducing admissions to hospital through system management and prevention is better for patients and may in some cases also be more efficient.
• Investment in primary and community care is a prerequisite of such change.  There is a need for better access (potentially 24/7).  Many additional requirements on GP Practices require different working practices, improved premises, better IT, more nurses and health visitors.
• Local primary and community care, providing a wider range of traditionally hospital-based services, are key to improving outcomes and equity, but still with support to access hospital care when it is needed. This may need a review of the GP “gatekeeper” role.
•  The small business independent contractor status for GPs may no longer be appropriate for high-quality integrated care. As the patient becomes the centre of integrated multi-disciplinary care, we may need a clinician whose orientation is centred on the patient not the practice. 
• There should be more GPs directly employed within the NHS. We should encourage other organisational models whilst still supporting the traditional practice model.

3)        Promoting Good health – Prevention and early intervention

3.1       Preventative Health Services

• Improving health requires addressing the social determinants of poor health of which income inequality tops the list. 
• Addressing these issues needs to be based on the principle that there is a role for an interventionist state, for redistribution of wealth and power and a role for public services not just in planning and commissioning but in delivery.  We need a collective approach. 
• There is now a strong economic argument, particularly in a recession, for increased investment in public services rather than cuts. We need to make the case for investing in a way that will offer the most benefit in terms of jobs and health gain.

3.2       Sugar & Salt Consultation /Helping people make informed choices

3.3       Joined up services for children and families

3.4       NICE

4)        Reconfiguration of Services

4.1       Reconfigurations

• We support the principle that changes in service configuration should only be made after adequate engagement and consultation but we believe this to be a process rather than a one off set of events based on some imposed external rules or legal framework.
• Progressively better stakeholder governance within providers and greater democratic accountability over planning and commissioning should be the basis on which services changes are developed.

4.2       Changing role of hospital services – community based care

• We do not support the concept of a hospital as an organisation competing with others.
• Hospitals should be seen as valuable assets; as part of a whole system and could be as much a base for primary care as a setting where acute care takes place.
• Staff based at hospitals should also where appropriate be asked to work at other venues within NHS.
• We support moving care closer to home, out of hospitals, but hospital capacity can only safely be reduced once adequate alternative provision is already in place.
• We do not support any form of failure regime which is a market solution for a challenged service or organisation.  Avoiding failure is best achieved if the system allows support and assistance from other parts of the NHS.
• To avoid the natural suspicion of communities to changes in local services a system for more inclusive longer term planning is required based on safety, access and efficiency and also on the idea of whole system benefit.
• Professional bodies must be more open and explicit about the requirements for safe care and openness and transparency about financial reporting so evidence informed decisions can be made. 

4.3       Emergency Care

•  Models for dealing with emergency and urgent care will differ depending on the locality and sparsely populated rural communities need a different approach to urban areas.
• We support the need for A&E Departments to have 24/7 facilities to deal with all medical and surgical emergencies on the same site, meeting the many Royal College standards.
• Outside A&E departments there should be a primary care system for ensuring those with urgent needs get the response their condition requires.
• The current failing system which deals with emergency and urgent care is a clear example of how breaking up the NHS and fragmenting it into multiple competing providers does not work.
• Effective emergency and urgent care needs an overall architecture which can only be possible if there is some overall system design and development – and having some loosely defined “network” which does not control the funding or the performance is not enough. 
•  We need a single NHS body, probably based on the ambulance trust, clearly responsible for securing provision of all emergency and urgent care outside of the A&E for each locality. This works only with a single system for assessing the required response; ensuring patients go to or are taken to the best place to meet their needs regardless of how they choose to communicate their need. 

4A)  Private Provision

4.A1     The Role of Private Provision

• There should be no support or any form of incentive for privately provided care, through tax allowances or any form of subsidy. 
• There must be strong professional guidance about the circumstances when non NHS provided health care options should be offered and proper independent expert advice available to all care users on their rights and options (including, where appropriate, advocacy).
• The NHS should continue to be a provider of privately funded health care only where this can bring benefits to the NHS.  There must however be proper guidance over separation of accounting to ensure transparency. 
• All Trusts must report separately in their accounts the level of income and expenditure from private patient activity in a prescribed manner covering Joint Ventures and similar organisational devises.  The calculation of expenditure on private patients must include a contribution for the NHS costs in training the staff involved and the finance costs of the equipment used. In addition, the “profit” derived from treating private patients must be greater than the “surplus” which would have arisen from treating NHS patients with similar conditions.
• Any plans by an NHS provider to significantly change the level of private patient activity must be consulted upon and supported by appropriate local authorities and the Governing Body. 
• Healthcare must remain a predominantly publicly delivered service, and the public provision of social care should be strongly supported. 
• All providers of care must comply with minimum standards around workforce terms and conditions, training, development and supervision as well as quality standards.
• Commissioners/planners should review all care services on a regular basis and include in that consideration proper engagement with service users.  Reviews should be published.  Where they are satisfied that the service provided is appropriate they should support it (preferred provider). 
• Any proposed change to care services should be examined also for its wider impact on other services – a whole system test.
• Where a service from the current provider cannot be improved to the required quality standard or where a new service is required which is currently not provided then competitive procurement including private providers may be used. Organising a new service through supporting development of current NHS providers would also have to be considered. 
• Commissioners must ensure that all providers of NHS care have public and patient involvement embedded in their governance.
• No service may be procured using a contracting arrangement unless:-
  •   the service is largely independent of other services
  •   the quality requirement can be properly specified in a legal contract
  •   there are already a number of recognised providers of such a service.
• The national procurement regime as permitted under EU Public Procurement Directive for care services should ensure that there is no compulsory competitive tendering.
• There should be a test of suitability applied to prospective private care providers applied through continuing registration conditions or through contracting.  Major changes in capitation (for example) could enable contracts to be terminated.
• Where a public body has a legal contract with a private provider that contract must ensure full openness and transparency – with no “commercial confidentiality” outside the actual procurement process. 
• Contracts and procurement requirements should specify steps to ensure continuity of care (which might include some financial bond being required) and knowledge of local conditions and services and populations would be an essential condition. 

4.A2     Private Medical Practice

4.A3 Private Provision of NHS Funded Healthcare

4.A4     PFI

• All major PFIs should be transferred to PropCo or a similar national “toxic asset” management regime that should take over the major contract management issues and use its scale and expertise to ensure contract compliance.
• Contracts should be assessed against any opportunity for renegotiation or possible buy out, insofar as that has not already been done. 
• Trusts should be charged a fair usage charge, as some variation of public dividend capital, using the same approach as has been adopted for a limited number of Trusts in difficulty.  The subsidy this implies should be met out of the top sliced national funds.
• It is unlikely that public capital funding will be available on any scale and every effort should be directed at maximising the best use of existing public sector assets.
• There should be no further PFI or PF2 deals but variations on P21 will be permitted for smaller scale works (<£50m).  There should be no further LIFT schemes.
• It is unclear how major capital schemes, say for a hospital rebuild could be financed.  Many suggestions have been made – borrowing from capital markets, raising local loans, using pension funds, using public loan board – but none have yet been developed into anything like a policy.

4.A5     Future Capital Funding

5)        Supporting people with long-term conditions

5.1       Integration/single point of contact

5.2       Prevention and intervention

6)        Mental Health

7)        Health inequalities

8)        Workforce issues

8.1       Workforce

• We support commitment to Agenda for Change and the national agreement on terms and conditions.
• We should bring back the agreement that prevented two-tier workforce arrangements. 
• We should look to establishing some form of concordat or contract terms for private providers to the NHS to accept obligations around TU recognition and staff engagement, comparable terms and conditions, disclosure of information, training and development.
• The social care workforce has to be dramatically unskilled, paid a living wage and put into structures where they get proper management, training and development.  Zero hours contracts should be banned and visit planning using 10 or 15 minute slots also banned.  The excellent Charter proposed by UNISON should be universally adopted.
• The case for minimum staffing levels, especially as regards nurses, but also levels recommended by Royal Colleges for clinical safety is generally agreed, but how this should translate into regulation or perhaps just to management and monitoring has yet to be resolved.  There should however be clear guidance which is publicly available along with monitoring which is also publicly visible.

9)        Dignity and older people

9.1       End of life care

Appendix A – Whole Person Care Definition

There is the start of a definition of what this means from the perspective of the recipient – you know what it is when you experience it.  This is adapted from the work done by National Voices:-

• I know who is in charge of my care
• I am involved in all discussions and decisions about me
• My family and carer are also involved (so far as I want)
• I have agreed a care plan which covers all my needs
• I have one first point of contact and they know about me and my circumstances and help me access other services
• I can see my records, decide who else can see them and I can make corrections
• There are no big gaps between seeing people having tests and getting results
• I always know what the next steps in my care are to be
• I know that all those involved with my care talk to each other and work for me as a team
• I get information at the right time and I can understand it, sometimes with some help
• I am offered the chance to learn more and set goals to include in my plan
• My plan is reviewed with me regularly and I am involved as much as I choose to be.

The suggestion is that something like this is set out in the NHS Constitution.

The major changes required to get to this kind of state are in the areas of clinical training, medical records, new tools and methods.  This has a cost implication and will take time.

Appendix B – Local Authorities Commissioning and Funding

At present funding flows to commissioners through formula established by NHS England and to providers through payment by results or through block contracts.  The amount to be spent in total on healthcare and public health is set by government then allocated by NHS England to various national streams then to CCGs.  There is no democratic involvement of any kind in the decisions about allocating resources.

The alternative is that funding flows through LAs as does the funding for various other public sector services.  This has advantages.  First it brings in democracy ie the major decisions about funding and priorities are set by elected people. (But they have to ensure the comprehensive NHS is provided and meet all guidelines.)  Second it allows LAs to make bigger decisions across the whole of the public services – so they may invest in measures which reduce future demand for healthcare.  Third it should bring scale economies into commissioning. 

Under this model funds are allocated to local authorities based on (weighted) population.  The LA makes the strategic allocations then delegates to the CCG the actual commissioning.

For CCGs there is a separation between the clinically critical tasks such as pathway design – but in some cases this can follow a national template.  They would also be involved in monitoring quality, agreeing standards, deciding on competing priorities and on how best to allocate scarce resources. But, as above, they have to ensure the comprehensive NHS is provided and entitlements to care are met.

This is like the BMA model for commissioning which leaves some commissioning functions like procurement, contract ,management, information processing in something like a shared service (to get economies of scale), where clinicians advised but did not manage or carry out all the processes.

Appendix C – Commissioning

First there does need to be some agreement about what planning/commissioning involves.  For any efficient system there has to be some objective basis for service planning, priority setting, allocation of funds, performance management.  Hopefully this would be underpinned by good information and informed by local public and patient involvement.

The conceptual cycle can be illustrated by:- 

These functions would be necessary in any system, and so would have to be paid for.