Equity and Excellence analysed

An analysis of the Government’s proposals in their White Paper, Equity and Excellence: Liberating the NHS. At the end there are links to other organisations comments and reactions. Our response to the document is here.

We cannot disagree with anything in the Forward as it accepts our version of a comprehensive publicly funded NHS free at the point of need.

It avoids the major issues:-

  • how to ensure commissioning is democratically accountable
  • how to reduce health inequality – part of how you get locally required changes within a national universal system
  • how to be patient centred when health and social care are fragmented
  • how to reduce unnecessary variation across the system

and it parks the issue of funding adult social care by promising an enquiry to report in one year

On the face of it the strategy is pretty coherent and could be viewed as building on the Blair/Milburn vision for the NHS.  It does not play in the role of the private sector at all but it is obvious that many of the changes will result in huge encroachment of the private sector as well as actual privatisation.

Taking the strategy point by point:-

  1. Shared decision-making will become the norm: no decision about me without me.

Fully support this and we should respond to the planned consultation.

  1. Patients will have access to the information they want, to make choices about their care. They will have increased control over their own care records.

Fully support.  But many patients will need navigators, advocates, agents or other support – without this it will be another facet of inequality.

  1. Patients will have choice of any provider, choice of consultant-led team, choice of GP practice and choice of treatment. We will extend choice in maternity through new maternity networks.

We support the principle of choice because it is good for the patient but do not support the use of choice as a market lever leading to closure of allegedly underused capacity.  If many patients choose not to go to their local facility and it is closed then this is a bad thing not a good thing.

  1. The Government will enable patients to rate hospitals and clinical departments according to the quality of care they receive, and we will require hospitals to be open about mistakes and always tell patients if something has gone wrong.

We support the principle but there have been huge problems with data accuracy and consistency for example as between CQC Rating, Monitor Rating and Dr Foster.  We must be clear about who owns the data and what it can be used for.  Subjective reporting by patients will be biased (in the statistical sense) and must be balanced by objective data and independent assessment.

It should extend to GP Practices and every other delivery part of the system not just hospitals.

  1. The system will focus on personalised care that reflects individuals’ health and care needs, supports carers and encourages strong joint arrangements and local partnerships.

We agree that this is required but how will the proposals will deliver it?

  1. We will strengthen the collective voice of patients and the public through arrangements led by local authorities, and at national level, through a powerful new consumer champion, HealthWatch England, located in the Care Quality Commission.

The voice of patients (and other stakeholders) is needed within Local Authorities, within the GP Commissioning Consortia and in Provider Foundation Trusts but none of this is actually provided for in any meaningful way. The voice of patients needs to be independent.

  1. We will seek to ensure that everyone, whatever their need or background, benefits from these arrangements.

This ducks the issue of who benefits the most and whether there is a definite policy to use the strategy in ways designed specifically to reduce health inequality.

  1. The NHS will be held to account against clinically credible and evidence-based outcome measures, not process targets. We will remove targets with no clinical justification.

We fully support a move to an evidence based approach but this needs to apply also to policy development which it clearly does not at present.  Most clinical decisions are not based on evidence anyway as Prof Maynard has shown.

There is evidence that targets have worked for example in reducing wait and the access targets were put in place as waiting times were repeatedly the number one concern of patients in surveys. Within the huge infrastructure of contracts between multiple commissioners and multiple providers will be all kinds of targets, objectives or whatever they are called.  Things that can be measured and tracked against will have to be part of contracting. Process targets are vital for efficiency improvements for example through “lean” what is wrong is the way that they are used and reported.

  1. A culture of open information, active responsibility and challenge will ensure that patient safety is put above all else, and that failings such as those in Mid-Staffordshire cannot go undetected.

The idea that patient safety comes first is at the heart of medicine.  The reference to Mid Staffs is bogus and misleading.  Failings were not undetected, many knew about them, especially the local newspaper, their Foundation Trust application was initially deferred by Monitor, and the system refused to listen.

  1. Quality standards, developed by NICE, will inform the commissioning of all NHS care and payment systems. Inspection will be against essential quality standards.

Fully support but it will not be possible for NICE to inform all commissioning. These quality standards are almost all about process, not outcomes. The information revolution will also need costing. The examples given of NICE quality standards are all new collections- and only 3 conditions are covered. One US health care system thinks it costs them $1 for collecting, collating, analysing and reporting every data item for every patient. These new data collections will have a signifcant effect on the resources available for front line care.

  1. We will pay drug companies according to the value of new medicines, to promote innovation, ensure better access for patients to effective drugs and improve value for money. As an interim measure, we are creating a new Cancer Drug Fund, which will operate from April 2011; this fund will support patients to get the drugs their doctors recommend.

Why just cancer drugs? Should people with other conditions not get the drugs their doctors recommend? Which doctors are we talking about? Those who make recommendations supported by evidence, or some other kind?

  1. Money will follow the patient through transparent, comprehensive and stable payment systems across the NHS to promote high quality care, drive efficiency, and support patient choice.

This is tautological; the idea of marketisation is that money following the patient creates instability – which can lead to market exit and/or market entry. This is how the huge cost of paying for the infrastructure of the internal market is justified.  If we accept that we need the payment system to promote quality of care then the later arguments about relying on professional judgement must be wrong.  You can’t have it both ways.  It is not the role of the payment system to bring about clinical improvement.

  1. Providers will be paid according to their performance. Payment should reflect outcomes, not just activity, and provide an incentive for better quality.

This will be unstable.  It is not the role of the payment system to bring about clinical improvement.  If poor quality leads to lower income the result could just be a downward spiral.  Early detection of poor quality should lead to clinical review, support and possibly investment – not financial penalties. This type of incentive is an efficient way of discouraging providers from taking on ‘high risk’ patients- those with greatest physiological risks and with least social support.

  1. The forthcoming Health Bill will give the NHS greater freedoms and help prevent political micromanagement.

Perhaps. It may also be a convenient way of deflecting political responsibility.

  1. The Government will devolve power and responsibility for commissioning services to the healthcare professionals closest to patients: GPs and their practice teams working in consortia.

This is the core of the system reform and it is based on no evidence and no feasibility studies or pilot schemes.  It is a huge gamble. It is right that GPs should be centrally involved in commissioning and it is obvious that PCTs have failed to involve them properly, indeed PCTs have failed.  It is wrong that commissioning responsibility and accountability is in private hands; allocating public money on this scale must be through democratic accountability.  Local authorities should have the strategic responsibility for integrated commissioning and they should then devolve their responsibility to the GP groups for a range of services in their locality (but not all). Making GP consortia financially and politically responsible for delivery and development of services is going to require a massive system for governance which is not yet spelt out. FTs have to acquire their autonomy and control over NHS resources by a lengthy and exhaustive authorisation process which half of NHS Trusts still cannot pass – yet GPs will get the authority with no requirement to meet appropriate standards. The system with 500 odd commissioners (as opposed to 150) combined with payments by results/volume will increase bureaucracy and management overheads.  The scope for disputes over payments with GPs who are private organisations not NHS bodies is enormous – lawyers charter.

How many GPs have the ability to commission and manage a complex system on behalf of large populations?

The performance management and failure regimes are yet to be spelt out.  What happens if a consortia goes bad – are all the practices closed down – are the actual GPs financially responsible for any losses etc. Who on earth would be the Accountable Officer of one of these consortia!!!

‘Public health specialists should be at the heart of commissioning’

  1. To strengthen democratic legitimacy at local level, local authorities will promote the joining up of local NHS services, social care and health improvement.

We do not need promotion.  They should have strategic commissioning responsibility and that is the only way we will ever get genuine joined up and patient centred care. This has nothing to do with democratic legitimacy, which is absent. The LibDem idea around democratic involvement was flawed and has anyway been dropped.

  1. We will establish an independent and accountable NHS Commissioning Board. The Board will lead on the achievement of health outcomes, allocate and account for NHS resources, lead on quality improvement and promoting patient involvement and choice. The Board will have an explicit duty to promote equality and tackle inequalities in access to healthcare. We will limit the powers of Ministers over day-to-day NHS decisions.

Maybe.  Ending the bullying, top down, management by shouting culture of the DH/NHS is fundamental to reform.  Look out for all the senior shouters in DH/SHA/PCTs moving into other positions and shouting from the sidelines. The Board should have a majority of non executives appointed through some proper independent process not controlled by DH.  Board meetings should be like NHS Trust meetings are supposed to be, open to the public an properly reported.  Should be observer status for nominees from LGA, HealthWatch, SHA etc.

  1. We aim to create the largest social enterprise sector in the world by increasing the freedoms of foundation trusts and giving NHS staff the opportunity to have a greater say in the future of their organisations, including as employee-led social enterprises. All NHS trusts will become or be part of a foundation trust.

The aim is to get all the staff out of the NHS with its national bargaining, A4C, and pension arrangements. Increasing freedoms means ending the private patient cap which is not a good idea.  It also allows freedom to borrow and freedom to retain surpluses in a way controlled by the regulator. The one employee led social enterprise was hardly a glowing success.  What about employee ownership – that has established evidence base of success. Why can’t there be social enterprises which are not FTs?  We can support social enterprises and co-operatives, and would support an FT model if it was genuinely a method for establishing community ownership.  There must be major changes in FT governance.

Huge questions about who employs staff and about ownership of assets.

There is also an issue of what happens when an FT fails.  Who intervenes and when and what are the powers.  Looks like Monitor intervenes to force a takeover of the services by another FT (or other provider) and uses funds from some kind of top slicing of all FTs – fraught with all kinds of problems. What happened to the idea that some services could go to local authorities – it now says they all have to become FTs – as a whole?

  1. Monitor will become an economic regulator, to promote effective and efficient providers of health and care, to promote competition, regulate prices and safeguard the continuity of services.

Strange mixture of roles and Monitor is not set up to carry them out.  It has taken 6 years to authorise half the acute and MH trusts now it has to authorise then supervise the rest as well as all the provider trusts (150 plus) from primary care trusts break-up, ambulance trusts and perhaps in some way GP consortia?  It has dealt with authorisation but has not yet developed effective systems around ongoing regulation – whatever form that takes. Monitor has no experience of primary care organisations. Mid Staffs and other events have showed Monitor’s procedures are deeply flawed.

Huge changes will be needed and the whole character and function has to be changed – this is not an adaptation and expansion of the current organisation – it is a whole new organisation. Given the role the new body must have a Board that is properly appointed and accountable not SoS nominees. Ensuring continuity of services will require major powers of intervention.

  1. We will strengthen the role of the Care Quality Commission as an effective quality inspectorate across both health and social care.


  1. We will ring-fence the public health budget, allocated to reflect relative population health outcomes, with a new health premium to promote action to reduce health inequalities.

Good.  But better would be all funding for health and social care flowing through local authorities as strategic commissioners, with no ring fencing. Evidence shows additional NHS funding did not reduce health inequalities, it is far more complicated.

  1. The NHS will release up to £20 billion of efficiency savings by 2014, which will be reinvested to support improvements in quality and outcomes.

Sophistry.  If NHS expenditure is cut by £20bn then it is not being reinvested – it is not being expended at all.  The aim is for increased costs due to demography, technical innovation and demand shifts to be paid for through productivity gains.  Unlikely.

  1. The Government will reduce NHS management costs by more than 45% over the next four years, freeing up further resources for front-line care.

Bet it isn’t.  The costs will come back described as something else.  Also there will be transitional costs such as redundancy payments.

  1. We will radically delayer and simplify the number of NHS bodies, and radically reduce the Department of Health’s own NHS functions. We will abolish quangos that do not need to exist and streamline the functions of those that do.

Good.  But many quangos do actually do things which will still need to be done.  More likely is amalgamations, renaming and smoke and mirrors.

Campaigns against the White Paper

Unite 4 our NHS

NHS Support Federation


The Bow Group