Monday, 26 July 2010

After the liberation: White Paper and consultations published

Equality and excellence: liberating the NHS”, a White Paper setting out the coalition government’s vision for the NHS was published on 12 July. This is a significant document for kidney services setting a long term plan for the NHS. It aims to give the NHS a stable, enduring framework for quality and service improvement. It sets out the “what” and the timescales that are, in part, dictated by the next Parliamentary session legislative programme. The scale is large and the pace is quick, do read the document; it builds on Lord Darzi’s aphorism “quality is the organising principle of the NHS”. The focus is on measurable quality and the need for innovation. The pendulum is swinging from the centre to local determination, from hospital focussed processed targets to primary, community and social care delivery. The £20 billion cost saving challenge remains and at the heart of the White Paper are proposals for
  • an information revolution, for patients and clinicians and to hold the NHS to account
  • a shift toward better outcomes
  • an increasing role for clinicians

this goes with the grain of what the kidney community, NHS Kidney Care and professional and patient associations have been working hard to achieve – better experience and better outcomes for those with kidney disease. We should all welcome the fact that the NHS hasn’t suffered from indecision and uncertainty despite the events of the past few years – the global financial crisis, the election and the coming together of the first coalition government in living memory for most of us.

So the “what” is clear but the “what” is usually the easiest part and that’s the case here as well. The “how” is more difficult. It’s going to occupy us in the months and years to come. The timetable at the back of the White Paper lays out the programme of work. First up are a series of consultations on outcomes and commissioning. It’s your chance to comment and for individuals and organisations to help shape the “how” for the new direction of the NHS.

In the Outcomes Framework, the principles on how the proposed NHS Commissioning Board should be held accountable to Government and taxpayer, what overarching indicators are likely to be chosen, what methods could be used to prioritise improvement areas and some examples of potential outcome indicators are presented. The 5 domains of the NHS Outcomes Framework are:

  • prevent people from dying prematurely
  • enhancing the quality of life for people with long term conditions
  • helping people recover from episodes of ill health of following injury
  • ensuring people have a positive experience of care
  • treating and caring in a safe environment and protecting them from avoidable harm.

Quality standards will set what high quality care looks like across all major pathways of care. NICE are currently working to produce quality standards for kidney disease and the indicators for quality improvement, based on NICE guidelines, the Quality and Outcomes Framework of primary care, Renal Registry returns and the National Renal Dataset will map to the quality standards.

left: fig 5 “Transparency of outcomes – a framework for the NHS

OK? Following things so far? So how will the money flow? “Increasing democratic legitimacy in health” introduces health watch. Health watch is being commissioned to enable patients and the public to shape health services. Councils will be responsible for ensuring local voices are heard and patients are able to exercise genuine choice. One of the central features of the proposals in the White Paper is to devolve commissioning responsibilities and budgets as far as possible to those who are best placed to act as advocates and support them in healthcare choices. Most commissioning decisions will now be made by consortia of GP practices, supported and held to account for the outcomes they achieve by the NHS Commissioning Board. It will not be appropriate for all commissioning decisions to be made at a local GP consortia level and some specialist services such as dialysis and transplantation will need to be commissioned for a larger population, by the NHS Commissioning Board. “Commissioning for Patients” published alongside “Increasing Democratic Legitimacy in Health” gives further detail of how GP commissioning consortia and the NHS Commissioning Board will work. Read it and comment; it will affect the kidney services you provide or use.

One proposal is to establish a Health and Wellbeing Board within the Local Authority. This would provide a vehicle and focal point through which joint working could happen. Alternatively local partners may prefer to design their own arrangements. The Government would like your views on how best archive partnership working and integrated commissioning. If Health and Wellbeing Boards were created their primary aim would be to promote integration and partnership working between the NHS, social care, public health and other local services and improve democratic accountability. Whilst responsibility and accountability for NHS commissioning would rest with the NHS Commissioning Board and GP consortia, the Health and Wellbeing Board would give Local Authorities influence over NHS commissioning and corresponding influence for NHS commissioners in relation to health improvement, reducing health inequalities and social care.

These changes will be complemented by the creation of a National Public Health Service with a ring-fenced improvement budget to deliver national and local priorities. The local Directors of Public Health will be directly accountable to both the Local Authority and, through the public health service, to the Secretary of State.

Read these documents and comment, the “what” is determined but the “how” is yours to shape.