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Welfare Reform on the Web (June 2011): National Health Service - Reform - General

All that glisters: are the NHS reforms good for local government?

B. Hudson

Journal of Integrated Care, vol.19, Apr. 2011, p. 4-12

The 2010 NHS White Paper seems to herald the introduction of a greater role for local government in running the health services since the creation of the NHS in 1948. The proposed changes involve: transfer from the NHS to local government of some public health responsibilities; the elevation of the position of the Joint Needs Assessment; the creation of health and well being boards; and the production of joint commissioning strategies. This article suggests that the impact of the changes may be less than hoped and expected.

Anti-abortion group drafted in as sexual health adviser

B. Quinn

The Guardian, May 25th 2011, p. 1

A group which is opposed to abortion in all circumstances and favours an abstinence-based approach to sex education has been appointed to advise the government on sexual health. The Life organisation has been invited to join a new sexual health forum set up to replace the Independent Advisory Group on Sexual Health and HIV. In contrast, the British Pregnancy Advisory Service has been omitted from the forum despite its long term position on the previous advisory group and 40 year track record in providing pregnancy counselling and abortions nationwide.

Cameron: reform is the only way to save the NHS

N. Watt and D. Campbell

The Guardian, May 17th 2011, p. 4

David Cameron has warned that the NHS will face a funding crisis without major changes and insisted reform is the only way to save the health service. In a speech to NHS staff at Ealing hospital, West London, the prime minister reached out to the medical profession by admitting the government did not explain its reforms effectively and professed his love for the NHS.

(See also Independent, May 16th 2011, p. 14)

Challenges and opportunities associated with the introduction of assistant practitioners supporting the work of registered nurses in NHS acute hospital trusts in England

K. Spilsbury and others

Journal of Health Services Research and Policy, vol. 16, 2011, Supplement 1, p. 50-56

Over the past decade, the NHS has recognised the need to improve staff efficiency and productivity. Efforts have focused on making better use of NHS human resources through role expansion and redesign. A significant development for nursing has been the emergence of the assistant practitioner role. Despite increasing numbers of assistants, there are still wide-ranging debates about role boundaries between registered nurses and assistant staff. Based on three case studies, this article seeks to understand the challenges and opportunities associated with the introduction of assistant practitioner roles supporting the work of ward-based registered nurses in NHS hospital trusts in England. Through 'vertical substitution', assistant practitioners are taking on roles and activities previously only undertaken by registered nurses. A major consequence of vertical substitution is the potential for role conflict, role confusion and professional disputes. This study highlights how these manifest themselves in practice.

Changed NHS bill faces fresh scrutiny by MPs

R. Ramesh and R. Davis

The Guardian, May 24th 2011, p. 7

The changes to the government's NHS bill could be so substantial that it has to undergo fresh scrutiny by MPs, thus delaying the passage through the Commons, the health secretary has said.

Clegg angers Tories with new delay on NHS reform

N. Watt

The Guardian, May 27th 2011, p. 1

A full-scale row erupted at the highest levels of the coalition government yesterday after Nick Clegg denounced Downing Street and the Department of Health by announcing that the government's troubled NHS reforms would be delayed by at least six months.

(See also The Guardian, May 27th 2011, p. 19)

Clegg demands rethink over role of regulator in fresh blow to NHS bill

A. Stratton and P. Curtis

The Guardian, May 18th 2011, p. 8

Nick Clegg has singled out the role of the NHS economic regulator Monitor as the area of the embattled NHS bill that needs the 'most substantial changes', saying that all references to the body being an economic regulator should be removed.

Clegg threatens to veto NHS reforms in bid to reassert himself.

Andrew Grice

The Independent, May 9th 2011, p.6

Nick Clegg has threatened to veto the Government's health reforms in a move seen as an effort to reassert his authority following Liberal Democrat's heavy defeat in the local elections and AV referendum. The article suggests that, after the failure of the effort to bring about constitutional reforms, Mr Clegg will focus the LibDem's efforts on issues such as the economy, education, health, and welfare. Although Mr Clegg has promised not to indulge in what he called 'tit-for-tat politics', the LibDem leader has said he would instruct his MPs and peers to vote down the health bill, unless significant changes are introduced.

Clegg's change of heart on NHS

A. Porter

Daily Telegraph, May 9th 2011, p. 1 + 4

Liberal Democrat leader Nick Clegg has threatened to derail the Coalition's plans to reform the NHS unless he gets changes to suit his party, despite having previously endorsed the proposals. Prime Minister Cameron is allowing him to amend the Health Bill as part of a deal to shore up the Coalition, risking a Cabinet split with health secretary Andrew Lansley.

Clinical guidance

A. Moore (editor) Health Service Journal, May 5th 2011, p. 19-24

The articles in this special report cover changes to the role of the National Institute for Health and Clinical Excellence, disinvestment in existing services, healthcare rationing priorities and principles in different countries, and public involvement in decisions to cut or ration services.

Commissioning: further issues

Health Committee

London: TSO, 2011 (House of Commons papers, session 2010/12; HC 796)

The Health Committee believes that effective commissioning is a precondition for the successful delivery of the requirement for the NHS to achieve an efficiency gain of 4% per annum over the four years from 2011-12. Failure to deliver this requirement would undermine either the quality or the availability of care for patients-which would in turn lead to pressure for extra resources. This report produces further analysis for the House of Commons when it reaches the report stage of the Health and Social Care Bill. As in the Committee's first report on this issue, it remains convinced that meeting increasing demand for high quality health care while delivering 4% efficiency gains year on year remains the biggest challenge that faces the NHS. Effective commissioning is key to that target being achieved.

CQC fears its regulation model is not sustainable

C. Santry and S. Calkin

Health Service Journal, May 26th 2011, p. 9

The Care Quality Commission is concerned that it has insufficient resources to cope with registering 9,000 GP practices plus dentists by April 2012. There is a major risk that it will be unable to identify and deal with non-compliance with its standards while delivering this task. The CQC could respond by asking the Department of Health to either provide more funds or to reduce its remit.

Dignity and nutrition for older people: [first 12 reports]

Care Quality Commission


These reports contain the results of unannounced inspections of two wards each of 12 NHS hospitals. This inspection programme examined whether elderly people received essential standards of care in 100 NHS hospitals in England. The inspections ascertain if care meets legal requirements on dignity and nutrition. The inspectors found that three of the hospitals visited were failing to provide even basic care for older people, and there were some concerns at three more. Patients in some wards had to be prescribed water after nurses left them thirsty for more than 10 hours, while others went hungry after being denied help with eating. Pensioners spent all day in their nightclothes and were put to bed at 6pm while nurses ignored them to talk amongst themselves or play music.

Doctors praise benefits of health reforms

S. Adams

Daily Telegraph, May 11th 2011, p.1 + 19

In a letter to the Daily Telegraph, 42 family doctors, who together lead 100 practices across England, call on the government to press ahead with the Health and Social Care Bill and not to withdraw support from health secretary Andrew Lansley. They argue that the reforms have received a very bad press but have been misunderstood.

(For support for NHS reforms from pensioners' groups see Daily Telegraph, May 12th 2011, p. 1 + 2)

Fitter, faster: improved pathways speed up recovery

C. Grace and others

Health Service Journal, May 5th 2011, p. 28-30

Enhanced recovery pathways provide optimal care for patients having surgery. Patient centred pathways prioritise thorough preparation and high-quality peri-operative care and post-operative rehabilitation, to help patients recover quicker and so release resources. This article describes the stages of a project to implement enhanced recovery systematically across North Central London. The project took a novel three-pronged approach to encourage adoption:

  1. to sell a well evidenced transferable system
  2. to aggressively drive delivery with change and clinical experts
  3. to require robust executive sponsorship before starting work with a trust.

The future of leadership and management in the NHS: no more heroes

Commission on Leadership and Management in the NHS

King's Fund, 2011

The Commission found that the NHS in England was 'overadministered' but not overmanaged, despite claims to the contrary. It pointed out that the increase in NHS managers and administrators in England since 1997 was not matched in the rest of the UK and appeared to be due to the imposition of targets and increased regulation by central government. It described government targets for reducing administrative spending by one third by 2014/15 as arbitrary and called on ministers to re-think proposed cuts. It argued that the creation of new bodies, such as GP commissioning consortia and health and wellbeing boards, would be likely to result in an increase in management and administrative posts rather than a reduction. Moreover, the policy of replacing single waiting time targets with multiple performance measures could only add to administrative and possibly management costs.

(See also Health Service Journal, May 19th 2011, p. 18-19)


Health reforms may wreck the NHS, doctors' leaders warn Cameron

D. Campbell

The Guardian, May 9th 2011, p. 14

The leaders of the Royal College of General Practitioners (RCGP), representing 42,000 family doctors in the UK, have warned David Cameron to radically overhaul the government's unpopular health plans or risk them wrecking the NHS. The key risks identified by the RCGP are:

  • Intensifying competition in the NHS will lead to the service breaking up, drive up costs, and damage patient care
  • Family doctors and hospitals could start charging patients for certain services
  • The NHS mission of providing healthcare to all, irrespective of need or ability to pay, could disappear as the bill removes the health secretary's historic duty to ensure provision of a comprehensive health service.
  • The NHS should be preferred provider of NHS services and controversial plans to allow any willing provider to treat patients should be removed.
  • Making the NHS subject to EU competition law could result in parts of the organisation ending up in foreign ownership or in the hands of venture capitalists.
  • Removing GP boundaries will threaten the viability of certain surgeries, especially in rural areas.

The impact of patient choice of provider on equity: analysis of a patient survey

R. Robertson and P. Burge

Journal of Health Services Research and Policy, vol. 16, 2011, Supplement 1, p. 22-28

Patient choice was a major part of the Labour government's programme of market-based reforms to the NHS and was intended to 'create a route to equity as well as excellence'. Since 2006, patients referred for their first outpatient appointment in England have been entitled to a choice of at least four hospitals, which expanded to a 'free choice' of any NHS or registered private provider in England in April 2008. This study uses data from a survey of patients who experienced choice at the point of referral in four areas of England, to consider whether there have been inequities in uptake of choice in the current programme. Results showed that more educated, affluent patients were no more likely to be offered choice than other population groups. However poorer patients were less likely to choose to travel beyond their local area for treatment. There is therefore a risk that when local hospitals are failing, patient choice could result in inequitable access to high quality care, rather than enhancing equity as the policy's architects had hoped.

Lansley bows to Clegg pressure to dilute role of NHS watchdog

M. Beckford

Daily Telegraph, May 24th 2011, p. 2

Under pressure from Liberal Democrat criticisms, health secretary Andrew Lansley has signalled that he will amend the Health and Social Care Bill to change the role of regulator Monitor. Under 'improved' plans, Monitor would no longer be set up to promote competition above all else but to protect the interests of patients and facilitate choice.

Lansley forced into U-turn on scrapping cancer network

D. Campbell

The Guardian, May 20th 2011, p. 1

Andrew Lansley has been forced to ditch controversial plans that would have put the NHS at risk of losing the services of teams of cancer experts who help patients, GPs and hospitals. He has decided to reprieve the 28 NHS cancer networks after MPs of all parties as well as charities and the government's own cancer tsar warned that letting them disappear would have damaged both patient care and the drive to cut the number of cancer-related deaths.

Lansley holding out on role for hospital doctors

O. Wright

The Independent, May 10th 2011, p. 12

Oliver Wright reports that the health secretary, Andrew Lansley, is resisting calls from Downing Street to give hospital doctors a greater say in the commissioning of care for NHS patients. Lansley is understood to be concerned that if hospital doctors are given a greater say in the care to be commissioned, a conflict of interests might arise. The article also relates that Downing Street aides are calling for Lansley to step down entirely, possibly to be replaced by Jeremy Hunt. The same sources say that agreement has already been reached that all references in the Health Bill to promoting competition between NHS and private providers will be removed. A clause requiring that the Secretary of State take full responsibility for providing a comprehensive service, free at the point of delivery, will be reinstated. GP Commissioning boards will include nurses, council representatives, and an independent chair.

Making normative structures visible: the British National Health Service and the hospice movement as signifiers of compassion and hope

P. Brown and R. Flores

Acta Sociologica, vol.54, 2011, p. 53-65

Through their contribution to social cohesion, social justice and emancipatory social change, compassion and hope are significant forces for individual and social flourishing. This paper argues that the NHS and the hospice movement play a critical role in making the practice and value of compassion and hope visible throughout British society. In so doing, and beyond their role as service providers, they stand as symbols of the possibilities for society to cultivate social justice and care (through compassion) and to transform itself for the better (via hope). In spite of its importance, this dimension often eludes policy-making analyses that focus too narrowly on instrumental and utilitarian conceptions of these institutions.

Managing high value capital equipment in the NHS in England

National Audit Office

London: TSO, 2011 (House of Commons papers, session 2010/12; HC 822)

In the past three years, NHS trusts in England have spent around 50 million annually on purchasing three specific types of high value capital equipment - Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) scanners, used for diagnosis, and Linear Accelerator (linac) machines for cancer treatment. The current value of these three types of machines in the NHS is around 1 billion. This report examines how efficiently these three types of high value equipment are used. It examines:

  • Planning for high value equipment
  • Meeting the demand for services
  • Improving management of high value equipment

The report concludes that the NHS trusts do not have the means to know if they are making best use, or getting best value out of, their high value equipment. Equally, they do not have the means to determine if they are getting value for money from purchasing or maintenance. There are significant variations in levels of activity between trusts, and a lack of comparable information about performance and costs. In these circumstances the planning, procurement, and use of high value equipment are not achieving value for money across all NHS trusts.

Management of NHS hospital productivity

Committee of Public Accounts

London: TSO, 2011 (House of Commons papers, session 2010/12; HC 741)

Productivity is defined as the ratio of the volume of resources (inputs) to the quantity of healthcare provided (outputs), adjusted to reflect their relative costs and quality. Figures produced by the Office for National Statistics (ONS) estimate that, since 2000, total NHS productivity fell by an average of 0.2% a year, and by an average of 1.4% a year in hospitals. The taxpayer has therefore seen a better quality NHS as a result of the additional investment but, per taxpayer pound, is getting less in return. The trend of falling productivity will need to be reversed if the NHS is to meet the Department of Health's productivity challenge, to deliver up to 20 billion of efficiency savings by 2014-15, without compromising services. The Department of Health promotes efficiency and productivity improvements in hospitals primarily through national pay contracts and by setting a fixed price, or 'tariff', for individual hospital procedures (Payment by Results). While Payment by Results does seem to have driven some improvements, the system only covers 60% of hospital activity and there is substantial variation in hospital costs and activity. The Department is introducing 'best practice tariffs' to promote greater hospital efficiency. On the one hand, this tariff system can promote efficiency and productivity, but on the other hand could prioritise price over quality. Although potentially positive, the system will need to be carefully monitored to ensure quality is maintained, as the Department acknowledges that cutting tariffs could damage quality. National pay contracts have not yet been used to manage staff performance effectively, and consultants' productivity has fallen at the same time as they have had significant pay rises. The report also notes that hospitals have concentrated primarily on meeting national performance targets and not specifically on optimising productivity.

NHS Pay Review Body

G. Morris (Chair)

London: TSO, 2011 (Cm 8029)

The NHS Pay Review Body (NHSPRB) is an independent body whose role is to make recommendations to the Government on the remuneration of all staff paid under Agenda for Change (AfC) and employed in the NHS. The UK Government announced in the last budget 'a two-year pay freeze for public sector workforces, except for workers earning less than 21,000 a year who will receive an increase of at least 250 per year in these years'. During the period of the pay freeze the role of NHSPRB is limited and therefore it urges the Health Departments to plan their strategies so that, at the end of the pay freeze, they can implement any changes that may be necessary to ensure the AfC pay structure continues effectively to support recruitment, retention and motivation of staff.

Open warfare inside the coalition over NHS

P. Wintour

The Guardian, May 19th 2011, p. 4

The two sides of the coalition appear to be in open warfare over the future of the NHS after the health secretary Andrew Lansley praised competition as a legitimate way to improve standards while allies of the deputy prime minister Nick Clegg warned that it had to be reined back. A policy document issued by the LibDem Party signed off by Nick Clegg says: 'we cannot treat the NHS as if it were a utility, and the decision to establish Monitor as an economic regulator was clearly a misjudgement, failing to recognise the unique characteristics of a public health service'.

Passing judgement on Lansley's vision

S. Dorrell and others

Health Service Journal, May 5th 2011, p. 14-17

Four experts debate health secretary Andrew Lansley's reforms of the NHS. Stephen Dorrell argues that the reforms set out in the Health and Social Care Bill are evolutionary and not revolutionary. The real revolution in the NHS is being driven by the need to achieve 15-20bn of efficiency savings over four years and the need to integrate health and social care to deal with the rise in chronic illness. On the other hand Alan Milburn takes the position that the reforms are a failure of both politics and policy. Prof. David Kerr argues that the basic principle of the Bill, the promotion of clinical engagement in management, is sound but has not been communicated clearly to NHS staff or the public. Finally Bill Moyes states that, while the vision behind the Health and Social Care Bill of GP commissioners and autonomous hospitals competing to provide services was right, failure to build consensus and apparent disdain for detailed implementation planning mean that it has been lost and the government may be reduced to salvaging what it can from the wreckage. He proposes remedial actions.

PM and Clegg told to end 'arm-wrestling over NHS'

D. Campbell

The Guardian, May 23rd 2011, p. 4

David Cameron and Nick Clegg should resolve the coalition's deepening difficulties over the NHS reform and make the future of the health service clear as soon as possible, says Professor Chris Ham, chief executive of the King's Fund health thinktank, adding that the arguments between political leaders are worrying and unsettling people in the NHS.

Quarter of acute trusts' FT plans slip back a year

B. Clover

Health Service Journal, May 5th 2011, p. 4-5

Of the 71 acute hospital trusts still bidding for foundation status, 19 have seen their application date for authorisation by Monitor slip by over a year. Fourteen trusts plan to merge or have this route marked as an option. Twenty-two are awaiting the results of a review of their private finance initiative schemes after these were labelled by the Department of Health as an obstacle to FT status. Just 10 organisations have made initial applications to the Department of Health or are being assessed by Monitor. Some trusts plan to submit applications for foundation status to Monitor only 12 months before the April 2014 deadline for all NHS hospitals to have become foundation trusts.

Radical reforms are only way to save the NHS, Cameron insists

R. Winnett

Daily Telegraph, May 17th 2011, p. 8

David Cameron has warned that the NHS faces a 20bn annual funding shortfall by 2015 without radical reform. He insisted in a speech that the NHS's long term future was in doubt and that modernisation was essential to save it. He argued that the NHS would have to change its focus from saving lives to supporting people with chronic illnesses. However he also confirmed that the NHS would not be privatised and that patients would never have to pay for treatment.

(See also Daily Telegraph, May 16th 2011, p. 1 + 6)

Trust me - I'm a patient

D. Carlisle

Health Service Journal, May 19th 2011, p. 26-27

This article presents an overview of patient involvement in promoting safe practices in the NHS, often in the face of resistance by staff. It highlights case studies of use of feedback from patients during their hospital stay at Royal Devon and Exeter Foundation Trust and board level action at Bedford Hospital Trust and presents the views of campaigning charities working in the field.

Understanding public preferences for prioritising health care interventions in England: does the type of health gain matter?

H. Mason, R. Baker and C. Donaldson

Journal of Health Services Research and Policy, vol. 16, 2011, p. 81-89

Healthcare budgets in the UK are finite and decisions must be made about which interventions to provide. The aim of this study was to investigate what features of healthcare interventions, including the type of health gain, are important to members of the public and to understand the reasons why. Results showed that people take into account the type of health gain which arises from treatment when making judgements about which interventions to prioritise, but there are also other issues which are important to them. Gains associated with life saving interventions are valued more highly than those which are life extending or quality of life enhancing. There are two explanations for prioritising life saving interventions. Those interventions which yield the greatest health benefits are prioritised as are those which benefit younger people who were seen not to have had a fair chance of a life.

Using evidence is not an open and shut case

E. Gkeredakis and C. Roginski

Health Service Journal, May 26th 2011, p. 23-25

The need for unprecedented improvements in quality and productivity in the NHS means that the use of evidence for service commissioning and redesign is crucial. The NHS urgently needs a methodology for using evidence effectively. A multidisciplinary team from Warwick University has conducted a large study of how evidence is used on the ground to support the development of such a methodology. Results show that commissioning and service redesign would benefit from considering a plurality of evidence, including clinical and non-clinical evidence (i.e. local and national policies, delivery models, commissioning toolkits, local intelligence and benchmarking data) and narratives of implementation (i.e. expert advice, feedback from knowledgeable colleagues, and stories of successful implementation)

What better market could you be in?

C. Dowler

Health Service Journal, May 26th 2011, p. 18-19

In this interview report, Adrian Fawcett, chief executive of the General Healthcare Group, argues that population ageing, demand for costly new treatments, and rising global commodity prices will force the government to open up the NHS market to private providers. He argues that part of Monitor's role as economic regulator would be to ensure that private providers do not cherry pick routine elective work and so undermine the viability of hospitals providing essential services such as accident and emergency. He explains that in order to maximise its ability to respond to NHS demand, the General Healthcare Group would be prepared to invest in capital assets specifically for health service provision.

(See also Health Service Journal, May 19th 2011, p. 10-11)

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