U.K. Coalition Government Outlines Radical Strategy for "Liberating" NHS

NHS Reform Plans Spelled Out by Coalition

The United Kingdom's coalition government has published its long-awaited strategy for the National Health Service (NHS) in England. The 56-page White Paper entitled "Equity and Excellence: Liberating the NHS" contains radical changes that aim to transform the NHS into a more efficient organisation.

The White Paper goes on to outline how the government intends to realise this vision.

Patient- and Carer-Focused Organisation

This will be facilitated through an "information revolution", whereby patients will have a greater say in decision making. The government will extend choice so that patients have the freedom to choose a GP practice regardless of their catchment area, consultants, hospitals, and treatment. Patients will have the option to rate healthcare providers based on quality-of-care parameters. Furthermore, more choice will be introduced for maternity services, mental health services, diagnostic testing, long-term care, and end-of-life care. Finally, access to 24/7 urgent care will be improve through the country.

In order to ensure that patients' voices are heard, an independent body—Health Watch England—will be set up within the Care Quality Commission. The role of this body will be to ensure that patient feedback is incorporated into commissioning decisions at a local level, and at a national level the role will be to provide leadership and advice to other bodies within the NHS.

Improving Healthcare Outcomes

The NHS will be less focused on meeting targets and more focused on improving evidenced-based clinical outcome measures. Steps will be taken to foster a culture of open information so that hospital failings can be more easily identified. The National Institute for Health and Clinical Excellence will remain responsible for setting quality standards, and it will be given more responsibilities in order to establish a comprehensive library of over 150 standards for all main care pathways. This information will form the basis for the commissioning of NHS care. A new cancer drug fund will be established in order to ensure that cancer patients gain access to the drugs recommended by their doctors. In terms of wider drug pricing, the White Paper outlines that the government 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".

Autonomy, Accountability, and Democratic Legitimacy

Perhaps the most radical elements of these reforms are plans to shift decision-making responsibilities for commissioning and within the NHS from primary care trusts (PCTs) to "GP commissioning consortia". The theory behind this strategic shift is to ensure that decision making is made by those who are actually responsible for delivering patient care and are therefore best equipped to make important decisions about what type of care to provide. An independent NHS Commissioning Board will be established to support the development of GP commissioning consortia, in addition to other responsibilities such as providing leadership, fostering wider patient choice, and commissioning additional services outside the responsibility of GP consortia in the area of community pharmacy, dentistry, and ophthalmic services. The Commissioning Board will essentially replace the role of the strategic health authorities, which will also face the axe. The NHS Trust system will remain in place, but over the next three years, all NHS Trusts will be supported in their transition to Foundation Trusts. Monitor will be transformed into an economic regulator for the NHS, and its main functions will be to promote competition, regulate prices of services, and ensure continued access to services.

Cutting Bureaucracy and Improving Efficiency

As expected, concerns about excessive bureaucracy and improving efficiency lay at the heart of these reforms. To this end, the government has said that the NHS will need to make substantial efficiency gains in order to be better equipped for the healthcare challenges that lay ahead, in the context of an ageing population. Although the commitment to increase spending in real terms during each year of the parliament remains in place, the government hopes to deliver efficiency savings of up to £20 billion (US$30 billion) by 2014. These savings will be used to improve front-line services. In order to achieve this, NHS management costs will be slashed by more than 45% over the next four years.

Outlook and Implications

These latest plans come as little surprise, as it has been well documented that the NHS is in dire need of a shake-up. Although some of the proposals are not new, especially those related to increasing patient choice and access to care, certain aspects of this reform package are highly radical and affect core NHS functions. PCTs and Strategic Health Authorities (SHAs) currently form the structural focus of the NHS, and at present PCTs control an estimated 80% of NHS expenditure. The paper doesn't make it clear whether roles within the PCTs and SHAs will be abolished outright or whether these roles will be transferred to the Commission Board or other functions within the NHS. It is fair to say that job losses lie ahead for those in management positions, although the extent of these job losses remains unclear. With GPs essentially being given further responsibilities, it is likely that they will be in a good bargaining position to renegotiate their contracts when they come up for renewal. GPs have been identified as being best able to judge which services to deliver, but it is not clear at this stage how these new commissioning responsibilities will be aligned with their current service provision duties or how time will be split within the two functions.