Working in rapid political changeCase study: NHS White Paper - 'Equity and Excellence: Liberating the NHS'

Presentation by Leela Barham, Policy Unit

Exeter 18th May 2011

Objectives

To reflect on a recent political change To understand how the RCN policy unit analysed this

political change  To understand how the RCN policy position was

formulated To understand the timescales involved with policy

announcement, analysis and RCN response To explore how RCN regions can influence

organisational direction in rapid political change

Proposed approach

Case study of White Paper Questions as we go through Group discussion on case study Current state of play Group discussion so I can learn from you:

What worked well? What would you change? Working together in the future

Why this case study?

Reforms to NHS stem from change in Government Unprecedented political environment with Coalition Unprecedented financial challenge for UK plc Nicholson Challenge (identified back in May 2009) Uncertainties in direction for reform because of need

to bring together 2 political viewpoints into 1 plan for the NHS in England

Reforms were not fully trailed in Manifestos

2010 timetable 6th May General Election (new Coalition Government) 13th May Initial Coalition Agreement (promised real terms funding increase for

NHS) 21st May Final Coalition Agreement 13th May Andrew Lansley New Secretary of State for Health in England (shadow

since June 2004) 21st June NHS Operating Framework 22nd June Emergency Budget 28th June RCN briefing on Emergency Budget and Coalition Programme 12th July NHS White Paper (and 8 related Consultations over the next weeks) 26th July RCN briefing on White Paper 3rd September RCN Breakfast Roundtable 6th September RCN Evening Seminar with Nurses in Commissioning 17th September close date for members comments on White Paper 4th October RCN response to NHS White Paper (and 8 related Consultations

over the next weeks) 20th October Comprehensive Spending Review 12th November RCN Frontline First Interim Report

2011 timetable 17th January joint letter to the Times with others (e.g.

UNISON, BMA and others) 19th January Draft Health and Social Care Bill 31st March Bill finished Committee stage 4th April ‘Pause’ announced 21st April first meeting of NHS Future Forum 13th April RCN congress vote of no confidence in

Lansley

NHS White Paper

Main NHS White Paper ‘Equity and Excellence: Liberating the NHS’

Supporting consultation documents:

Transparency in outcomes Commissioning for patients Local democratic legitimacy in health Regulating healthcare providers Achieving equity and excellence for children Greater choice and control An information revolution Developing the healthcare workforce Healthy lives, healthy people

Approach to analysis

Policy unit has leads on key areas e.g. system regulation, competition Leads reviewed relevant sections and separate consultation documents Often, leads also reviewed the whole reform proposals Team discussions Linked into broader discussions (e.g. with ERD) and into key internal working

groups (e.g. HSCPG) Identified opportunities, threats and risks and compared to evidence base and

RCN principles Papers and presentations to support discussions Internal working drafts of response by individual Chapter leads Final response was a composite and with separate Editors to ensure the whole

read together Final sign off from Exec Team

What the white paper said…Chapter 1: ‘Liberating theNHS’- Key themes ‘Empowering’ frontline

clinicians Government to ‘uphold’ the

values & principles of the NHS

Commitment to increase health spending in ‘real terms’ in each year of the current Parliament

Decentralisation and significant reduction in size of DH

Responsibility for local health improvement to transfer to Local Authorities

Chapter 2: ‘Putting patients and the public first’- Key themes Patient focus and shared

decision-making: “ no decision about me, without me.”

New independent consumer champion: Health Watch

More information for patients (as part of ‘information revolution’)

Patients to rate services provided

Chapter 3: ‘Improving healthcare outcomes’- Key themes

Outcome measures, not process targets NHS Outcomes Framework will include a set of

national outcome goals against which the NHS Commissioning Board will be held to account

Health Bill will strengthen NICE and extend its remit to include social care

Incentives for quality improvement Commissioners will be able to impose contractual

penalties on providers delivering poor quality care From April 2011 a new Cancer Drug Fund will operate

What the white paper said…

Key themes Pay and pensions:

Pay will be frozen for 2 years for those earning more than £21,000

Fundamental structural review of public service pension provision

Workforce planning and training: Employers given the freedom to

plan and develop their workforce locally

Role of DH in deciding and allocating resources for training and education reduced

Care Quality Commission as the system regulator for providers and new Economic Regulator (new Monitor)

Chapter 4: ‘Autonomy, accountability and democratic legitimacy’

Commissioning: Creation of GP commissioning

consortia Independent Board to oversee

commissioning process Foundation Trusts:

Every NHS Trust to become a Foundation Trust, with extended freedoms and autonomy

Abolition of trusts’ private income cap trusts

Pro-market: Focus on competition A role for ‘any willing provider’

in delivering health care

What the white paper said…

Chapter 5: ‘Cutting bureaucracy and improving efficiency’- Key themes

Abolition of PCTs and SHAs Review of arms length bodies Acknowledgment that overall changes will cause

significant disruption and loss of jobs Efficiency savings of £20 billion, which includes

significant reductions (up to 45%) in NHS management costs.

Government will not bail out commissioners who fail

What the white paper said…

New structure

Source: http://www.bbc.co.uk/news/health-10647910

RCN’s own consultation Dedicated section on RCN web site All member email and online member survey Film (to support survey) RCN briefing for members PowerPoint presentation (for RCN Boards, activists and groups of members), policy

presentations in person when invited Website story – Peter Carter’s message to members Nursing press articles, features and news reviews RCN Bulletin stories - asking for member feedback and link to resources on website Blogs for RCN web site Podcast RCN round table breakfast meeting with royal colleges and RCN evening meeting

with commissioning nurses Webcast

Over 1000 members responded to inform the RCN response to the White Paper and RCN materials reached over 175,000 members

Group discussion

What did you see? What did you think of it? What else would you have wanted?

Forming the RCN position

Policy unit supports formulation of position Informed by responses and discussions In conjunction with others within RCN including:

Nursing Dept Employment Relations Dept Legal Dept Parliamentary Dept RCN Institute RCN England Exec Team

Formal positions discussed and agreed via NPPC and then Council Then positions disseminated via number of routes (e.g. Policy web pages,

submissions to Health Select Committee etc), led by Comms with support from many others (e.g. Parliamentary briefings to MPs)

Key RCN concerns

Fragmentation concerns/need for co-operation Nursing representation on consortia and NCB Impact of forced competition and maximum tariff price

on quality of patient care Public and Patient Involvement Role of Monitor and EU competition law Private Income Cap and bonuses Opposition to localised pay structures Health inequalities Piloting and evaluation

The 18 assurances we seek…In our response to the NHS White Paper we asked for

18 assurances. Key examples include: Structural reforms should be piloted and only introduced

if they work No move away from national pay or undermining AfC Nursing leadership must be protected National oversight of nurse education and training Nursing must be represented in commissioning regimes The risks of system reform must be managed in the

interests of the NHS, staff and patients

Are changes possible?

•RCN and others raising serious concerns about impact of NHS Reforms on safety of services

•A ‘fluid’ situation with increasing media attention (Lib Dem Spring conference, BMA meeting etc)

•Nurse leadership beginning to win support – nursing representation on NCB, mentions in parliament and by Prime Minister.

•Concessions on price competition

• Govt pause for ‘listening’ and Forum

•RCN Congress – no confidence in theSec of State’s management of reforms

Current state of play

Currently in a ‘pause’ Number of groups looking at reforms and changes needed to the Bill

NHS Future Forum Special Number 10 Group DH running listening events Stakeholders putting forward their ideas (e.g. UNISON, RCGP)

But changes on the ground PCT Clusters (and redundancies in PCTs, SHAs etc) Frontline First suggests cuts and more cuts

But some things stay the same Agencies e.g. CQC Drive for quality Need to make efficiency savings

Pathfinder ProgrammeOn 21st October 2010 the Department of Health announced a Pathfinder Programme to identify and support groups of GP practices who would like to make faster progress in taking on the new commissioning roles:

On 8th Dec the first GP consortia under the Pathfinder Programme were announced

On 17th Jan 2011 a second wave of GP pathfinder consortia were announced. This took the total to 141 groups of GP practices of various shapes and sizes from across England

On 2nd March the Govt announced a third wave with the names of 40 more GP consortia, predominantly in the East of England, East Midlands & London

On 1st April DH announced a fourth wave of GPs to join the Programme

The total programme now covers 90% of the total population in England that have come forward. This means that 45.7 million people around the country are covered

Links to ongoing work

Frontline first Continuing ‘usual’ work Informal discussions with stakeholders

on the future and policy directions

What next?2011 New Outcomes framework NHS National Commissioning Board begins (in shadow form) First GP Consortia start work in shadow form

2012 NHS National Commissioning Board established New local health and well-being boards established SHAs abolished

2013 New Public Health Service to be in place GP consortia fully operational PCTs abolished All trusts become, or are part of a foundation trust

* Subject to passage of Health and Social Care Bill through the Lords

Group discussion

What worked well? What would you change? Working together in the future

Thank you!

Read the RCN Policy Unit website for more…www.rcn.org.uk/policy

And please do call (020 76473723), email (policycontacts@rcn.org.uk), or if you’re in London pop in to Room 204 at HQ