National issues affect us all and in 2011, with the Health and Social Care Bill progressing through its parliamentary stages, we face an uncertain future ahead. This page will be used for information on any NHS issue with national impact.
Summary of key actions (extracted verbatim from the White Paper)
The Government will work with partners – including carers, people who use services, local authorities, care providers and the voluntary sector – to make our vision a reality.
The key actions we will take include:
• Stimulating the development of initiatives that help people share their time, talents and skills with others in their community.
• Developing and implementing, in a number of trailblazer areas, new ways of investing insupporting people to stay active and independent, such as Social Impact Bonds.
• Establishing a new capital fund, worth £200 million over five years, to support the development of specialised housing for older and disabled people.
• Establishing a new national information website, to provide a clear and reliable source ofinformation on care and support, and investing £32.5 million in better local online services.
• Introducing a national minimum eligibility threshold to ensure greater national consistency in access to care and support, and ensuring that no-one’s care is interrupted if they move.
• Extending the right to an assessment to more carers, and introducing a clear entitlement to support to help them maintain their own health and wellbeing.
• Working with a range of organisations to develop comparison websites that make it easy for people to give feedback and compare the quality of care providers.
• Ruling out crude ‘contracting by the minute’, which can undermine dignity and choice for those who use care and support.
• Consulting on further steps to ensure service continuity for people using care and support, should a provider go out of business.
• Placing dignity and respect at the heart of a new code of conduct and minimum training standards for care workers.
• Training more care workers to deliver high-quality care, including an ambition to double the number of care apprenticeships to 100,000 by 2017.
• Appointing a Chief Social Worker by the end of 2012.
• Legislating to give people an entitlement to a personal budget.
• Improving access to independent advice to help people eligible for financial support from their local authority to develop their care and support plan.
• Developing, in a small number of areas, the use of direct payments for people who have chosen to live in residential care, to test the costs and benefits.
• Investing a further £100 million in 2013/14 and £200 million in 2014/15 in joint funding between the NHS and social care to support better integrated care and support
Ruislip Residents' Association is a member of The Community Voice, which had the pleasure of welcoming Patrick South from The King's Fund as guest speaker at its meeting on 2nd February 2012. His interesting address is summarised below:
The Speaker’s last visit was in November 2010. He proposed to review developments since that time, noting that the King’s Fund is a non-aligned think-tank, which talks widely, including MPs and Ministers.
The earlier White Paper aimed to improve services at lower cost by giving more powers to clinicians, placing patients first, and replacing targets with outcomes – with no more top-down reorganisations.
The big idea was GP commissioning. Initially GPs were enthusiastic but concerns grew about choice and competition, and about the amount of reorganisation proposed. There were early signs of trouble in November 2010 when the Chair of the Royal College of GPs claimed that the Bill could destroy the NHS.
The Health and Social Care Bill was published in January 2011, a very long document in two volumes, which faced discontent at the Lib.Dem. Conference in March 2011, with a motion passed against the Bill.
By July 2011, mounting criticism led the government to halt the Bill, although it had passed through the Committee stage in the Commons. Steve Field, ex-Chairman of the Royal College of GPs was appointed Chairman of the NHS Future Forum, which undertook a listening exercise on the Bill. Proposals for changes followed before the Bill’s return to the Commons. Its subsequent passage through the Lords was stormy, with various amendments made. It is now about to embark on the Lords Report Stage and is likely to be passed.
From July 2011 the BMA campaigned against the Bill. Views are now very polarised. Some Royal Colleges are calling for the Bill to be scrapped. The King’s Fund has concerns but supports some of the changes in the Bill.
Implementing clinical commissioning was always going to be a big challenge. Not all GPs are ready to take that responsibility. The King’s Fund supports clinical rather than GP commissioning and new health and wellbeing boards which will see health and social care working together, and welcomes both greater public involvement and clinical networks, although the networks’ function is unclear. CCGs will now be established in full or in shadow form by April 2013.
From the start, the Bill’s most controversial aspect concerned competition and choice. Initially Monitor had a duty to promote competition - this has been amended so that Monitor’s prime responsibility is now to promote the interest of patients. Competition was also initially allowed on price as well as quality - this was dropped after strong opposition by the BMA and the King’s Fund among others. Other controversial features included commissioning from “any willing provider”, now modified to “any qualified provider”, and the requirement for all NHS hospitals to become foundation trusts, on which the 2014 deadline has been relaxed. There is now a stronger emphasis on promoting integrated care for people with long-term conditions.
There are major structural changes in the Bill with Strategic Health Authorities and Primary Care Trusts proposed for abolition in April 2013, and temporary arrangements in the mean-time. Local authorities will be more involved through the creation of health and wellbeing boards and will be responsible for public health. A National Commissioning Board is proposed, with around 50 regional branches. The proposals involve losing around 10,000 NHS Managers, which the King’s Fund considers reckless. It fears loss of institutional memory and lack of strategic responsibility for reorganisation of hospitals. Overall, despite this and concerns over its complexity, it considers the Bill greatly improved.
However, by 2015 the NHS requires efficiency savings greater than any system in the world has ever achieved, risking major service cuts if these savings cannot be achieved. The King’s Fund believes it would have been better to focus on those issues instead of NHS reorganisation. It is also concerned about potential NHS staff unrest and fears that quality of care may suffer. The expected Social Care White Paper will have to address the issue of future funding for social care.
In terms of current performance, the NHS is still doing a good job, with waiting lists and other key indicators stable, but in some localities hospitals are struggling. An enormous challenge remains.
The speaker answered many questions before being thanked by the Chairman and receiving warm applause.
The legal duty to establish HealthWatch is dependent on the Health and Social Care Bill becoming law. If enacted, implementation is currently expected to be in April 2013.
HealthWatch is intended as a new independent consumer champion created to gather and represent the views of the public. It is expected to play a role at both national and local levels:
- Local HealthWatch:organisations funded by and accountable to the public via local authorities
- HealthWatch England at national level
HealthWatch England will work with local HealthWatch and will also
- Advise the NHS Commissioning Board, local authorities, Monitor and the Secretary of State
- Have the power to recommend that action is taken by the Care Quality Commission (CQC) when there are concerns about health and social care services
The vision for HealthWatch will be:
- HealthWatch will promote better outcomes in health for all ages and in social care for adults
- HealthWatch will be representative of diverse communities. It will provide intelligence – including evidence from people’s views and experiences – to influence the policy, planning , commissioning and delivery of health and social care. Locally it will also provide information and advice to help people access and make choices about services as well as access independent complaints advocacy to support people if they need to complain about NHS services.
- HealthWatch will have credibility and public trust through being responsive and acting on concerns when things go wrong, and operating effectively and efficiently.
A programme board and advisory group were created to establish the HealthWatch programme before its launch. The programme board is to ensure stakeholder engagement and involvement in the development of HealthWatch. Also help to ensure readiness for both local HealthWatch and HealthWatch England. The advisory group is to provide expert, practical advice and make recommendations to the programme board about implementation of the Government’s proposals for HealthWatch.
- Local HealthWatch will take on the work of the Local Involvement Networks (LINks) and also Represent the views of people who use services, carers and the public on the Health and Wellbing boards set up by local authorities.
- Provide a complaints advocacy service from April 2013 to support people who make a complaint about services.
- Report concerns about the quality of health care to HealthWatch England, which can then recommend that the CQC take action,
The local health and wellbeing boards will bring key players together to facilitate strategic and integrated commissioning across the health, social care and public health systems and support better working. Local HealthWatch will be a statutory member of the health and wellbeing board and will have a role in maximising local engagement by bringing the community and patient voice to the commissioning process. The Department of Health will continue to work with public health colleagues and with councils and LINks (and then HealthWatch) to help to determine what information and evidence HealthWatch will need and how they can best get it and use it.
From 2013 an additional £3.2 m will be made available to local authorities to establish Local HealthWatch, In addition, funding of over £370,000 will be made available in 2011/12 for 75 HealthWatch Pathfinders – a partnership between Local Involvement Networks and local authorities to test out the role of Local HealthWatch. HealthWatch England will be established in October 2012, ensuring that the learning and experience taken from the pathfinders will support and create consistency amongst Local HealthWatch ahead of the new April 2013 deadline.
The above notes are taken largely from papers presented to Hillingdon’s External Scrutiny Committee in January 2012 and they incorporate the official Government views, not necessarily the views of The Community Voice or Ruislip Residents Association
The Health and Social Care Bill was introduced in the House of Commons in January 2011. The bill aimed “to change how NHS care is commissioned through the greater involvement of a new NHS Commissioning Board; to improve accountability and patient voice: to give NHS providers new freedoms to improve quality of care: and to establish a provider regulator to promote efficiency, In addition, the Bill will underpin the creation of Public Health England, and take forward measures to reform health public bodies”
The Bill’s passage through the House of Commons was contentious. Following its Commons committee stage, the Health Secretary, Andrew Lansley made a statement recognising the concerns and stating that he proposed a break in the passage of the Bill to pause, listen and engage with all those who wanted the NHS to succeed.
The Department of Health then launched the NHS Future Forum, chaired by Professor Steve Field. Following the Forum’s report in June a number of amendments were introduced. The Bill was passed at third reading.
The Bill has been subject to further scrutiny at conferences of the main political parties, with much media coverage. In October, ahead of the Bill’s second reading in the Lords, the Daily Telegraph published a letter signed by 400 public health specialists opposed to the Bill.
This Bill is one of the largest Bills of recent times and the largest ever in the history of the NHS, with 420 pages and more than 300 clauses. It is also one of the most controversial. It will force the NHS through a massive reorganisation, which is already happening even though the legislation has not yet been passed.
1,000 Government amendments were tabled in September 2011, 363 considered significant. The briefing published ahead of the Report Stage debate by the Department of Health explained the purpose of the amendments. This included:
- Commissioners (Clinical Commissioning Groups) would take the lead in securing access to services, overseen by the NHS Commissioning Board.
- Monitor would intervene to prevent providers becoming unsustainable
- Companies delivering essential NHS services would be subject to safeguards to protect patients and taxpayers.
- If a provider became unsustainable, the Secretary of State would have a veto to protect access to NHS services , but this would be used only in exceptional circumstances.
Any summary of the Bill’s proposals is likely to be controversial. The statements above were précised from the Library Note of the House of Lords, dated 4 October 2011. The Lords scrutiny is expected to continue until January 2012. The stages in the Lords will be as in the Commons:
- First Reading (no debate)
- Second Reading (initial debate)
- Committee Stage (line by line scrutiny)
- Report Stage (whole House debates and amendments)
- Third Reading (final debate)
The following may be considered the Bills major proposals – an arbitrary list
Patients are expected:
To have more control over where they are treated and who they are treated by.
To have more information to assist their choices
To be able to rate hospitals and clinics according to the quality of care provided
To be able to choose a GP practice regardless of where they live
Central Government is expected:
To have much less control over health services.
To measure how successfully the NHS treats patients eg survival rates
The NHS Commissioning Board is expected:
To allocate and account for NHS resources
To commission health services for the armed forces, the prison population
To commission specialised services, ophthalmology, pharmaceutical services and dentistry
To lead on improvements in quality, patient involvement / choice, and inequalities.
To have around 50 local branches ( there are at present 50 PCT clusters) .
To take responsibility for contracting GPs from 2013
To authorise CCGs to take commissioning responsibility / commission for those not ready to do so.
Monitor is expected:
To become an economic regulator
To promote effective and efficient providers of health care
To support choice, collaboration and integration
To regulate prices
To safeguard the continuity of services
The Care Quality Commission is expected:
To be an effective quality inspectorate of both health and social care
Clinical Commissioning Groups are expected:
To design and commission most local health services for patients
To answer to central government through the NHS Commissioning Board
To promote the NHS Constitution
To take over from PCT’s from April 2013, when authorised.
Local Authorities are expected:
To have much greater leadership in local health services
To be responsible for local healthcare priorities
Care in the community is expected:
To integrate care between the NHS and Local Authorities
To provide care closer to home
To save public money
Health and Wellbeing Boards are expected:
To improve health and wellbeing across their area
To strengthen the link between NHS and Local Authorities
To include representatives from CCGs, Councillors, patient groups and the Directors of Social Services, Children’s Services, and Public Health.
To tackle priorities including inequalities / generate health and social care integration
To publish an annual account
Public Health is expected
To have a national impact via Public Health England
To straddle Local Authority and NHS responsibilities
To prevent people from getting ill.
To encourage people to keep fit and to eat more healthily
HealthWatch is expected:
To provide a strong collective voice for patients, carers and local communities.
To have a national voice through HealthWatch England
Health Service Providers are expected:
To have more freedom and less centrally set targets
To include more private sector providers
Foundation Trusts are expected:
To have greater rights to sell assets
To be allowed to treat private patients without a cap on numbers
To publish Board papers and minutes and to hold board meetings in public
From early December 2011 there will be some changes to the Blue Badge Scheme for Disabled Persons, allowing the local authority more options for withdrawing or refusing to issue a badge.
From 1st January 2012 there will be more changes.
- A new badge design will be issued.
- Local authorities will be able to charge up to £10 for issuing the badge.
- Confirmation of eligibility for the badge will be determined by an independent mobility assessor, not the applicant’s GP
The November 2011 meeting of The Community Voice, of which we are a member, was a night to remember. The guest speaker, Gill Robertson, Student and Education Adviser, Royal College of Nursing, responded to the provocative question: “Is nursing no longer a caring profession?” Only the highlights are noted here from the many facts she quoted:
The Royal College of Nursing has 40,000 student members, but fewer are school leavers than in earlier years - the average age is now 29 years. Training still covers the traditional three years, but there are many other changes. Students used to be junior members of staff, sometimes with responsibilities for wards of patients. Now they are usually supernumerary, with no patient responsibilities but with time to learn about practical nursing care. Half their 45 weeks training per year is as university students and half in wards for practical experience. Training is free, but unpaid.
Nightingale wards with many beds were once the norm, lacking privacy and hated by patients, but by discharge after long stays many patients were relatively well, at far end of wards, with very sick patients close to the nursing station. Now, in small bays, or single rooms, nursing is more difficult. Old wards often had only 60% or 70% beds in use but today this is often 100% and all patients are relatively sick. Now only complex needs are treated in hospital and discharge is rapid. More detailed records are required too. So nurses have very different demands.
Demands to cut costs bring new pressures too. Staffing suffers. Senior and specialist nurses cost more, so they are axed. Registered nurses now usually lead a team of cheaper untrained nursing assistants - now cared for by the Royal College of Nursing, a positive advance, but their training should be greatly improved. In the NHS assistants do receive at least basic training before being allowed to work on wards, which is not always true outside the NHS. Training is a soft target for cutting costs, but then standards slip. Short term gain brings long-term loss.
Poor nursing is a disgrace. If it occurs then patients must be willing to challenge. In a profession with over 700,000 members there will inevitably be some who let the others down. However, remember that changes within society impact on expectations for NHS care. In families, few grandparents now live with children, or depend on family care. Local Authority care and community nursing have changed greatly. Hospital doctors, Executive Directors and other staff must increasingly take responsibility for high standards of patient care.
Election promises of no top-down change in the NHS were sadly not honoured. 40,000 frontline staff will be lost throughout the UK by the end of 2011. Qualified nurses are already stacking shelves in supermarkets. Such loss cannot be achieved without impact on services.
However, despite so much change, the speaker firmly maintains that nursing is still a very caring profession.
The Health Bill passed to the House of Lords on 11thOctober 2011. The proposal to refer sections of the Bill to a select committee of peers was unsuccessful, but the Bill is likely to face a number of hurdles as it moves through the Lords.
The Community Voice, of which we are a member, does not usually meet in January but its members agreed at their Ooctober meeting to hold a special meeting on Thursday 5thJanuary at 7.45pm in the Post Graduate Centre at Mount Vernon Hospital to discuss this issue. GPs with differing views are being invited to lead the discussions. Visitors are welcome - they should 'phone 01895 636095 for an agenda and a free parking permit