NHS: white paper, the devil may well be in the detail

The top-line messages of the NHS white paper 'Equity And Excellence: Liberating The NHS' are quite right: clinicians need to lead commissioning, and that the system needs to focus on patient outcomes. Almost everything else in it contains massive risks. It is also desperately short of crucial details, which will be the subject of 10 consultation documents, due to be issued over the summer period. The document also represents what policy experts generally agree to be radical, and possibly the biggest restructuring of the NHS since 1974. It unquestionably represents a "top-down reorganisation" of the kind explicitly ruled out in the coalition agreement document. That, however, is the least of its problems Where power is going In the NHS, the savvy observer always locates the power by following the money. The drive in 'Equity And Excellence' is to give the bulk – between 70 and 80% of the NHS £105bn (ring-fenced) budget - of the money to GP commissioners in consortia, via the newly-created independent NHS Commissioning Board. The Board will also draw up national commissioning guidelines, and in a recent interview with Health Service Journal, Health secretary Andrew Lansley suggested that he will expect these to be followed locally in 80% of instances, with the balance happening on a "comply or explain" basis. Although we are told that the board is to be independent, the white paper is without detail as to its proposed constitution. The crucial question for the board is over who will be able to appoint or dismiss its chief executive or executive chair. The document states merely that it will be free from "day-to-day" political interference. The number and constitution of GP commissioning consortia is, however, unclear, although the document states explicitly that each will have an "accountable officer" – a nod to the Treasury's well-known objection to the original draft, which proposed unsatisfactory financial governance arrangements. Interesting challenge An interesting challenge arises because the contracts for GP practices, which will form the commissioning consortia, will be held not with the individual consortium but with the national board. This instantly poses the question of whether consortia will be able to act when a practice does not follow the commissioning or financial guidelines that will have to be agreed locally. The issue of geographical basis for the commissioning consortia is likewise diffuse. The document initially suggests that over the next couple of years, the independent Commissioning Board (which will have an unspecified number of regional offices) will replace the intermediate tier of geographical region-wide strategic health authorities, which will be abolished in 2012-13. The GP commissioning consortia will replace the local administrative primary care trusts (abolished from April 2013), which currently commission services (largely ineffectively, according to the recent House Of Commons health select committee report) and previously provided community services. All providers – hospitals, mental health and children's trusts, ambulance services – will go into foundation trust (FT) status in 2013-14. The NHS will no longer directly own providers, but merely fund healthcare. FTs are high-performers who earned semi-autonomous status, and are not directly accountable to the Health Secretary but to Parliament via their regulator and accreditor, Monitor. Monitor becomes vastly powerful in the new system. It assumes responsibility for national tariff-setting all economic regulation in the system among both commissioners and providers, taking over the NHS Co-operation and Competition Panel's remit as well as large aspects of regulatory responsibility in association with the Care Quality Commission (which survives for now). Patients will have increased choice in the new system, which promises choice of consultant-led team "where clinically appropriate" and also choice of any GP anywhere whose practice lists are open. Choice, commissioning and competition are this white paper's improvement tools of choice, as opposed to the New Labour methods of national targets and close regulation. A significant review of regulatory arms' length bodies is under way, and is scheduled to report at the end of the summer. A new consumer champion, HealthWatch UK, will be formed to replace Local Involvement Networks. The system also emphasises greater publication of data at all levels, and by next summer, will compel hospitals to report when care goes wrong or mistakes are made. The white paper cannot be faulted for its ambition. Detail is desperately lacking on crucial issues. Andy Cowper is the editor of Health Policy Insight