13. Equity and excellence and patient care

Resolution submitted by the RCN Public Health Forum

That this meeting of RCN Congress does not believe that changes to commissioning arrangements outlined in the NHS white paper ‘Equity and excellence: liberating the NHS’ will best serve patients, health care, or the NHS in England

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Progress report

Submitted by: Public Health Forum
Council lead and committee assigned: Gill Cort and Jane Bovey (until October 2011), Ian Norris and Stuart Young (from October 2011), Nursing Practice and Policy Committee
Committee decision: Integrate project into ongoing work stream
Members involved: Members extensively consulted on the Government white paper

Final update at May 2012

The 2011 RCN Congress debate covered concerns around the NHS White Paper “Equity & excellence: liberating the NHS”.

In its response to the White paper the RCN published 18 assurances, one of which stated that nursing must be represented at a senior level in GP consortia and on the NHS Independent Commissioning Board.  Nursing expertise must also be recognised and utilised at all levels of the commissioning process”.

On 13th April 2011 RCN Congress passed a vote of no confidence in the Secretary of State’s management of the Coalition Government's NHS reforms (See separate update on Congress agenda Item 27E). On 20th June 2011 the Government’s response to the Future Forum report stated that “we do not intend to prescribe in detail the wider professional membership of the governing body, but it will have to include at least one registered nurse and one doctor who is a secondary care specialist”. The Government response to Future Forum recommendations also gives a commitment for nurse representation on clinical senates.

In September 2011 the re-Committed Health and Social Bill placed a more direct duty on the Board and on clinical commissioning groups (replacing the term GP consortia) to obtain this advice from a broad range of professionals with expertise in the “prevention, diagnosis or treatment of illness” and in the “protection or improvement of public health”, appropriate for enabling them to effectively discharge their functions.

In January 2012 as a result of a meeting of RCN Council, the RCN took the position of opposing the Health and Social Care Bill and has called for it to be withdrawn. The RCN highlighted that many serious concerns expressed by members had not been addressed during the parliamentary process, listening exercise or political engagement. The RCN has also stated that the reform proposals would not deliver on the principles originally set out by the Government. The RCN has restated that this is decision reflected genuine, honestly held concerns about the quality of patient care and where the health service is headed.

By April 2013, subject to the approval of the Health and Social Care Bill, the whole of England will be covered by established Clinical Commissioning Groups (CCGs). The RCN has highlighted (in its parliamentary lobbying work on the Health and Social Care Bill) that in order to commission effectively, strong nursing leadership will be critical for CCGs boards to ensure that there is a clear understanding of what is required to deliver effective services for health and wellbeing to communities. The RCN continues to be concerned about senior nurse leadership in the new clinical commissioning groups (CCGs). Information gathered at regional and national level indicates that is some areas junior nurses without the requisite skills are being appointed in ‘token’ roles whilst experienced senior nurses working in PCTs and other areas are being overlooked. The RCN has therefore produced guidance on the ‘Lead Nurse role in Clinical Commissioning Groups (CCGS) – towards authorisation. The RCN is planning a series of resources for members and events across the country to equip nurses to influence commissioning.

In Scotland the RCN has been asked for its views on the future of GMS contracting in Scotland.  Although the commissioner / provider split was removed from NHS Scotland in 2004, possible developments in health and social care integration could affect some current arrangements and an announcement from Scottish Government is anticipated at the end of 2011.

In Northern Ireland, the commissioning of health and social care is undertaken jointly by the Health and Social Care Board, the Public Health Agency and five Local Commissioning Groups. In its evidence to the current Review of Health and Social Care, the RCN is seeking a review of these arrangements, particularly in light of the complex inter-relationships and governance arrangements between the various different bodies, and the need to specify precisely what is being commissioned, by whom and to what effect. The RCN is also highlighting the need to ensure that commissioning is a transparent and inclusive process based upon assessing health and social care need and then designing regional and local services to meet that need, rather than simply a conduit for directing funding streams around the system.

In Wales the Welsh Government established a system of planning and provision of NHS primary and acute care centred on 7 Local Health Boards in 2009. The current Welsh Government (elected in 2011) has so far made no move to substantially alter this arrangement.”

Update at November 2011

The reforms

The Coalition Government in England set out its intentions for the future of the NHS in England in the NHS in the White Paper Equality and Excellence: Liberating the NHS and the supporting consultation document ‘Equality and excellence: Commissioning for patients’. The Government believes that those working in general practice are best placed to understand patients' needs and to decide where money can be spent most effectively.

UK implications

The reforms could:

In Scotland the RCN has been asked for its views on the future of GMS contracting in Scotland.  Although the commissioner / provider split was removed from NHS Scotland in 2004, possible developments in health and social care integration could affect some current arrangements and an announcement from Scottish Government is anticipated at the end of 2011.

In Northern Ireland, the commissioning of health and social care is undertaken jointly by the Health and Social Care Board, the Public Health Agency and five Local Commissioning Groups. In its evidence to the current Review of Health and Social Care, the RCN is seeking a review of these arrangements, particularly in light of the complex inter-relationships and governance arrangements between the various different bodies, and the need to specify precisely what is being commissioned, by whom and to what effect. The RCN is also highlighting the need to ensure that commissioning is a transparent and inclusive process based upon assessing health and social care need and then designing regional and local services to meet that need, rather than simply a conduit for directing funding streams around the system.

In Wales the Welsh Government established a system of planning and provision of NHS primary and acute care centred on seven Local Health Boards in 2009. The current Welsh Government (elected in 2011) has so far made no move to substantially alter this arrangement.

RCN assurances (England)

In its response to the NHS White paper for England RCN published 18 assurances.  One of the key RCN assurances stated that “Nursing must be represented at a senior level in general practice commissioning consortia and on the NHS Independent Commissioning Board.  Nursing expertise must also be recognised and utilised at all levels of the commissioning process”.

Timeline of key events in England

In England the RCN has achieved a number of significant changes to the Health and Social Care Bill, in particular a much clearer emphasis on the multidisciplinary, and nurse input into commissioning. The RCN is absolutely clear that nurses have a role to play at all levels of commissioning. The Board level role will be strategically important to the success of the proposed reforms. It should be a substantive senior role with a commensurate level of responsibility and authority within the organisation. Building on ongoing policy and advocacy work, the RCN is planning:

The future

By April 2013, subject to the approval of the Health and Social Care Bill, the whole of England will be covered by established CCGs. Each one will have been established as a statutory body but where a CCG is not ready or willing to undertake its full statutory functions it may have conditions imposed on the grant of its application, and it is possible that some of its functions may be carried out by the Board or other CCGs. This is in line with the Government’s commitment to allow CCGs to come forward “when they are good and ready”.

In the briefing to the House of Lords for their scrutiny of the Health and Social Care Bill the RCN expressed concern that significant reform was already under way and irreversible changes had been made even though the Bill is still being debated. We highlighted that consortia groups now cover almost all of England (there are currently more than 253 shadow CCGs across England) and were preparing to take over Primary Care Trusts (PCT) responsibilities. Large swathes of guidance had been published by the Department of Health (DH) and PCT and Strategic Health Authority (SHA) structures are being dismantled. With vast levels of service reorganisation and staff upheaval taking place on the ground, the RCN believes that, despite what is happening in Westminster, the reforms are now firmly moving forward before any approval by Parliament.

Debate report

Linda Bailey from the RCN Public Health Forum led the debate by stating that the Coalition Government is “trashing the NHS and all the hard work of her clinical colleagues”, despite the standards of care continuously improving and the life span of the population increasing. She stated that the NHS White Paper will give control of the NHS to GPs who are not experts in commissioning, she said “it’s a nonsense”. Linda explained how the Kings Fund said one in seven GP practices are currently not fit for purpose, so this does not give her confidence that the new system will work either. She said not to be fooled by the majority of GPs signing up, “Just because someone gets into a lifeboat doesn’t mean they support the sinking of the ship”.

The resolution was seconded by Patricia Leung from North West London Inner Branch, who backed up Linda by saying “GPs do not understand the complexities of care” like nurses do. She is worried that the huge cuts will lead to a loss in organisational memory. She doubted that the ‘pause’ was a real one, as she recounted that cuts were already being made.

Helen Brown from London region was worried about care being governed by the financial year, rather than the need of patients. Thomas Murray, Devon Branch said “These changes are not reforms, reforms make things better, and this makes it worse”.

Members voted overwhelmingly in favour of the resolution.

Result

For                         434         98.19%
Against                 8              1.81%
Abstain                 7

PASSED

The NHS White Paper Equity and excellence: liberating the NHS (July 2010) (Department of Health, 2010) set out the Government’s reforms for the NHS which include the introduction of GP consortia commissioning, the abolition of strategic health authorities and primary care trusts, the introduction of a new NHS Commissioning Board, the transfer of public health responsibilities to local authorities, and the establishment of an economic regulator to set prices, promote competition and ensure service continuity of essential services.

These reforms are intended to support the delivery of £20 billion efficiency savings in England by 2015, and the Government believes those working in general practice are best placed to understand patients’ needs and decide where money can be spent most effectively.

In December 2010, the Health Secretary announced the first wave of GP consortia: under the Pathfinder Programme, 52 GP practice groups across England (covering 12.8 million patients) have been selected to road test the ability of GP consortia to take over from PCTs. By 2011/12 every GP will be a member of a 'shadow' consortium and it is planned that GP consortia will take full financial responsibility from April 2013.

While the reform proposals are for England only, there are clearly implications for all four countries – including cross-border health care provision. In Scotland the RCN has been asked for its views on the future of General Medical Services (GMS) contracting, while the abolition of public bodies such as the National Patient Safety Agency (NPSA) will affect Wales in particular. In Northern Ireland the Health and Social Care Board has recently established a series of primary care pilot projects designed to enable GPs, nurses and others to work together to ensure patients have treatment and care available in the right place at the right time.

In preparing its response to the NHS White Paper (England), the RCN consulted members on their views; 86 per cent of those responding to an online RCN survey felt nurses should have a central role in the future commissioning of patient services, and 71 per cent did not agree that responsibility for the bulk of the NHS budget should be handed to GP consortia to commission/buy services.

In its final response to the commissioning proposals, the RCN stated:

The commissioning proposals also present fundamental challenges around workforce, and the RCN believes that skills and knowledge will be lost through the process of transferring responsibility to GP consortia and new clustering arrangements.

References and further reading

Department of Health (2010) Equity and excellence: liberating the NHS, London: DH Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353  (Accessed 02/02/11) (Web)

Royal College of Nursing (2010a) Response to the NHS White Paper: ’Equity and excellence: liberating the NHS’ (England), London: RCN Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0016/341404/RCN_response_to_NHS_white_paper41.pdf (Accessed 02/02/11) (Web)

Royal College of Nursing (2010b) RCN response to ‘Liberating the NHS: Commissioning for patients’ (England), London: RCN Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0004/343039/RCN_Response_to_WP_consultation_on_commissioning_for_patients.pdf (Accessed 02/02/11) (Web)