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Future Forum recommends dilution of Monitor role and public accountability for consortia

The health secretary must remain “ultimately” accountable for the NHS, Monitor’s proposed role in promoting competition should be “diluted” and consortia must have a governing body that meets in public, the Future Forum has recommended.

The forum has today published 16 recommendations on amendments to the Health and Social Care Bill, drawn up during the “pause”.

The most striking change recommended by the forum is the watering down of the powers proposed for Monitor in the bill. The forum says the proposal that Monitor promote competition should be removed and replaced by a requirement to “support choice, collaboration and integration”.

On consortia, the forum has recommended that commissioning consortia have a “governing body” that meets in public, because there“must be transparency about how public money is spent and how and why decisions are made”.

In line with this recommendation, it has also called for foundation trusts to be required “as a minimum” to publish board papers and minutes, and hold their board meetings in public.

However, it has stepped back from recommending that their boards must include hospital doctors and nurses, which had been strongly lobbied for by groups such as the Royal College of Nursing.

Instead, the forum has called for consortia to be required to obtain “all relevant multi-professional advice to inform commissioning decisions and the authorisation and annual assessment process should be used to assure this”.

To achieve this, it has recommended that consortia be required to use “clinical and professional networks” and “multi-speciality clinical senates” to provide strategic advice.

Additionally, the forum has responded to widespread and growing concerns that health and wellbeing boards would lack sufficient teeth to ensure consortia and local authorities worked together closely.

It has called for the bill to give the health and wellbeing boards stronger powers to “require commissioners of both local NHS and social care services to account”, should their commissioning plans not be deemed in line with the board’s local joint health and wellbeing strategy.

In his introduction to the forum’s report, its chair Professor Steve Field said: “It was right to pause and reflect. It has, however, been a destabilising period for the NHS and an unsettling time for staff and for patients.

“It is time for the pause to end. I believe that the advice and recommendations we present in this report, if acted upon, will help the NHS to move forward and refocus its efforts on delivering excellence in patient care and building the NHS of the future.”

The government is due to publish its initial response to forum’s report tomorrow, which will set out an agreement between the Conservatives and the Liberal Democrats on future health policy.

A more detailed response, in the form of a new command paper, is expected to be published next Monday.

It has also been suggested that the bill will not now be returned to the committee stage – as had been previously predicted by some MPs – and will instead be given a longer period at the report stage.

The recommendations in full are:

  • The enduring values of the NHS and the rights of patients and citizens as set out in the NHS Constitution are universally supported and should be protected and promoted at all times. The bill should be amended to place a new duty on the NHS Commissioning Board and commissioning consortia to actively promote the NHS Constitution. In addition, Monitor, the Care Quality Commission, the NHS Commissioning Board and commissioning consortia should all set out how they are meeting their duty to have regard to the NHS Constitution in their annual reports.
  • The NHS should be freed from day-to-day political interference but the Secretary of State must remain ultimately accountable for the National Health Service. The bill should be amended to make this clear.
  • Patients and carers want to be equal partners with healthcare professionals in discussions and decisions about their health and care. Citizens want their involvement in decisions about the design of their local health services to be genuine, authentic and meaningful. There can be no place for tokenism or paternalism. The declaration of ‘no decision about me, without me’ must become a reality, supported by stronger and clearer duties of involvement written into the bill focused on the principles of shared decision-making.
  • Because the NHS ‘belongs to the people’ there must be transparency about how public money is spent and how and why decisions are made. The bill should require commissioning consortia to have a governing body that meets in public with effective independent representation to protect against conflicts of interest. Members of the governing body should abide by the Nolan principles of public life. All commissioners and significant providers of NHS-funded services, including NHS Foundation Trusts, should be required, as a minimum, to publish board papers and minutes and hold their board meetings in public. Foundation Trust governors must be given appropriate training and support to oversee their Trust’s performance – until governors have the necessary skills and capability to take on this role effectively, Monitor’s compliance role should continue.
  • GPs, specialist doctors, nurses, allied health professionals and all other health and care professionals state that there must be effective multiprofessional involvement in the design and commissioning of services working in partnership with managers. Arrangements for multiprofessional involvement in the design and commissioning of services are needed at every level of the system. The bill should require commissioning consortia to obtain all relevant multiprofessional advice to inform commissioning decisions and the authorisation and annual assessment process should be used to assure this. In support of this, there should be a strong role for clinical and professional networks in the new system and multi-speciality clinical senates should be established to provide strategic advice to local commissioning consortia, health and wellbeing boards and the NHS Commissioning Board.
  • Managers have a critical role to play in working with and supporting clinicians and clinical leaders. Experienced managers must be retained in order to ensure a smooth transition and support clinical leaders in tackling the financial challenges facing the NHS.
  • There should be a comprehensive system of commissioning consortia but they should only take on their full range of responsibilities when they can demonstrate that they have the right skills, capacity and capability to do so. The assessment of the skills, capacity and capability of commissioning consortia must be placed at the heart of authorisation and annual assessment process. Where commissioning consortia are not ready, the NHS Commissioning Board should commission on their behalf but provide all necessary support to enable the transfer of power to take place as soon as possible.
  • Patients want to have real choice and control over their care that extends well beyond just choice of provider. Building on the NHS Constitution, the Secretary of State should, following full public consultation, give a ‘choice mandate’ to the NHS Commissioning Board setting out the parameters for choice and competition in all parts of the service. A Citizens Panel, as part of Healthwatch England, should report to Parliament on how well the mandate has been implemented and further work should be done to give citizens a new ‘Right to Challenge’ poor quality services and lack of choice.
  • Competition should be used as a tool for supporting choice, promoting integration and improving quality and must never be pursued as an end in itself. Monitor’s role in relation to competition should be significantly diluted in the bill. Its primary duty to ‘promote’ competition should be removed and the bill should be amended to require Monitor to support choice, collaboration and integration.
  • Private providers should not be allowed to ‘cherry pick’ patients and the government should not seek to increase the role of the private sector as an end in itself. Additional safeguards should be brought forward.
  • The duties placed on the Secretary of State, the NHS Commissioning Board and commissioning consortia to reduce health inequalities are welcome. These now need to be translated into practical action. The Mandate for the NHS Commissioning Board, the outcomes frameworks for the NHS, public health and social care, commissioning plans and other system levers and incentives must all be used to help reduce health inequalities and improve the health of the most vulnerable.
  • Local government and NHS staff see huge potential in health and wellbeing boards becoming the generators of health and social care integration and in ensuring the needs of local populations and vulnerable people are met. The legislation should strengthen the role and influence of health and wellbeing boards in this respect, giving them stronger powers to require commissioners of both local NHS and social care services to account if their commissioning plans are not in line with the joint health and wellbeing strategy.
  • Better integration of commissioning across health and social care should be the ambition for all local areas. To support the system to make progress towards this, the boundaries of local commissioning consortia should not normally cross those of local authorities, with any departure needing to be clearly justified. The government and the NHS Commissioning Board should enable a set of joint commissioning demonstration sites between health, social care and public health and evaluate their effectiveness.
  • Most NHS staff are unfamiliar with the government’s proposed changes to the education and training of the healthcare workforce. Those who are aware feel that much more time is needed to work through the detail. The ultimate aim should be to have a multi-disciplinary and interprofessional system driven by employers. The roles of the postgraduate medical deaneries must be preserved and an interim home within the NHS found urgently. The professional development of all staff providing NHS funded services is critical to the delivery of safe, high quality care but is not being taken seriously enough. The National Quality Board should urgently examine how the situation can be improved and the constitutional pledge to ‘provide all staff with personal development, access to appropriate training for their jobs and line management support to succeed’ be honoured.
  • Improving the public’s health is everyone’s business but should be supported by independent, expert public health advice at every level of the system. In order to ensure a coherent system-wide approach to improving and protecting the public’s health, all local authorities, health and social care bodies (including NHS funded providers) must cooperate. At a national level, to ensure the provision of independent scientific advice to the public and the Government is not compromised we advise against establishing Public Health England fully within the Department of Health.
  • Clinical leaders, managers and all those who care about the success of the NHS agree that quality, safety and meeting the financial challenge must take primacy and the pace of transition should reflect this. To ensure focused leadership for quality, safety and the financial challenge, the NHS Commissioning Board should be established as soon as possible.

Readers' comments (6)

  • On first read this seems reasonably aspirational but I can't see, in terms of operational impact, a massive change to the current proposals. Is it me, or does all of this have a feel of fait accompli?

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  • Ray

    True enough. However, observe:
    - Wanting Consortia to be coterminous with local authorities.... like.... PCTs are today.
    - No 'board positions' for provider medics, patients, or local councillors, but involvement in Senates (for which read network/ advisory groups, just as today) and commitments to processes of involvement.
    - Public health outside the DH is a very significant move.
    - A requirement for public board meetings for providers of NHS care gives a real challenge to the private sector who currently provide services.
    - The "choice mandate" idea puts all the politics of where to introduce competition right back at the secretary of state's door. (some would say, where it belongs) requiring full public consultation (expect a bun-fight).
    - The patients right to challenge lack of choice or poor quality service should put the frighteners on many a complacent service manager.

    Most helpfully the language of "GPs know best" has been replaced with "multi-professional clinical and managerial partnership"

    However, note......
    - Complete silence on commissioning support public/private debate
    - Open ended time-frames mean the NHS is condemned to double running for a decade.

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  • There is a key unanswered question for me about the size of consortia. Too small would be a nonsense in efficiency terms; too big would be a rebadging of PCTs. I think this is a major problem and the overall transaction costs of change is not going to go away either.

    I still can't see a fundamental win for the public - Health and Wellbeing Boards could become politically dominated, healthwatch could be as toothless as the old CHCs, consortia could be parochial and still subject to massive conflict of interest issues.

    We're backpedalling into the future and the light at the end of the tunnel looks like a flickering candle rather than a blaze of glory ...

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  • Dog's breakfast is the reference to the report on PM today. HSJ summary reads like lashings of motherhood and apple pie, innocent aspirations and assertions and lots of good intentions. I cant see how the bill can be substantially re-written through the third reading process.
    Hospital doctors on commissioning consortia has to happen because David said so but it is yet another conflict of interest built in the system.
    Integration? - ha ha ha - consortia of a nation of primary care health shop keepers to manage 'Tesco's'. GP's heal thyself first. With no real deadlines and vesting dates and no standard model like PCT's it is a recipe for post code chaos.
    Sorry to be so negative but what was wrong with structural stability and a programme of innovation and incremental improvements.

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  • It sounds as though the RCN and BMA have won the day - the patient voice has been lost somewhere in these proposals, but staff will be a lot happier.

    And the glaring potential for conflicts of interests through icluding providers in decisions about commissioning, as highlighted on PM has not gone unnoticed, hence the reference to a dog's dinner.

    Why the Lib Dems are hailing a vctory when the proposals mean that they will be well out of the picture by the time this evolution is supposed to have happened is anyone's guess.

    I'm sure I'm not alone in finding this whole mess hugely disappointing.

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  • Steven Burnell

    It will cost a lot of money.

    So, is it now more likely to deliver:
    A series of recurring cost-reductions building to £20Bn per annum by 2015?
    Seamless, integrated care focused on the needs of the patient?
    Consistently high standards of care & accessibility to treatment & support throughout the country?

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