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Exclusive: government to publish second command paper

The government is planning to publish a second NHS policy “command paper” as it attempts to rescue its floundering Health Bill, HSJ has learned.

Senior Whitehall sources said the document – likely to come within a month – will attempt to explain the coalition’s new agreed position on NHS reform.

It will seek to sell the new proposals before amendments to the Health Bill are tabled, in the style of the “command paper” published by the Department of Health in December ahead of the initial legislation. It is being described as the “command paper mark II”. It is expected to respond to recommendations made by the NHS Future Forum review.

Senior sources said the key component of the government’s attempt to rescue the bill will be to promote integration of services – in contrast to what has been seen as a focus on competition.

Monitor’s duties will be changed to put more emphasis on integration and HSJ understands the NHS Commissioning Board is also likely to be given a similar duty.

The government is likely to encourage primary care-led commissioning consortia to work closely with local networks of other clinicians to integrate provision and ultimately potentially creating new provider organisations. Previously the focus has been on consortia as commissioners distinct from providers. The government may also highlight hospital trusts which are integrating with community services, having taken them on from primary care trusts.

It is planning to describe how these approaches, if they are shown to work, could be pushed more widely by Monitor under its new duties. It will significantly change Monitor’s role in practice, away from being a “proactive” economic regulator.

One senior source said there would be “a framework where people can start bottom up to create integrated care”. The source said: “The government will say very strongly that integrated care is a really good thing and you should support it as best you can, and roll it out.

“We will start to get a model emerging where consortia and others work together more directly as providers.”

The government is believed to see the plan as a key part of convincing opponents to the Health Bill. A source said ministers believed they were, “moving towards a settlement in a way the NHS will say, ‘That’s reasonable’”.

A DH source said it intended to respond to the Future Forum report quickly. It is understood the DH hopes this can happen by the end of next month.

A DH spokeswoman said in a statement: “Any speculation about the government’s response to the NHS Future Forum’s report is premature. We await their report which is due next month.”

Readers' comments (28)

  • 'The government may also highlight hospital trusts which are integrating with community services' and 'if they are shown to work'...... This is not a new configuration so they should have some idea of the risks (asset stripping) and benefits (integrated care pathways) of this model - or has the corporate memory from the 1980's and 90's been lost in one of the many re-organisations??

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  • Sorry but wtf!

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  • And so it begins again...

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  • And so it begins again...

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  • And bo it segins

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  • And so......

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  • And...

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  • command...of what?

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  • The DH will respond quickly: wouldn't it be better to respond thoughtfully, or even coherently?

    David Nicholson has raced ahead of the legislation (effectively pre-empting the abandonment of certain parts of the Bill) - he must be desperate to make sure that certain issues are not dropped.

    Now he's going to race ahead he a slow learner, or what?

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  • Acute and community services have been integrated in Wales since 1999, has anyone seen any evidence that it worked there? Have any of the academic institutions produced any reviews on that massive change from which we can learn?

    The fear we all share is that powerful consultants suck the resources away from community nursing and therapies and patients end up requiring treatment which could have been avoided - is there proof for or against this happening? Why are we not sharing the learning from over a decade ago?

    Answers on a postcard please...

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  • Sorry but wtf!

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  • I am an experienced NHS Senior Manager who is just about to leave the NHS because I am not prepared to work towards the unnecessary disintegration of the NHS and its fundamental principle that clinical need and care is free at the point it is required. Let me be clear - this is the ultimate goal. I have always worked hard for the patient (who could be me, my husband, my son, my family, my friends), always striving to lead by example to others "that if you treat others as you would have others treat you, you will never go wrong in this world". Instead I have consciously decided to move to new pathways/challenges where I can be of most help and service to others - that's my starting point.

    The NHS can choose to work cooperatively with a new set of values and assumptions. It collectively has the intelligence and knowledge to do so. The true spirit of these times isn't the fear of being down-sized or social unrest. There are many symptoms of what is really going on, we all need to look deeper to see the real spirit of what is being born. In fact, the nightly television news is documenting the dying of the 'old world' rather than the birth of the new. A 'real listener' senses the elements emerging for a new paradigm. He or she then acts in response to what has been noticed. That person is able to give expression and form to the new assumptions about life. This sort of person (who is within us all as a potential) is also able to put aside fears. He or she is able to courageously to accept that moment of void we encounter when we have to let go of the old and the new isn't yet fully within our grasp. We need the confidence of a trapeze artist who has let go of one swing and momentarily hangs helplessly out in space before grabbing on to the next: he knows his own momentum will carry him forward to meet the swing he trusts will be there.

    The current 'listening' exercise with ever increasing desperate headlines is a sham and utterly shameful as everything continues to be dismantled at lightening speed. The private companies are circling like vultures ready to swoop and pick over the best bits - all for the sake of £. The love of money really is the root of all evil.

    I believe the NHS needs to take all its interdependent elements and find new places for them. It's a crucial point to understand. The elements themselves do not change, instead it is our way ordering them that needs to be altered. The challenge therefore is to arrange, order and relate all the elements to each other based on a new set of rules. The NHS itself needs to vigorously define and defend its boundaries and that might mean telling the politicians to "go to hell" - reaffirming the NHS and all that is stands for, re-connect with our own courage and strength, and rededicate to what the NHS holds as its ideals. We need to return to a deeper understanding of the original meaning of "ideal". It means having the courage to actually live the ideals that we have set. He without an ideal is sorry indeed: he with an ideal and lacking the courage to live it is sorrier still.

    Watching President Obama this week in Westminster Hall, I for one was struck by the difference between Obama, his presence and his speech, and that of our front line coalition politicians who fidgeted and looked so much like the rich public schoolboys they really are - I felt ashamed that this is the best that this country can offer - they really don't give a dam about the vast majority of people in this country, and it shows. Who do they think they are kidding?

    In conclusion, those at the top of the NHS need to tell the politicians to 'go to hell', reaffirm the NHS founding principles and ideals and look afresh at how all parts of our National Health Service can efficiently work together in cooperation, integration and harmony. We all know things cannot stay as they are but the NHS really can do this by itself without constant political interference.

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  • Surely this should be called a countermand paper if it reverses or revokes directions outlined in the previous command paper !

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  • Whilst I firmly believe integration is crucial to delivery of effective healthcare I don't see how the reforms will address the systemic barriers to integration such as inequity in incentives?

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  • Paul Tovey

    And out of the lore of Kaos there was 1948 - and a scattering of light and some medical whizzical twizzicals and then beds of patient stars formed .....Wowwee and a twinkle of chromium with spit on and polish on ..

    A bit later dark natter Lansley matter was discovered and conversation happened and we ran out of air ...Now no-one screams in space and I talk telepathic nonsense picked up by a far planet somewhere in the West of triple Suns....

    I am off to pose with my hands on head and hyper dropped jaw to Edvard Munch's phantom painting away darkly .....

    See you there ... X


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  • Martin Rathfelder

    “And here I sit so patiently, waiting to find what price
    You have to pay to get out of going through all these things twice”
    Bob Dylan, Stuck Inside Of Mobile With the Memphis Blues Again

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  • In Wales, Hospital & Community services (excluding GPs) have never been disintegrated. For evidence on the benefits of integration in Wales (and Scotland) please see several papers written by me and others on the website of the Welsh Institute of Health & Social Care at the University of Glamorgan:
    David Hands
    Visiting Professor

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  • This is getting beyond a joke.

    Bill #1: Competition is the answer to everything

    Public Reaction: These clowns have no idea.
    Chris Ham says integration is good..... so.....

    Bill #2: Integration is the answer to everything

    This is no way to run Europe's biggest organisation.

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  • There's only one thing that will work and that's stability.

    Stability doesn't mean no reform/change. It does mean signalling early what the changes are, ensuring all can be at the starting line, and that the rules aren't changed in line with election cycles.

    Else, chaos will ensue, with needless organisation failure and bureaucracy..

    However, if we see the back of the old bill, fantastic. It's rubbish.

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  • Anon 28 May 9.22am: brilliant. And another inspired and no doubt inspirational leader departs while "top" leaders taciltly conspire with a dire government to make the best of it - for patients? or for themselves?

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