Health secretary Andrew Lansley is battling to publish his “white paper” on NHS reform next week amid government concern there is too little detail on his reform programme.
Last week Mr Lansley’s plans were rejected by a committee of senior Liberal Democrat and Conservative MPs formed to resolve disputes within the coalition government. The prime concerns were the extent of NHS restructuring implied by plans to abolish strategic health authorities and shift the majority of commissioning to GPs.
Mr Lansley has not set out how he will simultaneously free GPs to spend money where they see fit and ensure the NHS budget is not overspent
Mr Lansley was not present at the meeting. As HSJ went to press, figures close to him were trying to understand the scale of rethinking his colleagues require.
Those sources are now referring to the paper scheduled to be published on 12 July as a “white paper with a green-ish tinge”. Mr Lansley himself has also referred to it as a “strategy paper”. Whitehall sources said the ambiguity resulted from concerns among government colleagues and the Treasury that the paper would be light on detail.
The biggest concerns continue to focus on spending controls for GP commissioning consortia. Mr Lansley has not set out how he will simultaneously free GPs to spend money where they see fit and ensure the NHS budget is not overspent.
Last week HSJ revealed that GP commissioning could generate a gross annual deficit of at least £1.2bn a year, if £60bn of the NHS budget is devolved to practices.
A new proposal now being explored is to establish around 50 health authority organisations which would take on “accounting officer” status to control GP spending. These could also have elected members and run local public health services, a role currently envisaged for primary care trusts.
Mr Lansley also plans to announce his intention to move NHS foundation trusts from the public sector balance sheet, as initially planned by former Labour health secretary Alan Milburn in 2002.
Advocates of the policy argue the move would sharpen the incentive for foundation trusts to be efficient because it would be clear the government would not step in if they faced difficulties. It could also see thousands of people removed from the NHS pension scheme if new employees were not entitled to join it.
But to move FTs off balance sheet the Treasury and Office for National Statistics would need to be satisfied the government really did no longer control foundations - either directly or through undiluted dependence on NHS funds.
The ONS would also need to be satisfied assets had genuinely been transferred to foundation trusts at a commercial rate. Foundation net assets are valued at £15.8bn on their balance sheets, but any sale would likely involve a revaluation.
University College London Hospitals Foundation Trust chief executive Sir Robert Naylor told HSJ foundations with significant surpluses would be interested in using part of them as a lump sum down payment on the purchase of their assets.
At the end of March 2010, the accumulated cash surplus of foundations stood at £2.9bn.
Sir Robert called for foundations to explore establishing their own intra-foundation lending arrangements to aid asset acquisition.
The DH is also working on a separate white paper scheduled for “late autumn” publication due to set out proposed changes to public health. It is expected to include the ringfencing of a separate public health budget and the change in the DH’s focus to become a department of public health.
But plans for elected PCT boards, which were part of the coalition agreement and anticipated to be in the public health white paper, are also encountering difficulties. The Lib Dems are unhappy with Mr Lansley’s plans to strip PCTs of the majority of their commissioning role, which would minimise the role of elected board members.