'Equity and excellence: liberating the NHS' white paper

The Equity and excellence: liberating the NHS white paper was published in July 2010. The white paper set out the government's vision for a reformed health service.

While the white paper was predominantly focused on reforming the NHS, it also announced significant structural reforms to the public health system and a number of commitments relating to the integration of services between health and social care.

The significant structural changes included:

• the establishment of the NHS Commissioning Board (later NHS England)
• the establishment of GP consortia and a new focus on clinically-led commissioning
• the establishment of the Public Health Service (later Public Health England)
• the abolition of strategic health authorities (SHAs) and primary care trusts (PCTs)
• the establishment of health and wellbeing boards.

The new NHS Commissioning Board

The white paper set out plans to devolve the relevant powers of the Secretary of State for Health to the NHS, suggesting that the NHS could no longer be managed from the centre by the Department of Health. Instead, it would take a more strategic role, for example, by setting the strategic direction of the NHS through a formal mandate to the NHS Commissioning Board.

A new, independent NHS Commissioning Board would be established to set standards and benchmarks for the commissioning bodies of the NHS. It was intended to be free from political intervention and would provide leadership for quality improvement.

The NHS Commissioning Board would be responsible for holding GP consortia to account for their performance and quality, as well as commissioning some national and regional services.

The white paper set out the NHS Commissioning Board's five main functions as:

• providing national leadership on quality improvement
• promoting and accommodating public and patient involvement and choice
• developing GP consortia
• commissioning some national and regional services, such as general practice and dentistry
• allocating resources.

The shadow NHS Commissioning Board would be established by 1 April 2011 and would be fully established by 1 April 2012.

GP consortia

The government proposed to develop GP-level commissioning through GP consortia, and noted that:
'GP-led purchasing has history. Practice-based commissioning was an attempt by the last government to build on the successful parts of previous Conservative approaches, such as total purchasing pilots... Our model is neither a recreation of GP fundholding nor a complete rejection of practice-based commissioning. Fundholding led to a two-tier NHS; and practice-based commissioning never became a real transfer of responsibility. So we will learn from the past, and offer a clear way forward for GP consortia.'

This was intended to shift decision making as close as possible to individual patients, by building on the role that primary care professionals already played in coordinating patient care.

The department recognised that GP-led commissioning had been tried before, but suggested its plans for consortia would learn lessons from the past.

Under the proposals, GP consortia would be responsible for commissioning services. They were considered to be in the ideal position to involve clinicians and plan services for patients.

The paper reflected that, previously, GP fundholding led to the development of a two-tier NHS and practice-based commissioning failed to achieve full devolution of responsibility.

GP consortia were intended to be in place in 2012.

The Public Health Service

The white paper proposed the establishment of the Public Health Service (which would become Public Health England) as part of the Department of Health. This new body would seek to bring together and coordinate all existing health protection and improvement bodies and functions under a single service.

The Public Health Service would take over responsibilities for vaccination and screening programmes and have new powers to enable it to manage public health emergencies.

Abolition of primary care trusts (PCTs) and strategic health authorities (SHAs)

Primary care trusts (PCTs) and strategic health authorities (SHAs) were to be abolished.

PCTs' NHS commissioning functions would be taken over by GP consortia.

Public health improvement functions would return to local government, becoming the responsibility of upper-tier local authorities, led by the director of public health (DPH). The government committed to ring-fencing the public health budget, which would be allocated by population health outcomes and managed by the DPH. The government would introduce a health premium (a financial incentive), designed to encourage action to reduce health inequalities.

In order to facilitate better joint working between the NHS and local government, the government intended to establish health and wellbeing boards. The boards would be accountable to local authorities, thereby allowing local government to take a more strategic role in promoting integration. They would also enable and support local government to promote local integration between health and social care services

The government pledged to complete the separation between the commissioning and provider functions of PCTs by April 2011 and move to an 'any willing provider' model for commissioning, to be achieved through reducing barriers for new suppliers to enter the market, leaving commissioners free to select providers.

The establishment of health and wellbeing boards and the new transfer of public health responsibilities to local authorities were to take place by 1 April 2012.

Choice and providers

One of the central themes of the white paper was to place patients at the centre of the health service and to support them to have greater choice and control. The government made a number of commitments to this effect such as:

• significantly increasing the offer of choice across a range of services (for example, the introduction of choice of treatment and provider in some mental health services from April 2011 and the introduction of choice for long-term conditions and diagnostic testing)
• the introduction of choice relating to named consultants for elective care by April 2011
• the right to choose to register with any GP practice, without being restricted by where the patient lives.

The white paper made it clear that diversity of supply was a key objective. The government aimed to free up healthcare provision to allow any willing provider to provide services (where appropriate), thereby giving patients greater choice and stimulating innovation and improvement through greater competition.

The government was also clear that local commissioners should encourage a range of providers and use tools such as payment by results to ensure that money follows the patient. The system of control would no longer be based on national and regional management but would instead be based around quality and economic regulation, commissioning and payments by results.

The government committed to introducing new freedoms for foundation trusts (FTs), including removing the cap on income that FTs could earn from other sources, as well as tailoring governance arrangements. It was expected that, within 3 years, all NHS trusts would become foundation trusts and the legislative model for NHS trusts would be repealed. It was anticipated that there might be a few cases where the trust administration scheme set out in the Health Act 2009 might need to be used.

The government also committed to completing the separation of commissioning and provision by April 2011, while moving to an any willing provider approach for community services.

The government pledged to appoint a commission on long term care to consider social care funding and produce a white paper.

Strengthening patient involvement

Another pervading tenet of the white paper was the increased involvement of patients in all decisions affecting them. It was claimed that the paper would make 'no decision about me without me', a norm in a patient-led NHS.

The government suggested that a more transparent approach to publishing information on quality was needed to support patient choice.

Payment reform

The white paper reflected on the absence of effective payment in some aspects of the NHS and committed to developing payment currencies for a range of services, including adult mental health services and talking therapies. There was a commitment to accelerate progress towards the development of currencies for community services.

The department also intended to refine existing tariffs and would adjust the commissioning for quality and innovation (CQUIN) framework to support local quality improvement goals.

Regulation

The white paper also outlined the government's intention to amend the role of Monitor (the regulator of foundation trusts). Monitor was to become an economic regulator, with responsibility for promoting competition, regulating prices, promoting the effective and efficient provision of healthcare and safeguarding the continuity of services.

The Care Quality Commission (CQC) would act as a quality inspectorate across both health and social care and Monitor would be developed into an 'economic' regulator, an extension of its existing role as the regulator of foundation trusts. Providers would be required to hold a joint licence overseen by both Monitor and the CQC.

The white paper committed to the expansion of NICE's functions and the extensions of its remit to include social care.