NHS Modernisation: listening exercise and NHS Future Forum

Following a lengthy and turbulent committee stage in the House of Commons, the government announced that parliamentary scrutiny of the Health and Social Care Bill would be subjected to an unprecedented 'pause', with an independent forum established to examine the bill and report back.

Faced with widespread opposition, the pause was an opportunity to codify concerns that included the parliamentary accountability of the secretary of state for the NHS and the composition of clinical commissioning groups.

NHS modernisation: listening exercise

On 4 April 2011, Secretary of State for Health Andrew Lansley announced an 8-week break in the parliamentary passage of the bill to allow the government to undertake a 'listening exercise'. He stated: 'We want to continue to listen to, engage with and learn from experts, patients and frontline staff within the NHS and beyond and to respond accordingly. I can therefore tell the House that we propose to take the opportunity of a natural break in the passage of the bill to pause, listen and engage with all those who want the NHS to succeed, and subsequently to bring forward amendments to improve the plans further in the normal way.'

Lansley said that there was widespread support for the principles of the government's reforms and that there would be amendments to the bill, but that its main principles would remain intact.

NHS Future Forum report

The independent NHS Future Forum was set up on 6 April 2011 to examine the bill and report back. The forum undertook investigations into several areas, including competition and choice and integration. The listening exercise, faced with almost universal hostility, was an attempt to identify key differences with opponents and find a compromise path.

On 13 June 2011, the forum published a summary report with core recommendations on potential amendments to the bill, alongside four more detailed reports on choice and competition, clinical advice and leadership, public accountability and patient involvement, and education and training.

The report noted that: 'The government's stated aim of making improvement in quality and healthcare outcomes the primary purpose of all NHS funded care is universally supported. However, during our listening, we heard genuine and deep-seated concerns from NHS staff, patients and the public which must be addressed if the reforms are to be progressed. If the substantial changes we propose are accepted by government, then I believe that the resulting framework will place the NHS in a strong position to meet this objective and tackle the pressing challenges in the years ahead.'

On competition, Sir Stephen Bubb, Chair of the Choice and Competition work stream of the NHS Future Forum, concluded that it would be an error to assume that properly regulated competition would pose a threat to the NHS as a universal service. However, the report noted concerns that competition might work against efforts to integrate care and that competition might compromise patient care: 'The place of competition should be as a tool for supporting choice, promoting integration and improving quality. It should never be pursued as an end in itself. Monitor's role in relation to 'promoting' competition should be significantly diluted.' The report recommended stronger safeguards against the misuse of competition and that Monitor's primary duty should not be to promote competition but instead to protect and promote the interests of the patient. The report also recommended safeguards to prevent providers from 'cherry picking' where it could distort the market or undermine quality.

More broadly, the Forum had concerns about the ultimate responsibility of the secretary of state for the NHS and the advice available to GPs as commissioners.

Government response

In response to the recommendations, the government committed to a range of amendments to the bill.

Any deliberate policy to increase or maintain the market share of any particular sector was ruled out, with Monitor's core duties to be focused on protecting and promoting patients' interests and not on the promotion of competition as an end in itself. Monitor would be required to enable integration of services for patients and its powers would be limited with regard to its ability to take action against commissioners, with stronger duties on commissioners to promote integrated services.

The Bill would include additional safeguards against cherry picking and price competition. GP commissioning consortia would be known as 'clinical commissioning groups' (CCGs) and required to have governing bodies with at least one nurse and one specialist doctor.

Clinical senates and speciality clinical networks would be established to provide multi-professional advice on local commissioning plans. The bill would also be amended to make it clearer that the secretary of state would remain ultimately accountable for the NHS.

In addition, the government agreed to a more flexible timetable for implementation. CCGs would all be established by 1 April 2013, but where a group was not ready to take on full budgetary responsibility, the NHS Commissioning Board would commission on its behalf.