NHS Plan (2000)
The NHS Plan was published on 1 July 2000. Like the 1989 white paper Working for patients, it represented one of the key milestones in the development of choice and competition in the NHS.
The NHS Plan outlined significant changes to how healthcare in England was to be organised, with the intention of modernising the service. The government committed to large-scale investment in the NHS, designed to bring spending on the NHS up to the European average. Reforms also intended to ensure that the additional resources would maximise the potential benefit to patients and the public.
The plan set out a number of 'must do' targets for acute services, including that no patient should spend more than 4 hours in an A&E department from arrival to admission, transfer or discharge. The plan suggested the government was waging a 'war on waiting' and committed to maximum waiting times of 6 months (from 18 months) for inpatient treatment and 3 months (from 6 months) for routine outpatient appointments by 2005.
The NHS Plan marked an important step in establishing closer relationships between the private sector and the NHS. The government committed to an agreement between private providers and the NHS to make better use of the facilities in the private sector, with a particular focus on collaborative working in elective, critical and intermediate care:
'For decades there has been a stand-off between the NHS and private sector providers of healthcare. This has to end. Ideological boundaries or institutional barriers should not stand in the way of better care for NHS patients.'
The government also committed to developing diagnostic and treatment centres in partnership with the private sector. These centres were intended to separate routine hospital surgery from emergency work to help reduce waiting times. The original intention was to develop 20 diagnostic and treatment centres by 2004, with eight fully operational centres treating approximately 200,000 patients per year.
The plan also referenced the poor system of financial incentives in operation at a hospital level. The NHS Plan outlined the government's view that there needed to be additional mechanisms for assuring the quality and safety of services. The NHS Plan committed to:
- establishing a mandatory reporting scheme for adverse healthcare events by the end of 2001
- requiring all doctors employed by or under contract to the NHS to participate in annual appraisal and clinical audit from 2001
- requiring all doctors working in primary care to be registered with the health authority and subject to clinical governance arrangements, including annual appraisal and participation in clinical audit
- establishing a National Clinical Assessment Authority, which would provide a rapid and objective expert assessment of an individual doctor's performance
- strengthening the regulation of the clinical professions. Self-regulatory bodies would be required to have greater patient and public representation, develop meaningful accountability arrangements, and have faster, more transparent procedures
- establishing a UK Council of Health Regulators to support increased coordination across different regulatory agencies.
The responsibility for shaping and commissioning care had been given to groups of local doctors and nurses through primary care groups (PCGs). The government outlined plans for PCGs as a successor to the GP fundholder scheme, but which was not voluntary. Increasingly powerful, they would gain primary care trust (PCT) status by April 2004, a date that was later brought forward.
The emergence of PCTs was to affect the rest of the administrative structure, with the role of health authorities diminishing. From 1 April 2000, the first 17 PCGs had been given primary care trust (PCT) status.
Health and social care integration
Chapter 7 of the NHS plan, Changes between health and social care, focused on removing the barriers between health and social care. The government proposed to:
- establish multi-purpose organisations called Care Trusts to commission and be responsible for health and social care services
- make it a requirement for all areas to use the Health Act 1999 provisions to pool budgets and jointly commission services
- invest £900m in intermediate care services, such as intensive rehabilitation services and multidisciplinary rapid response teams
- enable the Commission for Health Improvement (responsible for regulating and inspecting health services), Audit Commission (which oversaw the auditing of councils and NHS bodies) and the Social Services Inspectorate (which inspected social care services) to carry out joint inspections to look at how health and social care organisations were working together.
Social care reform
As well as outlining the government's vision for the NHS, The NHS Plan: A plan for investment, a plan for reform responded to the 1999 Royal Commission's report on long-term care.
The government accepted many of the commission’s recommendations and committed to:
- providing statutory guidance to local authorities with the aim of reducing current variations in charging for home care
- making provisions to ensure that nursing care provided in homes would be fully funded by the NHS
- disregarding the value of a person’s home for 3 months from the means-testing assessment.
However, the government did not accept the key recommendation to fully fund personal care because ‘actioning the proposal would absorb huge and increasing sums of money without using any of it to increase the range and quality of care available to older people’.
While the NHS plan was mostly welcomed, there was some concern over the refusal to remove the boundary between personal care and nursing care, and keep personal care as a means-tested service.
On public health, the government intended to establish integrated public health groups linked to government offices for the regions by 2002. The plan acknowledged the unhelpful split between public health functions, the NHS and social services, and proposed to tackle this by appointing a single chief executive for the NHS, who would hold combined responsibility for these areas.
The public health aspects were minimal, as most of the document was devoted to the restructuring of the NHS hierarchy and encouraging competition. However, the plan did commit to:
- increasing the provision of primary care in deprived areas
- introducing screening programmes for women and children
- increasing the provision of smoking cessation services
- making fruit freely available for 4–6-year-olds in schools.
Department of Health.
The NHS Plan: A plan for investment. A plan for reform.