Session 2010-12
Health and Social Care Bill
Memorandum submitted by The Royal College of Physicians (RCP) (HSR 54)
The Royal College of Physicians (RCP) plays a leading role in the delivery of high quality patient care by setting standards of medical practice and promoting clinical excellence. We provide physicians in the United Kingdom and overseas with education, training and support throughout their careers. As an independent body representing over 25,000 fellows and members worldwide, we advise and work with government, the public, patients and other professions to improve health and healthcare. Our primary interest is in building a health system that delivers high quality care for patients. The RCP can provide a range of support and advice to government as the health reforms progress.
1. Introduction
1.1 The RCP welcomes the opportunity to submit written evidence to the Health and Social Care Bill Committee. This written submission builds on our oral evidence of 28 June 2011.
1.2 The RCP supports many of the changes the government has made to the Health and Social Bill following the legislative pause and Listening Exercise, and many of the statements contained in their response to the Future Forum’s report to be enshrined in future regulations and guidance. There have been a number of steps in the right direction, including:
· Mandatory involvement of a wider range of healthcare professionals in commissioning, with a place for secondary care specialists on the governing board of each clinical commissioning group [1] , the strengthened duty to obtain specialist advice placed on clinical commissioning groups and the NHS Commissioning Board (clause 22), the new duty to involve specialists placed on Monitor (clause 56) and the commitment to strengthen clinical networks [2] .
· The change of emphasis so that Monitor’s role focuses more on quality, collaboration and integration, with the removal of references to "promoting competition" (clause 5 2).
· The removal of the maximum price tariff (made after the previous committee stage) (clause 115).
· The strengthening of clinical commissioning groups’ responsibility for their geographical area (clause 9) and the decision to promote strongly coterminosity with local authorities [3] .
· The strengthened mechanisms for patient and public involvement, including in the two lay members on clinical commissioning groups (clause 22), and the increased involvement in the work of Monitor (clause 5 2).
· The decision to give the Secretary of State an explicit duty for to maintain of professional education and training as part of the comprehensive health service [4] and the commitment to ensuring a smooth transition for education and training and an ‘interim home’ for deaneries [5] .
1.3 The RCP calls on government to provide for the following additional amendments, commitments and assurances:
· A clear vision for how clinical networks, clinical senates, clinical commissioning groups, NHS and foundation trusts, the NHS Commissioning Board (NHS CB), Public Health England (PHE), Monitor and Care Quality Commission (CQC) will work together to deliver a coherent, efficient health service with clear lines of responsibility and accountability, and robust mechanisms for resolving conflicts, promoting innovation and improvement, and reconfiguring services where necessary.
· Clarification that the secondary care doctor appointed to the governing board of a clinical commissioning group does not have to be from outside the area or retired, but can appointed from the local secondary care community (see paragraphs 2.3-2.8).
· Local ownership of clinical networks and senates must not be undermined by the fact they are ‘hosted’ by the NHS Commissioning Board ( see paragraphs 2.9-2.11 ) .
· Robust mechanisms for ensuring secondary care involvement in Health and Wellbeing Boards , health and wellbeing strategies and Joint Strategic Needs Assessments ( see paragraphs 2.12-2.13 ) .
· A commitment to take forward the Future Forum’s recommendation that organisations release staff for work that contributes to the wider NHS ( see paragraphs 2.14-2.15 ) - this would include work for the including work for the royal colleges, eg standard setting and curriculum development.
· That the renewed emphasis on collaboration, integration and quality is backed up by a regulatory and pricing system that also values quality and collaboration above competition and choice of provider. To support this, the RCP would like clarification on: the intention of the new ‘duty as respects variation in provision of health services’ (insertion 12E); further detail about how this phased extension of ‘any qualified provider’ will happen and the safeguards that will be put in place to prevent fragmentation and destabilisation; and further clarification of how European procurement and competition law would apply, including the publication of relevant legal opinion ( see paragraphs 3 .1- 3.5 ) .
· To promote integrated services, the NHS Commissioning Board should introduce ‘integrated pathways’ (eg for stroke) as part of the NHS Operating Framework on a rolling basis (eg two per year). There should be investment in robust quality metrics and in a new, more complex tariff system that can meet the stated intention of reflecting clinical complexity [6] (see paragraphs 3.6-3.9 ).
· A more integrated regulatory approach to cooperation, choice, quality and safety. The option of merging Monitor and CQC, or at least streamlining their processes, should be explored ( see paragraphs 4.1-4.4 ).
· A clear vision for dealing with service failure and effectively managing reconfiguration . Once amended, time must be allowed for full and proper scrutiny of this section of the Bill ( see section 5 ) .
· A commitment to ensure crucial deanery roles and functions – including independent quality assurance and trainee supervision - are found a suitable home, not just in the transition, but in the long term (see section 6).
· A clear and coherent vision for commissioning for ‘uncommon conditions’ (see paragraph 7.1), and more detail on how the NHS Commissioning Board will build commissioning capability at a local level, and how they will involve local secondary care specialists in their local commissioning operations, particularly where they are fulfilling clinical commissioning groups functions.
1.4 It is crucial that the reforms do not distract from – but help services meet - the challenge of 4% [7] to 6.5% [8] efficiency savings.
2. Clinical advice and leadership
2.1 The RCP is supportive of the steps taken to enhance the range of healthcare professionals involved in commissioning, including: the mandatory place for secondary care specialist on the governing board of each clinical commissioning group [9] ; the strengthened duty to obtain specialist advice placed on clinical commissioning groups and the NHS Commissioning Board (clauses 19 and 22); the new duty to involve specialists placed on Monitor (clause 5 2) and the commitment to strengthen clinical networks [10] .
2.2 It will be essential that the interplay between the bodies in the new health service is clear, transparent and coherent. The potential complexity introduced by the new system of bodies with advisory roles (eg clinical networks, clinical senates and NICE), delivery functions (eg foundation trusts, GP practices and local authorities), oversight responsibilities (eg local authorities and the NHS CB), commissioning roles (eg clinical commissioning groups, NHS CB and Public Health England) and regulatory and performance management responsibilities (eg Monitor, CQC and NHS CB) must be minimised. There must be clearly designated statutory roles and responsibilities: the status and authority of the advice and recommendations provided by the new bodies like clinical senates must be made clear; there should be effective and transparent mechanisms for handling conflicts between organisations and functions; and there must be clear lines of accountability across the system.
Secondary care involvement in commissioning
2 . 3 The RCP welcomes the strengthened duty to obtain advice from those with professional expertise in physical, mental and public health place d on clinical commissioning groups and the NHS CB ( clauses 19 and 22 ) and the new duty placed on Monitor ( clause 5 2 ) .
2.4 The RCP, along with other medical royal colleges, supports ‘teams without walls’, an integrated model of care, where professionals from primary and secondary care work together across traditional health boundaries, to manage patients using care pathways designed by local clinicians [11] . We therefore welcome the government’s commitment to : "…include at least one registered nurse and one doctor who is a secondary care specialist [on the governing board of each clinical commissioning group] ." [12]
2.5 However, we do not support the assertion that this secondary care specialist "must not be employed by a local provider " [13] or subsequent statements that they should be from outside the area of retired. The RCP does not agree that appointing a secondary care doctor working within the local area would de facto result in a conflict of interest.
2.6 The purpose of having a secondary care doctor on the governing board of clinical commissioning groups is to bring their experience and knowledge of secondary care and the hospital environment to the table. Hospital doctors across the country want to work closely with their GP colleagues to challenge existing practice where it does not deliver good outcomes for patients, and promote innovation and high quality, joined up services across primary and secondary care. The secondary care doctor on the clinical commissioning group board would be expected to take an overview of commissioning issues generally and would not be limited by their own specialty area of medical practice.
2.7 The RCP’s key messages on the role and appointment of a secondary care doctor to the governing board of clinical commissioning groups are outlined below:
· The secondary care doctor should be appointed to the clinical commissioning group via a competitive appointment process, based on job descriptions and person specifications in the usual way.
· The secondary care doctor would not be a "representative" of any provider or specialism, but would use their particular knowledge and experience of the secondary care environment in order to provide context for commissioning decisions. The model of having a single representative across specialties is not new and exists within the current system - medical directors in trusts, for example.
· The secondary care doctor would be bound by governing board decisions in the usual way and there is no right of veto, and GPs would still be in the majority position on the governing board (unless otherwise decided by the clinical commissioning group) .
· The secondary care appointee should be the best person for the job. They may be appointed from "outside the area", but this should be a decision for the governing board.
· Other clinical advice to commissioning decisions of the governing board would come primarily from clinical networks and senates.
· Reciprocally, a GP representative should be appointed to each foundation/ NHS trust board at a governance level.
2.8 In relation to the conflict of interest ‘issue’, the RCP notes that:
· GPs on the governing board of clinical commissioning groups may also ‘provide’ some secondary care services within their practices. This situation exists to some extent now within PBCs (and PCTs) and is the subject of guidance from the BMA’s General Practice Committee.
· It should be for governing boards to decide the best person for the job, based on local candidates and local needs.
· Board papers, meetings and contracts will be made public.
Clinical networks and senates
2 . 9 The commitment to strengthen clinical networks is welcome. To be effective, this must build on existing good practice – eg for cancer and cardiology. To be successful, there must be local ownership of these networks across primary, secondary, tertiary and social care, and with patients. Although networks should be supported by national frameworks, they must be flexible enough to draw on and enhance local relationships and practice. This local ownership must not be undermined by the fact they are ‘hosted’ by the NHS Commissioning Board.
2 . 10 We support the commitment to involve clinicians of all types at a strategic level in clinical senates. However, as with clinical networks, there must be local ownership of these senates and the possibilities for co-ownership between the NHS Commissioning Board and clinical commissioning groups should therefore be explored.
2.11 The vision for clinical senates is not yet clear, and we await further detail. On the one hand, they provide specialist advice to the NHS Commissioning Board. O n the other, they will provide advice on local strategic issues, i ncluding reconfigurations. Their role, purpose and relationships (eg with clinical commissioning groups, the NHS Commissioning Board, providers, Health and Wellbeing Boards) must be clear. They must not add an additional layer of bureaucracy or make reconfigurations more difficult .
Health and Wellbeing Boards (HWBs)
2.12 The RCP is pleased that the government has provided more clarity on the role and power of Health and Wellbeing Boards ( chapter 2 and clause 22 ), and we welcome that fact HWBs can refer commissioning plans back to clinical commissioning groups if they are not in line with the Joint Strategic Needs Assessment (JSNA) and local health and wellbeing strategy.
2.13 HWBs should involve specialists when assessing needs through the JSNA, when setting priorities in the Health and Wellbeing Strategy, and when considering the extent to which commissioning plans reflect local priorities. The RCP would like secondary care doctors to be given a mandatory place on HWBs (clause 191 ). As a minimum, HWBs must have in place clear mechanisms for obtaining clinical advice.
Medical royal colleges
2.14 The RCP welcomes the acknowledgement in the Future Forum report and government response of the need to involve the medical royal colleges in the work of the NHS CB. The RCP has established national and regional networks which that operate across specialties and a strong record on setting standards and measuring quality (eg through our groundbreaking stroke audit). The RCP can provide advice and support at all levels, and we look forward to this engagement in practice.
2.15 The RCP also welcomes the clear acknowledgment in the Future Forum’s report that organisations release staff for work that contributes to the wider NHS [14] – this would include the extensive work royal colleges do for NHS. We look forward to working with government to ensure this is enshrined in legislation/ guidance.
3. Choice, collaboration and in te gration
Emphasis on quality, collaboration and integration
3.1 The RCP supports the increased emphasis on quality, collaboration and integration, and the removal of references to "promoting competition" (part 3). This goes some way to meeting the concerns RCP expressed in our previous written evidence to the Bill Committee (March 2011), our submission to the Future Forum (May 2011) and our response to the Liberating the NHS consultation. The new duty for clinical commissioning groups to promote integrated services for patients across the NHS and social care is also a step in the right direction (clause 22).
3.2 It is crucial that changes in tone and wording are backed up by a regulatory and pricing system that also values quality and collaboration over competition and choice of provider. Patients encounter many different health professionals along their care pathway, and the RCP looks forward to working with Monitor, the NHS Commissioning Board and our own members and fellows to help implement and develop integration across clinical pathways. The RCP looks forward to working with the NHS Commissioning Board and Monitor to develop guidance on how choice should be applied [15] .
Multiplicity of providers
3.3 The RCP remains concerned about plans for the phased extension of any qualified provider and the potential for this to destabilise existing services and the interdependency between clinical areas. The RCP looks forward to further detail about how this phased extension will happen and the required safeguards.
3.4 The RCP would like clarification on the intention of the new ‘duty as respects variation in provision of health services’ (insertion 12E , clauses 19 and 52). The proposed clause is ambiguous. As noted in the NHS Confederation’s written evidence to this committee, "it is not clear, for example that if services were put out to tender and this resulted in a ‘variation in provision of health services’ either by the public or private sector, whether this would be deemed to fall foul of this clause" [16] .
3.5 T he RCP would also welcome further clarification of how European procurement and competition law would apply within the new system . We would welcome the publication of the legal opinion obtained by the Department of Health and referenced by Professor Steve Field in his evidence to the Health Select Committee (16 June 2011) .
Tariff and quality measures
3.6 At present, the tariff does not cover 40% of NHS services. The RCP would welcome greater clarity on how and when the NHS tariff will be extended to cover a wider range of treatments.
3.7 The RCP welcomes the government’s commitment that Monitor, working with the NHS CB, will set a national tariff that ensures fair payment and reflects clinical complexity [17] . This demands the development of a more sophisticated pricing system, which will be a complex task. It will be necessary to consider the expected timescales and whether current levels of investment are sufficient to achieve this. We welcome the government’s commitment "to undertake a piece of work with the Royal Colleges to identify the procedures most at risk of cherry picking and prioritising work on Payment by Results to ensure that fair prices are set for these procedures from 2013/14 onwards." [18]
3.8 We would not expect measures for quality to be included in the Bill, but we believe work needs to be initiated now to identify quality measures. This will enable intention to measure provider success on the basis of outcomes. Although the identification of quality measures will be an ongoing process involving continuous review, we would expect a suite of quality measures to be ready by April 2013 when consortia and the NHS CB take responsibility for commissioning. Identifying quality measures earlier will help pathfinders, the embryonic NHS CB and the shadow health and wellbeing boards develop. The urgency of this crucial task cannot be underestimated. We offer the RCP’s services in identifying and developing a suite of evidence-based quality measures that can be used to drive up standards.
3.9 The NHS CB is given a mandate to embed national clinical and service standards across the system. As well as standard setting, this should involve measurement and supporting to improve. The RCP’s stroke audit provides an existing model. To promote integrated services (clause 19), the NHS CB should introduce ‘integrated pathways’ (eg for stroke) as part of the NHS Operating Framework on a rolling basis (eg two per year). Clinical commissioning groups’ performance would be measured against this framework. Commissioners’ responsibilities in relation to quality and safety must be clearly stated.
Patient choice
3.10 Choice must be clinically appropriate, and there are clearly occasions where choice and competition are neither the most appropriate nor most desirable mechanism, particularly in the provision of acute services. The RCP’s Patient and Carer Network calls on the government to work closely with patients to define more robustly what is meant by the term ‘patient choice’.
3.11 The RCP agrees that there should be a greater personalisation of services and access to services. Personal health budgets are one tool amongst many and, whilst there may be a limited set of circumstances in which they are useful, on many occasions they are not the most appropriate approach.
3.12 There must be robust analysis of whether the current informatics structure is sufficient to ensure meaningful patient choice and commissioning decisions made on the basis of service quality. The RCP strongly supports investment in the informatics structure to ensure robust clinical data and accurate information on quality and outcomes to enable meaningful choice for patients, commissioners and clinicians.
4. R egulatory bodies
Economics and patient safety
4.1 The relationship between Monitor and the Care Quality Commission (CQC), and CQC’s capacity, remain issues of concern. The RCP would support a more integrated regulatory approach to cooperation, choice, quality and safety. One option would be to merge Monitor and Care Quality Commission (CQC) or at least streamline and harmonise their processes. The current divide between economic regulation and the regulation of care quality could lead to a bureaucratic and disconnected system in which ‘choice’ trumps quality of services and patient care. The RCP believes that:
· The regulator’s remit should focus on minimum quality standards for registration, including financial viability. Its primary focus should be on promoting quality, integration and collaboration.
· Referral to the regulator’s cooperation and competition panel should happen only when it is justified by concerns about standards, outcomes or finance, or proposed service reconfiguration.
· The comprehensiveness of the local health economy and viability of hospitals and other health care services are considered in licensing and regulatory decisions – eg the viability of acute services if a new private provider is licensed to deliver certain non-acute treatments in an area.
4 .2 The power imbalance between economics and patient safety has been identified as a contributing factor to events at Mid Staffordshire Hospital between 2005 and 2009, currently subject to the Francis Inquiry. The Francis Inquiry is looking at commissioning, supervisory and regulatory organisations in relation to their monitoring role at Mid Staffordshire NHS Foundation Trust, and will identify important lessons to be learnt for the future of patient care. It will be crucial that the Bill takes account of the findings from the Inquiry.
4.3 The RCP believes that bringing together Monitor and CQC could help overcome the current separation of decisions about patient safety and quality on the one hand, and financial viability and efficiency on the other. We believe that in the longer term it will also lead to greater efficiency and a reduction in bureaucracy. W e accept that such an amalgamation may take time to embed and may need to be introduced as part of a staged process. However, all new processes must be established with this principle of joint working in mind.
4.4 More could also be done to formalise the how the complaints system feeds into, not just the regulatory process, but also commissioning decisions.
Role of Monitor
4.5 As noted in section 4 above, the RCP welcomes Monitor’s increased emphasis on quality, collaboration and integration, and the removal of references to "promoting competition" (part 3). However, we would welcome a clearer vision of how Monitor will operate in practice, its interplay with CQC, the NHS Commissioning Board, the Competition Commission and the Office of Fair Trading, as well as the application of EU competition and procurement rules.
4.6 The requirement to "promote competition" as has been replaced with a requirement to prevent "anti-competitive behaviour which is against the interests of people who use such services" (clause 52). The RCP echoes the NHS Confederation’s request for "clarification on how this amendment sits alongside the existing principles and rules on co-operation and competition which it proposes to retain – these refer to ‘patients and taxpayers’ interests’ and not just ‘the interests of people who use such services’" [19] .
Conflict resolution
4.7 Steps must be taken to ensure that new system does not introduce an overly complex regulatory regime, with overlapping responsibilities and remits, a duplication of information and inspection requirements and a range of potential conflicts between the interlinked parts of the system.
4.8 For example, both the NHS Commissioning Board and Monitor will play a role in determining the extent to which choice and competition will apply. Likewise, the NHS Cooperation and Competition Panel will continue to exist but will be part of Monitor; the Panel and Monitor may present differing interpretations, which may result in legal action. Within the current Bill there is no dispute resolution procedure outlined for such scenarios: the government must put in place clear and transparent mechanisms for managing and resolving disputes and conflicts between and within the variety of organisations engaged across the new system.
5. Reconfiguration and service failure
5 .1 The RCP understands that chapter 3 of the Bill on service designations and failure will be subject to considerable addition revision . We are disappointed that this part of the Bill is not yet available. The design of the failure regime (not just for whole provider failure, but individual service failure or failure of smaller district general hospitals) is a crucial, and is one of the key elements of the health service requiring review. The system must be able to respond effectively to both instances of failure arising from financial non-viability and failure due to issues of quality and patient safety. Likewise, there must an effective mechanism for ensuring the provision of essential services when these would not be delivered if left to the market. Once this section has been revised, appropriate time must be allowed for full and proper scrutiny.
5.2 The RCP fully supports the involvement of clinicians in reconfiguration decisions and, in this sense, clinical senates are welcome. However, there must be clarity on how reconfiguration decisions will be made in practice. The respective roles of clinical commissioning groups, clinical senates, scrutiny committees, Health and Wellbeing Boards, Monitor and the NHS Commissioning Board must be clarified. Decisions about reconfiguration must consider both clinical and financial criteria, and must not be made more bureaucratic. The engagement of clinicians must be meaningful, not just a tick-box exercise.
6. Education and training
6.1 The RCP welcomes the government’s commitment to giving the Secretary of State an explicit duty to maintain professional education and training as part of the comprehensive health service [20] . We also welcome the government’s commitment that postgraduate deaneries will continue to oversee the training of junior doctors and be given ‘a clear home within the NHS family’ during the transition [21] . However, the RCP emphasises that these crucial deanery roles and functions must be found a suitable home, not just in the transition, but in the long term. These functions include essential quality assurance, delivered with support from the RCP.
6.2 The RCP recommends that postgraduate deaneries are retained with local hosting arrangements (eg in medical schools) and accountable directly to Health Education England (HEE). The RCP also urges national planning of all postgraduate medical education (led by HEE working closely with the medical royal colleges, etc), with the number of trainee placements for specialties set at a national level and some scope for flexibility for local implementation through liaison between deans and providers. The provision of medical education and training should be considered by Monitor when licensing new providers and by clinical commissioning groups in commissioning decisions. This system must be supported by a system of levies and tariffs - applicable across providers - that covers the full costs of training and acts as sufficient incentive to ensure the training of the next generation of doctors.
7. Other issues
Uncommon conditions
7.1 A clear vision on commissioning arrangements for ‘uncommon conditions’ is required. Facilities such as a trauma centres, or severe burns units, and conditions such as immunodeficiency, haematology, and haemophilia require a critical mass to be cost effective and are therefore currently commissioned on a regional basis. Clinical commissioning groups and the NHS CB will need to work together to commission theses services.
Public health
7.2 All specialists in public health should be required to be registered and appointed by statutory appointments committees. Training in public health should continue to be provided alongside that for other medical specialties with similar arrangements for recruitment and quality assurance. Directors of public health (DPH) should be required to be trained and registered to specialist level in public health.
Accountability
7.3 The RCP supports the steps taken to strengthen the transparency of the governance of clinical commissioning groups and foundation trusts. Nolan principles should apply equally to the NHS CB (and Health and Wellbeing Boards), which should also meet in public and be required to publish its papers.
Patient and public involvement
7.4 The RCP supports efforts to strengthen the involvement of patients and the public, including the additional requirements placed on Monitor and around the membership of Healthwatch organisations. However, there should be better mechanisms in place to measure and assess the effectiveness of Healthwatch organisations, and clear routes by which patients and the public can raise concerns about the operation of their local organisation.
July 2011
[1] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 19, paragraph 3.38 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[2] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 17, paragraph 3.20 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[3] Department of Health. Government changes in response to the Future Forum report . June 2011. Page 2 . ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127578.pdf )
[4] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 50, paragraph 6.1 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[5] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 50, paragraph 6.15 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[6] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 48, paragraph 5.42 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[7] Department of Health target over five years, December 2010
[8] Monitor target for 2011-2012, April 2011
[9] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 19, paragraph 3.38 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[10] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 17, paragraph 3.20 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[10]
[11] Royal College of Physicians, Royal College of General Practitioners and Royal College of Paediatrics and Child health. Teams without Walls. The value of medical innovation and leadership . London, 2008
[12] Department of Health. Government changes in response to the Future Forum report . June 2011. Page 3. ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127578.pdf )
[13] Department of Health. Government changes in response to the Future Forum report . June 2011. Page 3. ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127578.pdf )
[14] NHS Future Forum. Clinical advice and leadership: A report from the NHS Future Forum . June 2011. Page 17, paragraph 3.25 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127542.pdf )
[15] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 45, paragraph 5.20 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[16] NHS Confederation. Health and Social Care Bill: Public Bill Committee written evidence . June 2011. Page 14, paragraph 8.8 ( http://www.nhsconfed.org/Documents/Health%20and%20Social%20Care%20Bill%20Confed%20Cttee%20Written%20Ev%20FINAL%20FOR%20WEBSITE.pdf )
[17] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 48, paragraph 5.42 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[18] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 48, paragraph 5.42 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[19] NHS Confederation. Health and Social Care Bill: Public Bill Committee written evidence . June 2011. Page 14, paragraph 8.8 ( http://www.nhsconfed.org/Documents/Health%20and%20Social%20Care%20Bill%20Confed%20Cttee%20Written%20Ev%20FINAL%20FOR%20WEBSITE.pdf )
[20] Department of Health. Government response to the NHS Future Forum report . June 2011. Page 50, paragraph 6.1 ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf )
[21] Department of Health. Government changes in response to the Future Forum report . June 2011. Page 10. ( http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127578.pdf )