Conclusions and recommendations
Current weaknesses in NHS Commissioning
1. The
starting point of our inquiry has been our predecessors' findings
on the significant shortcomings of the current arrangements for
commissioning in the NHS. Like the previous Committee, we are
motivated by the desire to deliver high quality care to patients
and good value to the taxpayer; and we see the need for an effective
instrument to drive innovation and quality if these objectives
are to be met. It is from this perspective that we have sought
to ask "How do we make commissioning effective?" and
reached our conclusions about the Government's proposals. (Paragraph
22)
The White Paper proposals
2. The
Committee accepts that it follows from the unprecedented scale
of the Nicholson Challenge, and the widespread recognition of
the weakness of existing commissioning structures in the NHS,
that action to enhance the effectiveness of NHS commissioning
is essential if the NHS is to deliver the pace of change implicit
in the Nicholson Challenge — and therefore in the Comprehensive
Spending Review. It is against this immediate challenge that the
Committee believes the White Paper process should be judged. (Paragraph
31)
3. There was a significant
policy shift between the Coalition Programme, published on 20
May 2010, and the White Paper, published on 12 July 2010. The
Coalition Programme anticipated an evolution of existing institutions;
the White Paper announced significant institutional upheaval.
The Committee does not believe that this change of policy has
yet been sufficiently explained given the costs and uncertainties
generated by the process. (Paragraph 36)
4. At a time when
the primacy of the Nicholson Challenge should have focused the
minds of NHS senior management on the need to secure unprecedented
efficiency gains, we have been presented with evidence of widespread
uncertainty about the Government's intentions. In addition to
its inevitable effect on management morale, the Committee believes
this will have had the effect of blunting the ability of the NHS
to respond to the Nicholson Challenge (Paragraph 42)
5. In the Committee's
view the policy described in the White Paper introduces significant
institutional upheaval into the NHS, without significantly changing
its policy objectives. The Committee broadly shares the policy
objectives so it therefore welcomes the fact that these are substantially
unchanged. It does not believe however that the approach adopted
by the Government represents the most efficient way of delivering
those objectives. (Paragraph 43)
6. Like most observers,
the Committee was surprised by the change of approach between
the Coalition Programme and the White Paper. The White Paper proposes
a disruptive reorganisation of the institutional structure of
the NHS which was subject to little prior discussion and not foreshadowed
in the Coalition Programme. (Paragraph 44)
7. While such a "surprise"
approach is not necessarily wrong, it does increase the level
of risk involved in policy implementation. It allows less time
to understand complexity and detail, and less time to develop
and explain policy; and it leads to less understanding of objectives
by staff, patients and local communities. (Paragraph 46)
8. A successful "surprise"
strategy requires clarity and planning, but the Committee does
not think that the White Paper reflected these qualities. There
appears to have been insufficient detail about methods and structures
during the transitional phase. The failure to plan for the transition
is a particular concern in the current financial context. The
Nicholson Challenge was already a high-risk strategy and the White
Paper increased the level of risk considerably without setting
out a credible plan for mitigating that risk. (Paragraph 47)
Events since the White Paper
9. The
Committee acknowledges the development of PCT clusters as a pragmatic
response to the situation that developed following the publication
of the White Paper. (Paragraph 64)
10. The Committee
welcomes the fact that the Government has acted promptly to fill
the post. It believes that this decision represents an important
step in developing a commissioning function which will allow the
NHS to achieve the efficiency gains which are required during
the lifetime of this Parliament. (Paragraph 65)
11. The formation
of clusters must not, however, serve as merely a short-term expedient.
The way that the clusters are constituted needs to be consistent
with long-term objectives for the NHS. (Paragraph 66)
12. Although the Committee
welcomes the establishment of PCT clusters it remains concerned
that the relatively protracted timescale is undermining the effectiveness
of the NHS response to the Nicholson Challenge. The Committee
believes it cannot be too often repeated that the commitment to
generate 4% efficiency gains four years running is extremely challenging
and it believes there must be a clear and effective management
every step of the way if the NHS is to have a realistic chance
of meeting the objectives it has been set. (Paragraph 68)
13. The Committee
recommends that PCT clusters should be in place by 1 April 2011,
in order to ensure that they are able to manage the delivery of
the Nicholson Challenge effectively. The Committee believes it
is important that clusters "own" the change process;
as the focus for financial control, they should be responsible
for the development of commissioning in their area. (Paragraph
69)
14. The development
of Pathfinder commissioning consortia represents a further important
step in clarifying future commissioning responsibility. The Committee
remains very concerned however that a timescale which involves
a further 15 month delay in establishing full coverage represents
a serious risk to the quality of commissioning decisions during
that period. It means that a total of two years will have elapsed
since the formation of the Government during which responsibility
for managing an unprecedented efficiency challenge will have been
unnecessarily weakened and diffused. (Paragraph 73)
15. Changes have taken
place in the management structures of the NHS in advance of Parliament
having the opportunity to debate and approve them. We think this
is unsatisfactory. However, given that these changes have been
made, it is important that they are put in place as quickly as
possible in order to ensure that the system is managed effectively.
(Paragraph 74)
16. The Committee
acknowledges that delivery of the efficiency gains required by
the Nicholson Challenge will require some difficult decisions
about service levels. It believes, however, that this unavoidable
prospect underlines the importance of effective commissioning
structures that are able to make decisions which reflect defensible
clinical and managerial priorities. It is concerned that there
appears to be a growing perception that the emerging pattern of
service developments reflects management instability and weakness
in the organisations on which this responsibility rests. (Paragraph
77)
17. The uncertainties
described in chapter 4 will almost certainly have added both to
the direct costs of transition, as well as the indirect costs
incurred as a result of poor decision making by Commissioners.
We welcome the Secretary of State's commitment to publish a full
Impact Assessment at the time of publication of the forthcoming
Health Bill and expect that it will include a full assessment
of the transition costs likely to be incurred as a result of the
White Paper proposals. (Paragraph 84)
Priorities for strengthening commissioning
18. We
intend to examine further the assurance regime which it is proposed
to establish around commissioning consortia in order to satisfy
itself that the NHS Commissioning Board has sufficient authority
to deliver its objectives defined in its Commissioning Outcomes
Framework. (Paragraph 89)
19. We intend to review
the arrangements proposed in the Bill for defining the lines of
accountability between the NHS Commissioning Board, the Department
of Health and the Secretary of State to prevent potential future
conflicts arising. (Paragraph 91)
20. The Committee
endorses the principle of clinical engagement in commissioning.
We heard evidence from doctors about how they had already become
involved in commissioning and they welcomed the emphasis on clinical
engagement in the White Paper. (Paragraph 95)
21. The Committee
believes it is essential for clinical engagement in commissioning
to draw from as wide a pool of practitioners as is possible in
order to ensure that it delivers maximum benefits to patients.
GPs have an essential role to play as the catalyst of this process,
and under the terms of the Government's changes they, through
the commissioning consortia, will have the statutory responsibility
for commissioning. They should, however, be seen as generalists
who draw on specialist knowledge when required, not as the ultimate
arbiters of all commissioning decisions. The Committee therefore
intends to review the arrangements proposed for integrating the
full range of clinical expertise into the commissioning process.
(Paragraph 96)
22. Real or otherwise,
the perception of a potential legal challenge of commissioning
decisions may be sufficient to deter GPs from engaging their secondary
care colleagues in pathway redesign. We recommend that the Government
addresses these concerns by clarifying the law on this issue.
(Paragraph 101)
23. The Committee
agrees that local engagement with the commissioning of primary
care services is important and therefore welcomes this development.
The potential conflict of interest between consortia and local
primary care providers does however remain. We therefore intend
to review the arrangements proposed in the bill for the commissioning
of primary care services. (Paragraph 104)
24. We intend to review
the arrangements proposed in the Bill to enable commissioning
consortia to address these issues effectively; this will include
a review of the ability of the new system to encourage commissioning
consortia to cooperate in achieving the benefits to patients which
may be available from major service reconfiguration. (Paragraph
110)
25. The Committee
intends to review the arrangements proposed in the Bill for enabling
consortia to reconcile this potential conflict by enhancing patient
choice at the same time as delivering the consortium's clinical
and financial priorities. (Paragraph 115)
26. In the light of
these concerns, we recommend that the Shadow NHS Commissioning
Board publishes its proposed funding formulae for consortia as
a matter of urgency. (Paragraph 116)
27. The Committee
does not find the current stance on patient and public engagement
in commissioning persuasive. The National Health Service uses
taxpayers' resources to deliver a service in which a high proportion
of citizens take a close interest both as taxpayers and actual
or potential patients. While the Department may be right to point
out that there is no special virtue in uniformity of structure,
the Committee regards the principle that there should be greater
accountability by commissioners for their commissioning decisions
as important. We therefore intend to review the arrangements for
local accountability proposed in the Bill. (Paragraph 118)
28. The Committee
urges the Government to clarify the management allowance arrangements
as a matter of urgency including when the higher figures will
be phased in, as this will have a significant impact on commissioning
capacity of consortia. (Paragraph 121)
29. The Government
must support consortia and existing commissioning organisations
to form clear and credible plans for debt eradication and for
tackling structural deficits within their local health economy.
The Committee intends to further review this issue in its further
work. (Paragraph 123)
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