6 Service reconfigurations
102. The Nicholson Challenge requires the NHS to
deliver 4% efficiency gain in each of the next four years. Although
some of this efficiency is expected to reflect pay restraint among
the staff of the NHS (if NHS earnings rise by 1% less than inflation
in a year, the economic result is a 1% improvement in efficiency),
the great majority of the efficiency gain will be the result of
changes in the delivery of care.
103. This requirement for change is not simply driven
by a requirement to achieve cost savings—it also reflects
the changing nature of the demand for healthcare. As demand increases
from elderly patients with long term complex conditions, it is
important that the pattern of clinical care reflects their requirement
for care which integrates primary, community and acute care into
coordinated pathways which achieve early and effective intervention
and avoid the tendency for patients to be referred around the
system for uncoordinated episodes of care which are both expensive
and poor quality.
104. Although change is a fact of life and the model
of NHS care delivery needs to be constantly changing to keep up
to date, change proposals are often strongly contested as a result
of community and professional loyalty to local structures and
institutions. Those who make the case for change in such circumstances
are rightly required to make their case on the basis of evidence,
and need to be able to sustain these arguments in discussion with
local stakeholders.
105. The configuration of hospital and community
health services is currently the responsibility of the local NHS;
that is, PCTs as commissioners and SHAs as the local representatives
of the DH. However, the DH has developed policies and guidance
on which types of services should be provided in which settings
in an effort to improve cost-effectiveness, quality and access
in the health service.
106. Since 2002, local authority Health Overview
and Scrutiny Committees (HOSCs) have had the power to refer decisions
by the NHS to the Secretary of State for Health if they consider
either that the public consultation process was inadequate or
that the proposed change is not in the interests of the local
area. In recent years the Secretary of State has, as a matter
of course, sought advice on contested reconfigurations from the
Independent Reconfiguration Panel, which is set up as a non-departmental
public body. Before referral is considered all options for local
resolution have to be explored.
107. In May 2010, the Coalition Agreement stated
that "We will stop the centrally dictated closure of A&E
and maternity wards, so that people have better access to local
services".[90] The
Secretary of State subsequently suspended the planned far-reaching
reconfiguration of services in London, pending a review, and said
that such changes would in future need to be signed off by GPs.[91]
108. The revision to the Operating Framework for
2010-11, published in June 2010, imposed a moratorium on service
reconfigurations, with any proposals now required to meet four
tests before proceeding. These relate to:
- support from GP commissioners;
- public and patient engagement;
- clarity on clinical evidence; and
- consistency with patient choice.[92]
109. The Command Paper says that the power to refer
significant service reconfiguration decisions to the NHS Commissioning
Board (and in exceptional cases to the Secretary of State) will
apply in certain specific circumstances only. When deciding to
refer services to the Board or Secretary of State, the Local Authority
must in future:
[…] first take account of a wider range
of considerations including the duties on NHS commissioners to
improve the safety, effectiveness and patient experience of services,
and the need for services to be financially sustainable.[93]
This power should be exercised by a full meeting
of the Council and not by the HOSC on its own.[94]
Under the Government's proposals the power of referral will also
only apply to designated services.[95]
110. The Committee believes that the ability to
manage service reconfiguration (i.e. keep service delivery up
to date and in line with current best value and best practice)
is fundamental to good stewardship of public funds and the delivery
of high quality, good value healthcare. In particular it believes
it is essential that local commissioning bodies are able to introduce
changes to clinical care in their communities which reflect the
changing needs of their patient populations.
111. The Committee also believes that the unprecedented
scale of efficiency gain required by the Nicholson Challenge puts
a particular emphasis on the ability of commissioners to facilitate
necessary service reconfigurations.
112. The Committee is mindful that this unprecedented
requirement to manage a process of change in the clinical model
of the NHS will require effort and commitment from NHS managers
whose work we believe should be valued, alongside the work of
the clinical staff of the NHS. The Committee regrets the fact
that the work of NHS management is sometimes the subject of unjustified
populist criticism.
113. The Committee believes the recommendations
it has made elsewhere in this report for broader clinical and
non-clinical engagement in the commissioning process are fundamental
to the delivery of necessary service reconfigurations.
90 HM Government, Coalition Agreement, 11 May 2010,
p. 24 Back
91
"Lansley confirms London reconfiguration halted", Health
Service Journal website, 19 May 2010, www.hsj.co.uk Back
92
Department of Health, Revision to the Operating Framework for
the NHS in England 2010/11, 21 June 2010, pp 8-9 Back
93
Cm 7993, para 5.44 Back
94
Cm 7993, para 5.43 Back
95
Ibid., para 5.41 Back
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