Commissioning: further issues - Health Committee Contents

Written evidence from the Department of Health (CFI 01)


1.    On 25 January 2011 the House of Commons Health Committee announced a follow-up inquiry into commissioning, taking as its terms of reference 10 points from its Third Report of Session 2010-11, Commissioning.

2.    On 31 January the Department published a Command Paper response to the Committee's Third Report commenting in detail on each of the Committee's recommendations, including those which form the terms of reference for the follow-up inquiry.

3.    This evidence provides further information on the Committee's topics. It should be read in conjunction with the Department's response to the Committee's Third Report, as it builds on our earlier response to these points.

4.    As the Health and Social Care Bill was introduced after the Committee published its Third Session Report, this submission of evidence provides a suitable opportunity for the Department to demonstrate how the Bill provides a coherent framework across the NHS and social care for a new approach to commissioning that will focus on empowering patients, carers and the public; on achieving better outcomes; and on promoting greater freedom for clinicians to work collaboratively to shape services.


5.    The House of Commons Health Committee's Third Report of Session 2010-11, Commissioning, summarised their inquiry as "How do we make commissioning effective?" In articulating our proposals, we have always identified effective commissioning as one of the cornerstones for improving the quality of patient care and the outcomes achieved by the NHS. We have also been clear that commissioning needs to be clinically led, that it needs to be more directly connected to patients' and clinicians' day-to-day experiences of the NHS, and that responsibility for commissioning needs to be aligned with existing responsibilities for coordinating patient care and making patient referrals. It is these principles that are at the heart of our proposals for GP-led commissioning.

6.    We would draw the Committee's attention to the consistency with which this message has been given in the successive statements of policy since the election, and how the proposals have been developed by an ordered process of consultation, engagement and discussion.

7.    The Coalition: our programme for government (May 2010)[1] said that GPs should be commissioners of care. Equity and Excellence: Liberating the NHS (July 2010)[2] reaffirmed the Coalition Government's commitment to devolve responsibility for commissioning most NHS services to groups of GP practices. As our response to the Committee's Third Report emphasised, rather than representing a "significant policy shift" or "change of approach", the White Paper proposals were foreshadowed in principle by both the Conservative and Liberal Democrat health manifestos, and represented a sensible development of the Coalition programme.[3]

8.    The consultation documents accompanying the White Paper invited views from professionals, from the public and from other organisations to help shape policy development. Liberating the NHS: commissioning for patients (July 2010)[4] sought views on the proposed framework for GP consortia and the NHS Commissioning Board. Transparency in outcomes: a framework for the NHS (July 2010)[5] proposed a robust framework of transparency and accountability for the NHS, including an NHS Outcomes Framework to allow the NHS Commissioning Board to be held to account for improvements in the quality of NHS care and healthcare outcomes. Liberating the NHS: local democratic legitimacy in health (July 2010)[6] sought views on proposals for patients and local communities to get a powerful voice through local HealthWatch and local Health and Well-being boards. Local authorities will have a major new role in promoting joined-up commissioning of NHS, public health and social care and they will also regain responsibility for local health improvement.

9.    We have maintained the consistency of purpose articulated in the White Paper. Our proposals constitute a credible programme of modernisation, developed through extensive engagement with the public and with stakeholders across health and social care. The Government's response to the consultations - Liberating the NHS: legislative framework and next steps - set out how we were adapting some aspects of these proposals to reflect the views raised during the consultation and engagement process, including the announcement of the GP consortia pathfinder programme to allow early testing of the principles of GP-led commissioning.[7]

10.  This process of planning and public engagement culminated in the introduction to Parliament on 19 January of the Health and Social Care Bill 2011,[8] which sets out the proposed legislative framework for the White Paper reforms including the establishment of commissioning consortia and the NHS Commissioning Board. On 31 January, the Commons agreed that the Bill should proceed to Second Reading, and it is currently under the scrutiny of the Health and Social Care Public Bill Committee.

11.  While the Bill is subject to Parliamentary scrutiny, the process of engagement and testing continues, in particular through the GP consortia pathfinder programme which now encompasses 141 pathfinders covering over half the population. The first cohort of pathfinders came together at a national event on 26 January to help shape the pathfinder programme and discuss how best to use the programme to support effective consortia development.

12.  The Department launched a pathfinder learning network at the 26 January event. This is an online resource that will complement the support given to pathfinders by primary care trusts (PCTs) and strategic health authorities (SHAs). It will help spread pathfinder learning through the wider GP community and accelerate the development of GP commissioning by facilitating engagement and organisational development. It will also help design and test the approaches that the NHS Commissioning Board will use to authorise consortia and hold them to account for outcomes. This network will be supported by national primary care stakeholders to help spread learning across the wider GP community, facilitate connections between pathfinders working on similar areas, and support the development of clinical leaders. The network is supporting a systematic approach to maximise and share learning, with—for instance—specific pathfinders working on areas such as cancer services, long term conditions, mental health and involving patients and the public.

13.  In order to support a managed transition to the new commissioning arrangements, the Department is establishing clusters of PCTs for the transitional period 2011-12 and 2012-13. Clusters will sustain PCT capacity and accountability during this transitional period, ensure continued pace in the delivery of quality and productivity improvements under the QIPP programme, support the development of GP consortia and ensure that consortia have access to high-quality and cost-efficient forms of commissioning support.

14.  On 31 January, Sir David Nicholson wrote to the NHS with guidance on establishing PCT clusters by June 2011 and on their functions during 2011-12 and 2012-13.[9] Each SHA has been asked to ensure that by the beginning of June 2011 sensible clusters of PCTs exist, each with a single Chief Executive, with responsibility for the development of the commissioning functions across the whole cluster, supported by a single executive team.

15.  The cluster model will support pathfinders in taking on increasing commissioning responsibilities on behalf of PCTs during the transitional period, with a number of staff from the clusters assigned to consortia to work on their behalf. This will support emerging consortia in developing to the point where they are ready to be established as statutory organisations and to commission services in their own right. It will also ensure that emerging consortia play a central role in shaping local responses to the QIPP challenge and in ensuring that these plans reflect the needs of local patients and communities.


16.  Each point raised by the Committee is given below in italics, numbered 1-10; the reference in brackets is to the relevant paragraph in the Third Report of Session 2010-11, Volume I: Report, together with formal minutes.

1.  We intend to examine further the assurance regime which it is proposed to establish around commissioning consortia in order to satisfy ourselves that the NHS Commissioning Board has sufficient authority to deliver its objectives defined in its Commissioning Outcomes Framework. (Paragraph 89)

17.  The Health and Social Care Bill 2011 creates a clear framework that will enable the Board to deliver its objectives (as reflected in its Mandate and the NHS Outcomes Framework) through the initial process of authorising consortia, through the subsequent framework for annual assessment of consortia (including the Commissioning Outcomes Framework) and through a range of powers to intervene to support consortia in defined circumstances.


18.  The Board must, before granting an application for establishment as a consortium, satisfy itself as to a number of key tests, including the ability of the proposed consortium to discharge its statutory functions. This will mean satisfying itself that the consortium has appropriate arrangements in place to commission healthcare for those patients for whom it is responsible, including appropriate arrangements for managing financial resources, promoting quality improvement, involving patients and the public, working in partnership with local government, and securing expert advice from other health professionals.

19.  The Board will also need to satisfy itself that the area specified in the constitution of the consortium is appropriate (eg for the purposes of commissioning emergency care and commissioning healthcare for patients not registered with any GP practice); that its constitution complies with the requirements of the legislation and is otherwise appropriate; that it has the right membership (eg each of its members will be providers of primary medical services on the date of establishment); and that it would be appropriate for the Board to appoint as the accountable officer the person nominated for this role by the consortium.


20.  During 2011-12, the shadow NHS Commissioning Board, supported by NICE, will start to develop a Commissioning Outcomes Framework. This will enable the Board to hold consortia to account for the quality of the services that they commission, the clinical and patient experience outcomes achieved from those services, and their contribution to reducing health inequalities. The Framework will ensure that there is clear, publicly available information on the quality of healthcare services commissioned by consortia and will support Health and Well-being Boards in understanding local healthcare needs and shaping strategic priorities for improvements in health and well-being. The Department will publish a discussion document shortly, seeking more detailed views on possible features of the Framework.

21.  The Commissioning Outcomes Framework will form part of a wider accountability framework that will also enable the Board to hold consortia to account for how effectively they perform their other statutory duties of consortia, including their duties relating to management of financial resources, involvement of patients and the public in commissioning, promoting patient and carer involvement in their own healthcare, partnership with local authorities and securing expert advice from other health professionals. There is likely to be an important role for local authorities, Health and Well-being Boards, local HealthWatch and other health and care professionals in feeding into this annual assessment.

22.  A significant element of the Board's oversight of consortia performance will be to ensure their financial stability. Consortia will be required to maintain annually audited accounts, and to provide financial and other data to the Board as required, to allow in-year monitoring against budgetary controls. The Board will have the power to support consortia in developing appropriate risk-sharing arrangements, for instance pooling resources with other consortia or local authorities or with the Board itself.

23.  Each consortium will have to produce an annual commissioning plan, which sets out how it intends to fulfil its responsibilities to its patients, particularly in regard to improving quality and outcomes and discharging its financial duties. The plan must take account of the relevant local joint health and well-being strategy (or strategies). Each consortium will also produce an annual report, which will further support accountability.

24.  The Bill gives the Board the power to make an additional payment to a consortium if it considers the consortium has performed well in the previous year. This "quality premium" will enable the Board to provide appropriate incentives and rewards for consortia that achieve high-quality outcomes for patients within the resources available to them. During 2011-12, the shadow NHS Commissioning Board will start to work with pathfinders and with patient and professional groups to design these arrangements.


25.  The Bill gives the Board the powers to intervene to support consortia where there is evidence that a consortium is failing to fulfil its statutory duties or there is a significant risk that it will fail to do so. The Bill will enable the Board to apply a range of proportionate measures to intervene and support consortia, depending on the nature of the problem or risk. Depending on the circumstances, this could include directing a consortium to fulfil its functions in a different way, arranging for another consortium or the Board itself to undertake some functions for a time-limited period, or appointing a new Accountable Officer. Where necessary, the Board will also be able to vary the constitution of a consortium, or—after consultation with those concerned and with relevant local authorities—to dissolve a consortium and make other arrangements for the GP practices in that consortium.

26.  The pathfinder programme will enable the Board to test these arrangements with emerging consortia and with other stakeholders to ensure that they provide an effective framework to anticipate and put right potential problems at a sufficiently early stage, whilst providing the freedom for well-performing consortia to decide for themselves how best to commission services to improve outcomes for patients.

2.  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)

27.  The Secretary of State will retain the duty to promote a comprehensive health service; and will be responsible for setting the strategic direction and legislative framework for the NHS. The Secretary of State will consult upon and set the Mandate for the NHS Commissioning Board (issued on a three-year basis with an annual update) and will hold the Board to account against it. The Mandate will include the objectives and requirements for the Board during that period. Each year the Government will report publicly on the performance of the health service. This will give the public and Parliament a clear basis for holding the Government to account. In addition, Parliament will continue to be able to scrutinise decisions and actions in the normal way.

28.  The Bill maintains the overarching duty of the Secretary of State, which dates from the original NHS Act of 1946, to promote, "a comprehensive health service designed to secure improvement in the physical and mental health of the people of England, and in the prevention, diagnosis and treatment of illness". It distinguishes for the first time between healthcare and public health, laying the way for the new public health system. It also sets clear constraints on the Secretary of State's ability to intervene in the NHS.

29.  Alongside the Mandate, the Bill proposes a power for the Secretary of State to make "standing rules" through regulations, setting legal requirements for commissioners. These would, for example, provide the basis for the continuation of certain rights in the NHS Constitution that currently depend on directions to PCTs and would also give Ministers power to ensure compliance with European Union (EU) obligations.

30.  The Bill proposes a limited list of areas where standing rules can be made. Balancing the need for future flexibility with proper Parliamentary scrutiny, the Secretary of State would be able to make new standing rules in additional areas only through regulations made by the affirmative resolution procedure. Furthermore, the expectation is that the Secretary of State would make changes to the standing rules only at the same time as the Mandate is set; where that is not the case, the Secretary of State would be obliged to lay a report in Parliament explaining why.

31.  The overall framework proposed in the Bill is designed to give the NHS greater freedoms, improve transparency and help prevent political micro-management. The powers of the Secretary of State would be constrained and made more transparent. At the same time, political accountability to Parliament would be strengthened. This is illustrated by the use of the affirmative resolution procedure to scrutinise the Secretary of State's powers in a number of areas, including the power to confer additional functions on the Board and to extend the existence of new Special Health Authorities beyond three years.

3.  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)

32.  We agree that effective commissioning will rely critically upon engagement and collaboration with a wide range of health and care professionals. Our proposals to root most healthcare commissioning responsibilities in the system of general practice are designed to build on the holistic overview that GPs and other practice staff have of patients' needs and on the existing role of general practice in coordination and continuity of care, making referrals to more specialist services, and acting as patients' advocates. Through these existing roles, GPs, nurses and other practice staff already have a network of local relationships with other health and care teams and professionals. We agree that it will be essential for them to build on and strengthen these networks so that commissioning draws on their collective clinical expertise and experience and improves clinical collaboration. This will mean commissioning that is not only clinically led, but also informed by an expert, multi-professional view of local health needs and solutions.

33.  One of the key aims of the White Paper and the Bill is to liberate clinicians from the burdens which previous governments have imposed on how services are planned and provided. The Bill places a statutory duty on consortia to obtain appropriate advice from health experts, but does not seek to prescribe precisely how they meet this duty. We consider that a more prescriptive approach would risk tokenism and would not achieve the meaningful engagement and collaboration that will underpin successful commissioning.

34.  The arrangements for authorisation, accountability and (where necessary) intervention described above will, however, enable the NHS Commissioning Board to satisfy itself that consortia have appropriate arrangements in place to involve other healthcare professionals and, if necessary, to work with consortia to support them in improving these arrangements if there were evidence that insufficient or ineffective clinical engagement were preventing a consortium for fulfilling its duties effectively.

35.  We envisage, in particular, that the authorisation process—and the wider developmental process for emerging consortia of which it will be part—will help ensure that consortia develop effective relationships with a range of health and care professionals. We also envisage that the ongoing accountability framework for consortia will allow health and care professionals to provide their own views of how effectively consortia are developing multi-professional engagement and for this to feed into the Board's annual assessment of consortia.

4.  Although the Committee understands the value of the separation of the commissioner and provider functions it believes it is important that this function separation is not allowed to obstruct the development of high quality and cost effective service solutions. We therefore intend to review the arrangements proposed in the Bill for reconciling these conflicts. (Paragraph 102)

36.  We regard it as a false dichotomy to suggest that the separation of commissioner and provider functions is in conflict with the development of high quality and cost-effective service solutions. The purpose of commissioning is to understand patients' healthcare needs, to ensure that patients have access to services that meet those needs, and to monitor the quality of those services. It has always been—and will remain—an integral part of good commissioning to work collaboratively with providers to review services and pathways of care and identify how to improve quality and cost-efficiency.

37.  The Government fully supports the development of more integrated care, for example for cancer services, emergency care, and rehabilitation and recovery. Clinically-led commissioning will support this. Commissioners will be able to "bundle" services together across a pathway where this makes most sense.

38.  There have been a number of suggestions that collaborating with providers or developing more integrated care would be regarded as anti-competitive. This is simply not the case. Collaboration with providers and greater integration of care are, on the contrary, good commissioning practice.

39.  Where services are commissioned through competitive tender, commissioners will need, as now, to ensure that services are specified in a way that does not give an unfair advantage to established providers. But, as now, commissioners will be expected to work with a range of providers and practitioners to develop innovative service models that contribute towards improvements in quality and productivity. This expectation is set out in existing DH procurement guidance. We expect it to remain central to the guidance developed in due course by the NHS Commissioning Board to support consortia in procuring services fairly and transparently and in ways that promote competition in the interests of patients.

5.  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)

40.  We welcome the Committee's support for greater local engagement in the commissioning of primary care services. We can reassure the Committee that GP consortia will not, however, have delegated responsibility for basic commissioning decisions such as deciding which providers should receive contracts for primary care services or dealing with any breaches of contract. These commissioning decisions will always be carried out by the NHS Commissioning Board.

41.  The role of consortia will be to assist and support the Board in securing continuous improvement in the quality of primary care services. This will allow the Board to draw on the relationships between GP practices within a consortium and for the members of consortia to take a collaborative approach to raising standards in primary care. There is a considerable appetite amongst consortia pathfinders to explore how this relationship will work, building on existing good practice in peer-driven quality improvement.

42.  The NHS Commissioning Board could also arrange for consortia to commission some enhanced primary care services on its behalf, subject to appropriate safeguards to ensure transparency and fairness.

43.  Whilst the NHS Commissioning Board will commission primary medical care services (under the GP contract), there are a range of other community-based services that consortia could in principle commission from GP practices. We agree that it will be important to ensure that consortia have good systems to prevent conflicts of interest when practices are bidding to provide services, or where they wish to provide services that are subject to an "any willing provider" model (i.e. where patients choose from which provider they wish to receive a referral service). These arrangements can build on existing good practice.

44.  Consortia will be required to set out their arrangements for dealing with conflicts of interest in their constitution. GPs are in addition bound by GMC guidelines on conflicts of interest and by the requirements of Good Medical Practice.

45.  The Bill provides that the Secretary of State may make regulations that impose requirements on the NHS Commissioning Board and consortia to ensure that they adhere to good procurement practice, protect and promote patient choice and promote competition. The regulations could include a power for Monitor to investigate complaints that consortia have not met the requirements of these regulations, although we would expect that the Board would aim to resolve complaints in the first instance. GP consortia and the NHS Commissioning Board will be required to act transparently and non-discriminatorily in their commissioning activities.

46.  The NHS Commissioning Board will develop guidance to help consortia ensure that they have good governance arrangements, including transparency of decision-making and clear procedures for declaring interests.

47.  Through a series of engagement events and working groups with pathfinders and other stakeholders, we are developing scenarios and testing safeguards to inform the approach of the shadow NHS Commissioning Board and Monitor.

6.  The commissioning of services that either work across [health and social care] boundaries, or are intimately linked is therefore an issue to which the Committee attaches great importance, and we intend to review the effectiveness of the structures proposed in the Bill which are designed to safeguard co-operative arrangements which already exist and promote the development of new ones. (Paragraph 107)

48.  The Health and Social Care Bill provides for a Health and Well-being Board to be established for every upper tier local authority. We propose that these will be established by April 2013, although we have invited all local authorities to become part of an early implementer programme to explore the potential of Health and Well-being Boards. The Boards will increase the influence of local people in shaping services through democratically elected councillors and local HealthWatch. They will bring together commissioners from the NHS, public health and social care to agree priorities and commissioning strategies and provide the opportunity to achieve greater integration of services and joint working.

49.  The proposed legislation governing Health and Well-being Boards will provide a consistent, yet flexible framework. We expect this to strengthen relationships between the different organisations represented as people can come together to discuss issues in an open manner, breaking down organisational barriers, misconceptions and historical rivalries. They can consider the total resources available and come to a joint understanding as to how resources can best be deployed to secure better health and well-being outcomes for local communities, better quality of care and better value for taxpayers.

50.  Building on this platform, local authorities and GP consortia will have a duty to undertake and publish joint strategic needs assessments (JSNAs). This duty will have to be discharged through the Health and Well-being Boards. PCTs and local authorities have been under a statutory duty to undertake a JSNA since 2008. Liberating the NHS—Legislative Framework and Next Steps; Healthy Lives, Healthy People and A vision for adult social care: Capable Communities and Active Citizens[10] set out the Government's ambition for an enhanced role for JSNAs that will sit at the heart of local action to improve the outcomes from NHS, social care and public health services. The Bill further strengthens this duty by requiring JSNAs to consider future, as well as current, needs.

51.  Having identified local needs through the JSNA, local authorities and GP consortia will be required to develop a joint health and well-being strategy for addressing these needs. This will span the NHS, social care and public health, and could potentially consider commissioning of services that cover wider determinants of health such as housing or education.

52.  Local authorities, GP consortia and the NHS Commissioning Board will each have to have regard to this strategy when developing their commissioning plans. Consortia will have to seek the views of the relevant Health and Well-being Board(s) when preparing their commissioning plan as to whether the plan takes proper account of the most recent JSNA and joint health and well-being strategy, and the Board's view must be included in the plan. Health and Well-being Boards may also write to the NHS Commissioning Board or the local authority if they feel that commissioning plans do not adequately have regard to the JSNA or the joint health and well-being strategy.

53.  Both Health and Well-being Boards and the NHS Commissioning Board will be under a duty to encourage integrated working. In developing the joint health and well-being strategy and in broader conversations, the Health and Well-being Board must encourage commissioners to work in an integrated manner, and in particular encourage commissioners to make use of the flexibilities in the NHS Act 2006 where these are likely to lead to improvements. For example, section 75 of the Act supports a range of partnership arrangements, such as pooled budgets or lead commissioner arrangements.

54.  To ensure existing arrangements are sustained during transition, we are using the NHS Operating Framework to ask all PCTs to work with their Local Authority partners to ensure that a succession plan is in place for existing pooled budgets and joint commissioning arrangements.

55.  In order to support local government in taking on its new roles, we will create a network of "early implementers" of Health and Well-being Boards to share learning and feed this into policy development. The emphasis of the work will be on working across local government and partners to accelerate sharing of learning and supporting the development of effective Health and Well-being Boards that can bring together partners in local areas to better serve their communities.

56.  Many of the responses to the consultation on Liberating the NHS underlined the importance of developing Health and Well-being Boards—and local authority capacity more generally—alongside the development of GP consortia. The Department is working with local authorities and with SHAs and PCT clusters to align the implementation approaches for Health and Well-being Board early implementers and GP consortia pathfinders.

57.  Our initial focus is on aligning communications through shared websites, bulletins and learning materials for GP consortia pathfinders and Health and Well-being Board early implementers, as well as ensuring early implementers and consortia are able to come together as part of regional transition events. We are also working to develop a "shared offer" on learning and support for pathfinders and early implementers. A number of pathfinders are already actively engaging with shadow Health and Well-being Boards, building on joint commissioning.

58.  The government is extending the remit of NICE to social care to support the creation of effective quality standards for all those using health and social care services. This will enable NICE to approach issues covering the whole pathway between health and social care, focusing on the holistic needs of individuals. One such NHS quality standard, published in June 2010, looks at quality in relation to services for dementia—an important cross-sector issue which has resonance for both social care and healthcare services.

7.  We intend to review the arrangements proposed in the Bill to enable commissioning consortia to address these issues [cross-area collaboration by consortia in reconfiguring services] 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)

59.  Our response to the Committee's Third Report of Session 2010-11 explained how GP commissioners would have unprecedented influence over how healthcare services are delivered locally, and that this brings the opportunity to lead service redesign.[11] Leading any major service change is about building effective partnerships, including with other consortia where changes may benefit a wider population. We emphasised also how patients and the public will be able to influence service redesign through requirements on consortia to involve the public.

60.  The scrutiny functions of local authorities will also be extended to cover any substantial changes to designated services, regardless of provider. This will bring a wide range of NHS services provided by independent providers within the scope of local authority scrutiny for the first time. We also intend to strengthen the democratic legitimacy of referrals from local authorities to the Secretary of State for Health, as we intend for these decisions to be subject to a vote of the full council, allowing every councillor to contribute to the discussion.

61.  The new arrangements for commissioning will provide a strong framework for local co-operation between providers, local authorities, GP consortia and local HealthWatch. This will help make commissioning decisions more responsive to local health needs and patient views. Health and Well-being Boards will support a culture of local collaboration, centred on the joint health and well-being strategy. This will facilitate the development of more joined-up services that make better sense for patients and the public and improve quality and efficiency.

62.  The Health and Social Care Bill provides wide-ranging powers to support collaborative working between consortia and with local authorities. Consortia may delegate commissioning functions to a lead consortium or local authority, commission jointly between consortia and commission jointly with local authorities, pooling funds and expertise as necessary. This will allow consortia to build on the success of existing regional commissioning networks and joint commissioning arrangements.

63.  The pathfinder programme will help the NHS and local authorities to explore how these collaborative arrangements can best evolve and identify any support that may be necessary. During transition, both PCT clusters and the NHS Commissioning Board will have a role in supporting the development of cross-consortia working arrangements. However, we will not be prescriptive in the approach consortia should adopt, as we want to encourage successful arrangements to emerge locally through the work of pathfinders.

8.  The Committee intends to review the arrangements proposed in the Bill for enabling consortia to reconcile this potential conflict [between patient choice and commissioning] by enhancing patient choice at the same time as delivering the consortium's clinical and financial priorities. (Paragraph 115)

64.  Giving patients choice and control over the care they receive should not be a luxury, but a routine element of the service which the NHS provides to patients. There is evidence that giving patients choice and control can improve both quality and efficiency of care—and should not, therefore, be seen as being at odds with clinical and financial priorities.

65.  It may be helpful to address here some common misunderstandings about how choice of provider will work under the "Any Willing Provider" model, which are inhibiting an honest assessment of its value to patients and commissioners.

66.  The "Any Willing Provider" model is not new: patients have been able to access a free choice of any qualified provider for routine elective care since April 2008. The proposal is to extend this to most NHS services by 2013-14. This will mean that, when a patient requires a referral, they will be able to choose from a range of providers who are qualified to provide safe, high-quality care and treatment and select the one that best meets their needs.

67.  Giving patients this choice will not conflict with a consortium's clinical priorities, as it will still very much be for commissioners to decide on the services to which they want to be able to refer their patients to have access and to establish quality criteria for these services. Only providers that meet the commissioner's quality criteria will be eligible to provide these services. Nor does it conflict with financial priorities, as consortia will set a fixed price that will then apply to all providers (so the patient's choice of provider does not affect the price paid) and the model does not alter the decisions that GPs and other clinicians reach with patients about whether a referral is needed. Allowing patients this choice of provider should help support effective commissioning, as commissioners will know that a range of safe, good quality and affordable providers are available. It will also avoid the cost, time and effort involved in competitive tendering.

68.  Obviously not all services will be suitable for the "Any Willing Provider" model. Tendering will be appropriate in some cases, including where a free choice of provider would clearly not be appropriate (eg for a range of emergency care services), or to provide complex, integrated packages of care (eg for frail older people with multiple complex conditions), or where commissioners need to provide income or activity guarantees in order to ensure a guaranteed service. Consortia will be responsible for determining which is the most appropriate approach.

69.  The Department is aiming to issue guidance in March about how the initial implementation of the "Any Willing Provider" model for community services will work, including how to select providers. The aim is to promote national consistency in terms of quality and safety and ensure, where possible, that a provider who is registered in one locality does not have to go through a full application process again for that service in another locality. This should maintain standards, whilst reducing duplication and bureaucracy. We will be working with commissioners and providers to decide how best to do this. We want to build in sufficient flexibility for the "Any Willing Provider" to work in the best interests of patients and fit local needs.

70.  Our consultation on information and choice, Liberating the NHS: greater choice and control, closed on 14 January 2011 and we expect to report back shortly on the results of that consultation, drawing on the public's responses to inform further proposals for enhancing patient choice and control.

9.  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)

71.  In our response to the Committee's Third Report we considered the range of ways in which the public could influence local commissioning. Without repeating our earlier comments, we would like to emphasise the clear lines of accountability which will support patient involvement and ensure commissioners are answerable for the outcomes they achieve.

72.  The NHS Commissioning Board will be responsible for holding GP consortia to account annually for the outcomes they achieve, their stewardship of public resources and their fulfilment of other statutory duties. Paragraphs 18-26 above set out the proposed arrangements for authorisation and ongoing accountability and for intervention to support consortia where they are not carrying out their functions effectively.

73.  Under the Bill, consortia will have a clear legal duty to ensure patients and the public are involved in the planning of commissioning arrangements, in developing and considering proposals that will significantly affect how services are delivered or the range of services available, and in making decisions that will have a similar impact. The NHS Commissioning Board will need to satisfy itself both at the point of authorisation and on an ongoing basis that consortia have effective arrangements in place to meet this duty. We envisage that the Board will wish to draw on the views of local HealthWatch, local authorities and other community groups to enable it to assess how effectively consortia are involving patients and the public.

74.  Arrangements for public accountability will be further enhanced through the introduction of a Commissioning Outcomes Framework that enables local communities to understand and compare the outcomes that consortia are achieving for patients and the progress they are making in improving quality and reducing inequalities.

75.  Health and Well-being Boards will further enhance accountability arrangements by enabling local authorities and local HealthWatch to work alongside consortia in reviewing local healthcare needs and in deciding strategic priorities for improvements in Health and Well-being. Boards will be required to include in its membership elected representatives, commissioners of NHS, public health, social care, and children's services, and representation from Local HealthWatch. They will also, if they wish, be able to involve others such as providers and voluntary sector organisations.

76.  The January event for pathfinders highlighted the enthusiasm amongst emerging consortia to build on what works well locally to engage with patients and the public, including Patient Participation Groups, local authority citizens panels and PCT membership schemes. One pathfinder had a representative from the patient participation group of every GP practice sitting on a locality group with representatives from the local authority, voluntary organisations and local special interest groups, to constitute a stakeholder forum which the consortium could use to gauge patient and public views.

77.  We want to see all consortia develop robust arrangements that are tailored to local circumstances and driven by local initiative, rather than prescribe a single central approach. The pathfinder learning network will provide a platform for consortia to share best practice on this. Ultimately, however, it will still be for the NHS Commissioning Board to satisfy itself that a consortium has effective arrangements to meet its statutory duty of public and patient involvement.

78.  The Department's Voluntary Sector Strategic Partners have been in early discussions to inform and develop the arrangements for GP commissioning consortia and the NHS Commissioning Board. Dame Barbara Hakin, the Managing Director of Commissioning Development recently met with ten leading patient organisations, including the Chair of National Voices and representatives from Age UK. This group will provide a link back into the broader voluntary and community sector.

10.  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)

79.  The 2011-12 NHS Operating Framework establishes that GP consortia will not be responsible for resolving PCT legacy debt that arose prior to 2011-12. We expect pathfinders and emerging consortia to work closely with PCT clusters during the transitional financial years 2011-12 and 2012-13 to ensure that no new deficits are created and that appropriate control and balance are maintained, so that from 2013-14 consortia will commence full responsibility for commissioning on a robust financial basis. GP consortia will otherwise be responsible (from 2013-14 onwards) for any unresolved debt that arises during these two years.

80.  Where consortia carry out commissioning functions during 2011-12 and 2012-13, they will do so on a delegated basis. In other words, the relevant PCT(s) will remain statutorily accountable for expenditure and service outcomes, but will delegate responsibilities to consortia (either as sub-committees of the PCT or, once consortia are statutorily established, as bodies in their own right). The Department is working with pathfinders to develop best practice guidance on the arrangements for delegating commissioning responsibilities and associated budget provision. These arrangements will support emerging consortia in taking an increasingly active role in shaping QIPP plans and ensuring that improvements in quality and productivity are based on a good understanding of patient needs.

81.  To support the transition, the NHS Operating Framework 2011-12 sets out our intention increasingly to deliver business through PCT clusters. They will in essence work as transition vehicles for overseeing and accounting for delivery of financial and service priorities, supporting the development of the new commissioning system, ensuring that emerging consortia have access to good commissioning support, and directly commissioning those services (such as primary care and specialised services) that will in future be commissioned by the NHS Commissioning Board.

82.  Some regions of the NHS have already developed clusters of PCTs. In order to secure the capacity and flexibility needed for the transition period, we shall undertake a managed consolidation of PCT capacity to create clusters across all regions of the NHS. As part of this transitional process, PCT staff will be increasingly assigned to emerging GP consortia to support their development and support them in taking on delegated commissioning responsibilities.

83.  In creating clusters, our aim is to maintain the strength of the commissioning system in light of the significant financial challenges ahead and to provide maximum opportunities and support for emerging consortia to grow their capacity and capability. Clusters of PCTs will have greater resilience to manage the demands of the service during transition, whilst supporting the development of emerging consortia.

84.  SHAs will oversee the development of PCT clusters and ensure local coherence across the local development of the new architecture, such as relationships between GP consortia pathfinders and local Health and Well-being Board early implementers.


85.  Equity and excellence: Liberating the NHS expressed the intention that in giving the NHS a stable, enduring framework for quality and service improvement, the focus of debates on health should move to priorities and progress in health improvement. With the new arrangements for commissioning still in development, we have not reached that stage yet. But as those new arrangements for commissioning and accountability take greater shape, we hope to reinforce the fact that these changes are not an end in themselves, but are designed to allow a renewed focus on improving health outcomes and reducing health inequalities.

86.  The Government has made it clear that tackling health inequalities is a priority, with a determined focus on equity and fairness. Everyone should have the same opportunities to lead a healthy life, no matter where they live or who they are. As well as helping people live longer, healthier and more fulfilling lives, we aim to improve the health of the poorest fastest.

87.  Tackling health inequalities and unacceptable variations in service outcomes is an important aspect of our drive to improve service quality and health outcomes of services across the board. People in many disadvantaged groups and areas live shorter lives and experience poorer health throughout their lives. The more devolved health system we are developing will support a sharper focus on the pockets of disadvantage that exist across the country.

88.  Reducing health inequalities will be embedded into the reformed systems of accountability for both the NHS and public health. Subject to Parliamentary approval, the Secretary of State for Health, the NHS Commissioning Board and GP consortia will each have specific duties as regards reducing inequalities. GP consortia and Health and Well-being Boards will need to look strategically at the needs of local populations when developing JSNAs and identify strategic priorities for reducing health inequalities.

89.  The Department has developed an NHS Outcomes Framework to provide national accountability for the outcomes that the NHS delivers. The framework will not only be a mechanism to hold the NHS to account, but will act as a catalyst to drive quality improvement and delivery of better outcomes across the system.

90.  One of the underpinning principles in developing the NHS Outcomes Framework has been the need to promote equalities and reduce inequalities in health outcomes. To encourage this, the outcome indicators, as far as possible, will be chosen according to whether data can be disaggregated by equalities characteristics and by geography so that outcomes for disadvantaged groups can be measured.


91.  Action to tackle health inequalities is also at the centre of our approach to public health. The Public Health White Paper, Healthy Lives, Healthy People: our strategy for public health in England (November 2010),[12] sets a radical new vision for improving the health of the nation. The public health budget will be ring-fenced and allocated to reflect relative population health needs, with a new "health premium" to promote action to reduce health inequalities. Public Health England will lead national action to protect and improve health, with local authorities given new responsibilities and ring-fenced funding for health improvement in local communities.

92.  The Department is consulting on the funding and commissioning routes for public health. We are also consulting on a public health outcomes framework, which will contain indicators designed to allow progress to be measured towards a number of public health outcomes and provide incentives for local health improvement and reductions in inequalities. A key criterion in choosing which indicators to include in the final outcomes framework will be whether or not they can be measured at the local authority level.

93.  Public Health England will publish progress against the outcome indicators for each local authority. This will enable the population locally to hold their council to account for local performance, and for Directors of Public Health and colleagues to assess their performance against comparator authorities.

94.  The Public Health White Paper responds to the report of the independent review, chaired by Professor Sir Michael Marmot, to explore the impact of the wider social determinants of health and advise on future action to reduce health inequalities in England. The White Paper adopts the review's life course framework to provide a focus for tackling the wider social determinants of health.


95.  Under the proposals in the Health and Social Care Bill, NICE will be re-established on a statutory footing and its remit will be extended into social care. NICE is at the heart of the Government's plans for promoting quality in the NHS, and the extension of its role into social care will help to create a seamless and integrated approach to health and social care. Our plans for NICE build on its strong track record, and NICE as re-established will continue to support the delivery of high quality health and social care through the production of robust, evidence-based advice and guidance.

96.  The Bill also sets out the key role of NICE quality standards in supporting the overarching duty of quality and improving outcomes. NICE quality standards describe the core elements of a high quality service or care pathway and, under our plans, the NHS Commissioning Board and the Secretary of State will be required to have regard to them in carrying out their functions. We envisage, for example, that the NHS Commissioning Board will draw on quality standards in developing indicators for the Commissioning Outcomes Framework and in developing appropriate incentives for healthcare providers through model contracts for secondary care providers and through the Quality and Outcomes Framework for GP practices.

97.  The Government wants to give NHS patients better access to effective and innovative medicines and we are currently consulting on plans to introduce value-based pricing for medicines. Our intention is to introduce the new arrangements from 2014, on expiry of the current Pharmaceutical Price Regulation Scheme. Through value-based pricing, our aim is to ensure that a drug's price appropriately reflects the value it offers, so that clinicians and commissioners can have greater confidence that medicines are cost effective as well as clinically effective. NICE's role will evolve under value-based pricing, but, as an international leader in the evaluation of drugs and health technologies, it will continue to have a crucial part to play through the provision of authoritative and expert advice to support clinical decision-making.


98.  On 12 January we published Improving Outcomes: A Strategy for Cancer.[13] It sets out how the Coalition Government's reforms of health and care services will drive improvements in cancer outcomes and put patients and the public at the heart of cancer services.

99.  Commissioning for cancer is complex and needs to be coordinated across the care pathway involving teams in general practice, community services, social care, acute general hospitals and specialist centres.

100.  The NHS, public health and social care outcomes framework will set the direction and provide clear accountability. The Secretary of State for Health will hold the NHS Commissioning Board to account for delivering national outcome goals.

101.  The NHS and Public Health England (PHE) will need to work together closely, offering integrated advice and care to the public and patients with many shared areas of accountability for cancer services. While the NHS Outcomes Framework has cancer survival as an improvement area, Healthy Lives, Healthy People: Transparency in Outcomes proposes that cancer mortality should be an improvement area for PHE as this covers improvements in prevention as well as in diagnosis and treatment. Key indicators spanning a number of domains will drive prevention and earlier diagnosis of cancer as well as improvements in NHS outcomes.

102.  The Coalition Government's proposed Health and Well-being Boards will provide a forum for the development of cross-cutting commissioning approaches to improve cancer services, providing more effective engagement between NHS, public health and social care commissioners.

103.  GP consortia are well placed to commission the majority of cancer services. Those cancer services best commissioned for larger populations may require consortia to group together to commission services and some services will continue to be commissioned at a national level, including specialised surgical services and services for some rarer cancers (eg children's cancers).

104.  The Strategy sets out how choice for patients in their cancer care will be extended and identifies the gaps in information on health outcomes which are crucial to ensuring patients are empowered.

105.  Although we have made considerable progress on cancer over the past 10 to 15 years, we know from available data that our survival rates lag behind those in comparable countries. The main reason for this is late diagnosis of many patients. The Strategy therefore has a significant focus on earlier diagnosis, which we will achieve through raising the public's awareness of the signs and symptoms of cancer and providing better access to diagnostic tests. To support the NHS to achieve earlier diagnosis of cancer alongside efficiency savings, the Strategy is backed up with over £450 million investment over the Spending Review period.

106.  The Strategy sets out our aim to save an additional 5,000 lives every year by 2014-15 and improve cancer outcomes through:

  • reducing the incidence of cancers which are preventable, by lifestyle changes;
  • improving uptake of screening and introduce new screening programmes where there is evidence to justify them;
  • achieving earlier diagnosis of cancer, to increase the scope for successful treatment; and
  • making sure that all patients have access to the best possible treatment, care and support including improving access to innovative treatments such as proton beam therapy.

107.  Improving outcomes for people with cancer is also about improving patients' experience of care and improving the quality of life for cancer survivors. The Strategy therefore also sets out a range of actions to deliver improvements in those areas.

108.  The Strategy highlights that information will be central to the drive for better outcomes, underpinning stronger commissioning and patient choice. Commissioners will need better information to drive up the quality of services and outcomes and to make efficient use of resources. We will ensure that we have better activity information and full clarity about costs for different services, and the right incentives to reward quality and efficiency. In addition to taking forward the tariffs for chemotherapy and radiotherapy, during 2011-12 we will investigate the potential development of a range of tariffs to incentivise high quality, cost-effective services.

109.  It is intended that the Commissioning Outcomes Framework will incentivise high quality commissioning and will be closely aligned with NICE Quality standards. The library of Quality Standards being developed by NICE will be an important resource for commissioners in identifying issues to prioritise and will enable scrutiny of the extent to which they are commissioning high quality care.

110.  The Department of Health and the National Cancer Action Team have provided guidance and support to commissioners through the Cancer Commissioning Toolkit and the Cancer Commissioning Guidance. We will now work with GP consortia to identify their specific needs for commissioning support. The Cancer Networks will support pathfinder consortia through transition.


111.  On 2 February the cross-Government strategy for mental health, No Health Without Mental Health,[14] was published. The strategy is based on outcomes, giving mental health "parity of esteem" with physical health issues as central to priorities across Government and in the mainstream of health and social care services.

112.  The strategy has the twin aims of promoting and sustaining good mental health and well-being in the wider population, and improving the quality of existing services for people across the full range of mental health problems. It looks at the prevalence of problems and effective approaches at different stages across the whole life course and stresses the importance of prevention and early intervention. The Strategy makes clear that our approach is based on the principles that the Government has laid down for its health reforms, such as focusing on measurable outcomes and the NICE Quality Standards that deliver them rather than top-down process targets.

113.  In support of the strategy, on 2 February the Department published Talking Therapies: a four year plan of action.[15] The plan sets out how the NHS will complete the nationwide roll-out of the Improving Access to Psychological Therapies programme, ensuring older people get good access to talking therapies and:

  • initiating a stand alone programme with the ambition of making the same step forward for children and young people as has already been made for adults;
  • achieving other NHS savings by offering talking therapies to people with long-term physical conditions or medically unexplained symptoms; and
  • developing ways to expand access to talking therapies to people with serious mental illness.


114.  A greater focus on the outcomes that matter most to patients, and in particular more attention given to patients' experience, has the potential to yield great benefits for people with kidney disease. For example, GP consortia will be well placed to maximise opportunities for the efficient integration of primary and secondary care for people with chronic kidney disease, meaning that people are seen at the right place and time without the frustration of unnecessary referrals and duplication. A Quality Standard on chronic kidney disease is in the final stages of preparation by NICE and will help to guide commissioners and providers of services in this area.

115.  Similarly the explicit emphasis on effectiveness and patient safety set out in the first Outcomes Framework, together with clinical leadership, lend themselves to a more systematic approach to the prevention, detection and management of acute kidney injury, which research suggests may affect up to 20% of emergency admissions—resulting in significant morbidity and mortality. This is primarily a matter of consistently providing good quality basic and generic care for the acutely unwell, which will benefit from a clear and unfettered drive by commissioners to yield improvements in all the domains of quality.

116.  Preparation for and delivery of renal replacement therapies—dialysis and transplantation—will be commissioned by the NHS Commissioning Board with due regard for patients' needs to maintain their day to day lives. Patient choice and control—"no decision about me without me"—will be the watchwords of quality services after the transition, with informed choice of treatment modalities including care at home; conservative care in the community and, at an appropriate time, good end of life care. For example, an increase in the availability of dialysis at home—which is known to be more clinically and cost effective than in-centre treatment—will mean that patients will be able to plan their treatment around their lives rather than vice versa. For dialysis patients of working age, this treatment modality will help them to continue in employment with benefits to themselves and the wider community.


117.  Diabetes is a life-long complex condition that affects every part of the body and throughout the course of their lifetime people with diabetes will need to engage with a range of healthcare professionals. There is no one single care pathway for people with diabetes and it is essential that they receive the relevant care and attention as and when they need it. The NHS reforms present the opportunity for stronger, closer partnership working between GP consortia and secondary care specialists, ensuring that evidence-based multi-disciplinary care is commissioned and is focused on the needs of the individual patient sitting in the GP practice.

118.  Engaging patients in a better understanding of their condition and educating them how to manage their own condition results in better outcomes. These reforms offer the potential to provide more tailored treatment for people with diabetes so that they can access specialist care from the primary, community and acute sectors.

119.  We know that there is significant scope for improvements in primary care in terms of managing people with diabetes in the community. Because the performance of local health services will increasingly be measured on whether or not patients are in good health and able to live active, fulfilling lives, it will become more apparent where people with diabetes are not receiving good primary care and community services to help them manage their condition, and there will be a greater onus on GP consortia, health professionals and Health and Well-being Boards to address this.

120.  Strengthening the relationship between primary and specialist care can only be a good thing for improving care for people with diabetes. In anticipation of these changes, the diabetes team in Portsmouth NHS Trust have already proposed a solution that will drive specialist diabetes care into the community cutting across the divide of primary and specialist care. This not only provides more convenient services for people with diabetes, but also ensures the integration of specialists into primary care.


121.  The focus on patient experience, empowerment and long-term conditions envisaged in the new arrangements should give a welcome emphasis to the commissioning of services for heart failure and cardiac rehabilitation. Moving commissioning decisions closer to patients should ensure they are better able to influence their care though direct discussion with their GP. This is of particular importance to people with long-term conditions. GPs should become more aware of the full menu of services available and will be able to offer greater choice and control to their patients to manage their own condition more effectively, with specialist medical support only where necessary.

122.  Facilitating the entry of new and different local provider organisations will help people tailor their care to meet their needs. For cardiac rehabilitation, this would mean that patients not only have a choice of services from a variety of providers in a range of settings, but also that they could select only the components of the services that meet their individual needs.

123.  The NICE Quality Standard on Chronic Heart Failure (due in summer 2011) will provide a robust evidence base to enable GP consortia to understand the benefits and cost-effectiveness of alternatives to hospital provision, through telemedicine and community teams, in addition to the importance of self-care and cardiac rehabilitation in preventing hospital admissions. It is also likely to help the NHS Commissioning Board develop suitable indicators as part of the Commissioning Outcomes Framework to hold commissioners to account for delivering the outcomes that people want.


124.  The focus on improved stroke linkage between primary and secondary care will offer opportunities to focus on prevention through, for example, better management of patients with atrial fibrillation and consequent reduction in the risk of stroke. Patients with atrial fibrillation have worse strokes with worse outcomes, so improving atrial fibrillation management can improve overall outcomes.

125.  As with cardiac services, the new arrangements will support a strengthened focus on patient experience and patient empowerment. GPs should become more aware of the benefits of continuing rehabilitation, including understanding how best to deliver it most effectively for most patients (eg via telemedicine facilities) for as long as patients are able to benefit from it. By offering greater choice and control to their patients to manage their own condition more effectively, GP consortia should be able to commission specialist medical support only where necessary.

126.  The acute phase of stroke is a very small part of the overall patient pathway. By providing improved focus on post-acute and social care, patient experience and outcomes will improve, enabling better integration into the community and reduced social isolation, which will also benefit carers. Improved understanding of the importance of high quality stroke care including rehabilitation should reduce the numbers of people who are admitted to residential care.

127.  The NICE Quality Standard on Stroke provides an evidence base to enable GP consortia to understand the benefits and cost-effectiveness of high quality stroke care. It will also help the NHS Commissioning Board develop suitable indicators as part of the Commissioning Outcomes Framework to hold commissioners to account for delivering the outcomes that people want.


128.  The NHS Health Check programme is a national public health programme aimed at preventing heart disease, stroke, diabetes and chronic kidney disease. The Government made clear its commitment to the continuation of the programme in the Public Health White Paper. The programme aims to prevent disease and help people stay well for longer. As such, it is proposed as an indicator in the Public Health Outcomes Framework.

129.  The NHS Health Check programme is a clinically and cost effective programme with a robust evidence base. It is for everyone in England between the ages of 40 and 74 that does not already have one of these diseases. Everyone having a NHS Health Check will have an individual assessment to determine their risk of having a heart attack or stroke, or of developing diabetes or chronic kidney disease in the future. Each person will be offered a tailored package of lifestyle advice and support to help them reduce or manage that risk. For those at low risk, this might be no more than general advice on how best to stay healthy. Others may be assisted to join a weight management programme or a stop smoking service. Those at the highest risk might also require preventive medication with statins or blood pressure treatment.

130.  Six Carers Strategy demonstrator sites, focusing on health and well-being checks, are testing different ways of reaching out to carers, including those in ethnic minority communities. The findings from the independent evaluation of the demonstrator sites, particularly around accessibility for carers will be fed into the ongoing policy considerations for the NHS Health Check Programme.

131.  There is also a related annual health check programme for people with learning disabilities that has been running since 2008-09. The Government has confirmed it is keen for this programme to continue in 2011-12, and is currently looking at the most cost effective way of ensuring that. Evidence shows people with learning disabilities value annual health checks. Evidence also shows people with learning disabilities have greater health needs than the general population, and that such checks lead to earlier diagnosis and earlier treatment. Annual health check data is analysed and published by the Public Health Observatory in relation to people with learning disabilities.[16]

132.  Vascular conditions (mainly coronary heart disease, stroke, diabetes and chronic kidney disease) are the largest contributors to the gaps in health between deprived and better off, and between different ethnic groups. This programme, if implemented sensitively, offers a real opportunity to make significant inroads in tackling health inequalities and fits with the wider agenda for improving public health.

March 2011

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3   Government Response to the House of Commons Health Select Committee Third Report of Session 2010-11: Commissioning, Cm 8009, p. 7, Back

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7   Liberating the NHS: legislative framework and next steps (December 2010) Back

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11   Government Response to the House of Commons Health Select Committee Third Report of Session 2010-11: Commissioning, Cm 8009, pp 22-23. Back

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14   No Health Without Mental Health: a cross-Government mental health outcomes strategy for people of all ages (HM Government, 2011) Back

15   Talking Therapies: a four year plan of action (Department of Health, February 2011) Back

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Prepared 5 April 2011