Analysis of the new NHS White Paper – Part 2

MAP Insights: Analysis of the new NHS White Paper

The New NHS White Paper on reforming the NHS, Integration and Innovation: working together to improve health and social care for all, which was foreshadowed in MAP’s blog on 9 February, was published on 11 February.

There are three main elements to the White Paper.

  •  A significant increase in the powers of the Secretary of State so that they can direct NHS England in setting out its objectives and relevant functions. They will also have more control over Foundation Trusts, the ability to create new Trusts, make changes to professional regulations and intervene in local service reconfiguration, such as integrated care services (ICSs).

  •  Two new local bodies will be set up to administer ICSs. The first will be an NHS ICS body, handling the funding and day-to-day running of ICSs; the other will be the ICS Health and Care Partnership, designed to support integration and development. Clinical commissioning groups (CCGs) will become part of ICSs.

  •  The Medicines and Healthcare products Regulatory Agency (MHRA) will be enabled to set up its own national medicines registry and to avoid or reduce competitive procurement for NHS services.

It was anticipated that the White Paper would mark April 2022 as a starting date for the new health and care reforms. A more flexible approach has since been suggested and ‘will start to be implemented in 2022’ (para 4.6). 

The increased powers of the Secretary of State

The White Paper states that the reforms will make it easier for the Secretary of State to set objectives for NHS England and adds that they will have ‘appropriate intervention powers with respect to NHS England….by allowing [him] to formally direct NHS England in relation to relevant functions’. (para 5.68). NHS England will remain answerable to the Secretary of State for all aspects of NHS performance, finance and care transformation.

Since the NHS White Paper was released, Sir Simon Stevens, the NHS England Chief Executive, has indicated that he will not be continuing his role under these reforms.

The forthcoming legislation will also enable the Secretary of State to:

  •  Set legally binding capital expenditure limits for Foundation Trusts

  •  Create new Trusts to ensure alignment within an integrated system

  •  Intervene in local service reconfiguration, particularly in relation to ICSs. In such circumstances, the Secretary of State will be required to seek appropriate advice in advance of their decision, including in relation to value for money and transparency in publication

  •  To transfer functions to and from arm’s length bodies (which include NHS Improvement, Public Health England, NHS Digital and the National Institute for Health and Care Excellence (NICE)) and to abolish such bodies when necessary via statutory instruments

  •  Provide additional powers to enable further reforms (by the Secretary of State) to ensure the professional regulation system delivers public protection and that professions are regulated in the most appropriate and cost-effective manner.

The White Paper states that these powers will ‘not undermine the established NICE process and guidance for treatments and medicines’ and will not ‘allow the Secretary of State to intervene in individual clinical decisions’ (para 5.71). This means that NICE will remain an independent body and the Secretary of State will be unable to override decisions made by NICE on a case-by-case basis.

Given that the NHS is funded almost exclusively by central government, and that Ministers are answerable to Parliament for the NHS in England, it is not surprising that Ministers and their officials felt that a clear line of authority to Ministers was needed and should be addressed by amending the Health and Social Care Act 2012.

With the proposed merger of NHS Improvement (currently a Department of Health and Social Care body) into NHS England, and the new powers to be given to NHS England in respect of ICSs, the case for ministerial control is even greater.

Yet the shift of power does mean that ministerial and departmental influence, official and unofficial, will inevitably be greater. This could create additional opportunities for pharmaceutical companies to consider when marketing their products.

The new ICS structure

Integration of the NHS and social care is at the heart of the changes being put forward in the New NHS White Paper on reforming the NHS. There will be legislation for local statutory integrated care systems (ICSs) to be comprised of:

  •  An NHS ICS body

  •  An ICS Health and Care Partnership.

The NHS ICS body will be responsible for the day-to-day running of the ICSs and will be responsible for:

  •  Setting out the strategic direction of the system

  •  Developing a capital plan for the NHS providers within their health geography and securing the provision of health services for its system population

  •  Meeting its financial objectives, with NHS England having explicit powers to set a financial allocation or other financial objectives.

In particular, the NHS ICS body will take over the commissioning and allocative functions of clinical commissioning groups (CCGs) and its responsibilities in relation to Oversight and Scrutiny Committees. CCGs ‘will become part of ICSs’ (para 5.24). However, the ICS board will not have the power to direct providers. Delegation of specialised commissioning to ICSs will be ‘subject to certain safeguards’ to ensure equity of access nationwide. However, the White Paper does not make clear what these safeguards are.

In order to retain a division of responsibility between strategic planning and funding decisions on the one hand, and care delivery on the other, each ICS NHS body will have a Board with the Chief Executive becoming the accounting Officer for the NHS money allocated. It will include representatives from NHS Trusts, general practice, local authorities and others determined locally.

NHS England will have the power to set a financial allocation or other financial objectives, with a duty placed on ICS NHS bodies to meet the financial objectives.

The ICS Health and Care Partnership will bring together systems to support integration and develop strategy to address the system’s health, public health and social care needs. The partnership will be formed of a wider group of organisations compared with an NHS ICS body. It will promote collaboration without imposing binding arrangements on either party. The implication is that the ICS Health and Social Care Partnerships will sit beneath NHS ICS bodies. 

The White Paper also proposes:

  •  All social care providers to produce data about their services, including private providers, and to ensure that the data is shared to promote integration and collaboration

  •  A specific power to issue guidance on joint appointments between NHS bodies and local authorities.

Medicines and Healthcare products Regulatory Agency (MHRA) and medicines registries

The White Paper outlines the government’s aims to enable the establishment of a comprehensive medicine information system, including collecting data from private providers, to support UK-wide medicines registries.

The registries of marketing authorisation holders are not always seen to deliver the required evidence in reasonable time frames. The new legislation will allow the MHRA to set up statutory registries themselves where the public need is clear, such as when there are substantive unknowns about the safety or effectiveness of a medicine and urgent evidence is required to support safe access to it (paras 5.159 - 5.164).

NHS procurement

The legislation will remove the current procurement rules by removing the commissioning of healthcare services from the scope of the Public Contracts Regulations 2015 as well as repealing some previous legislation. The aim is to recognise that competition is not the only way to drive service improvement and therefore eliminate competitive tendering where it adds limited or no value.

Conclusions

The White Paper describes major changes at local level for the NHS and local government involving a high degree of administrative reorganisation. At a time when the NHS is already under unprecedented pressure, with a considerable backlog of treatments, this reorganisation will divert attention from its current priorities, and absorb considerable government and NHS resource and capital. At present there has been no reference made to the financial commitments or savings to be made by local authorities and the wider NHS.

The difficulties of merging local authority social care into ICS county level (or metropolitan equivalents) are not addressed within the White Paper and careful consideration will need to be given to such major restructures. In addition, there remains considerable areas of uncertainty about these proposals, which might suggest that the White Paper was published before plans were finalised.

The number of ICSs as described in the new White Paper has not yet been specified although it is anticipated this will be around 42 . At present it is unclear how CCGs are expected to merge into ICSs. This is likely to create uncertainty within clinical commissioning groups about the future of newly established primary care networks (PCNs) and suppliers of services as well as staff and patients.

The description of what ICS social care will provide and how also remains ambiguous. It would be reasonable to assume that adult social care will be included, but explicit references to mental health, children’s social services and safeguarding and other services are not provided.

Whilst there are many areas of the new White Paper that need to be clarified and refined, there is evidence that the government is attempting to maintain the new ways of working following the COVID-19 pandemic, through tangible system change, which seeks to solidify the new ways of working that have developed organically, in many areas from the bottom up. These changes have already seen faster market access for pharmaceuticals and whilst the COVID-19 vaccine response was an extreme example, there is no reason currently to think that this trend will not continue. 

The White Paper can be accessed here:
Integration and Innovation: working together to improve health and social care for all

Christopher Mockler

Consultant
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