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Liberating the NHS: what does it mean for you?

Andrew Lansley, Secretary of State for Health, presented the proposals for the new NHS to Parliament in July. The white paper lays down the general principles of how health and social care will be managed in England over the next five years.

The introduction to the white paper stresses that the coalition's core beliefs centre on freedom, fairness and responsibility. There is an awareness that the present system is too bureaucratic and adopts a top-down approach. The coalition intends this to be reversed with local accountability and a bottom-up approach. The voices and choices of patients will be the central tenet of the new structure. There will be a focus on clinical outcomes, with quality and effectiveness being of prime importance.

The government will take a back seat position, relying on a new NHS Commissioning Board to oversee the running and effective management of services. Table 1 highlights the timeline for specific milestones and bodies to be in place. The vision for an improved health and social care system includes an expectation that the future NHS will:

  • Be centred on patients and carers.
  • Achieve quality and outcomes that are among the best in the world.
  • Eliminate discrimination and reduces inequalities in care.
  • Put clinicians in the driving seat and sets providers free to innovate and compete against each other.
  • Be less insular, with local authorities working in an integrated manner with hospitals and GP practices.
  • Have a scaled down structure, with only the bureaucratic overview that is really necessary.

Improving public health and reforming social care
The coalition acknowledges that there needs to be greater focus on public health. To this end, the public health budget will be ring fenced, with a new health premium to promote action to reduce health inequalities. A white paper on public health will be published at the end of this year (Table 1).

[[Tab 1 liberating]]

There will be a new public health service where local authorities will lead on health improvement. New statutory arrangements will be set up with local authorities, with the establishment of health and wellbeing boards. They will be tasked with co-ordinating activities across GP consortia, public health and social care. GP consortia will "have a duty to promote equalities and to work in partnership with local authorities".1 Health visitors will be managed within local authority bodies and will be responsible for safeguarding and working to reduce health inequalities. The focus will be on outcomes rather than activity per se.

How will outcomes in public health and preventive work be measured?
This has been a question that has been raised repeatedly over time, with no clear answer. How will health visitors and other community public health practitioners ensure that they maintain close links with their clinical colleagues, particularly GPs, if they are employed in separate organisations?

One can envisage that health visitors and others will have closer working relationships with social workers but their links with GPs may become more detached. Health visitors must not lose their clinical expertise, as it is precisely their ability to assess development and emotional wellbeing that adds to the picture when making safeguarding decisions.

The tension in the relationships between health and social care practitioners in the community will be a factor to consider and monitor in the next few years. The Director of Public Health will be employed by the local authority, but will be jointly appointed by the Public Health Service. In some primary care trusts (PCTs) this already happens and will be a helpful advance in ensuring that a co-ordinated approach to public health is realised.

The Department for Children, Schools and Families (DSCF) has been streamlined into the Department for Education. The intention is that both the Department of Health and Education will work closely together. This alignment will be especially relevant to those practitioners who work in Children Centres and with school-age children.

Putting patients and the public first
All governments like to adopt key phrases, and the coalition is no different. They have coined the term "Nothing about me without me". It does sum up well the vision for the new NHS, in that the intention will be that no decisions should be made without the full participation of the patient or client.

Patients will also be able to register with any GP practice they want with an open list, without geographical restrictions. Widening of choice has obvious benefits for patients and users but introduces new challenges for providers of services. Possibly the risks around ensuring adequate sharing of information will be the highest priority to address in the future.

The collective consumer voice will also be strengthened with the setting up of Health Watch England, a new independent consumer champion within the Care Quality Commission. Health Watch England will have powers to propose Care Quality Commission investigations of poor services.

This focus on shared decision-making is based on international evidence, which shows that involving patients in their care improves their health outcomes. There are also significant cost benefits as described by Wanless.2 This is to be applauded, but one can question how easily some of the vulnerable, less well educated patients will find this. The NHS is a hugely complex system that is increasingly difficult to navigate. It is open to question whether people will feel able to make complex decisions for themselves, despite all the reassurances that the white paper makes about support and information.

Outcomes and not targets
The government's agenda includes aiming to reduce mortality and morbidity, increase safety, and improve patient experience. Quality standards will be developed by the National Institute for Health and Clinical Excellence (NICE) and will inform the commissioning of all NHS care and payment systems.

NICE expects to produce over 150 standards within the next five years. The standards will span both health and social care, so they will be relevant to all health professionals. The previous government's top-down targets will be abolished and the Operating Framework for 2010/11 has already been revised.3 Targets with no clinical relevance have been removed. The government aims to create the largest social care sector in the world. All NHS trusts will become part of foundation trusts. The government will adopt a back-seat approach and facilitate local commissioning and decision-making.

Conclusions
The white paper sets out a radical new agenda for the NHS. There will be new provider organisations and new local commissioning bodies. The NHS will remain free at the point of use, but it will cease to be a national body centrally managed by the Department. A key challenge for public health nurses will be ensuring that they maintain effective links with primary care, especially GPs. There is a real danger that once employed by local authorities, health visitors' relationships with primary care will become more tenuous and ill defined. We await the white paper on public health and vision for adult social care later this year with great interest. 

References
1. Department of Health. Equity and excellence: Liberating the NHS. London: DH; 2010.
2. Department of Health. Securing our future health: taking a long-term view - the Wanless Report. London: DH; 2002.
3. Department of Health. Revision to the Operating Framework for the NHS in England 2010/11. Available from: www.dh.gov.uk