Dying by inches?: Understanding our NHS as it is now.

OK, today has seen a fascinating (frightening?)  White Paper, which looks like completely changing our NHS. I am probably going to talk a lot about back-door privatisation and the threat to our health system, but I thought I would actually read the White Paper first, and as always I encourage others to check the facts for themselves, rather than relying on media spin or what bloggers have to say. So I hope once you have had a look at my little piece you will actually look at the proposals for yourself.

So why am I bothering to blog on the subject at all? Because a sense of proper outrage generally requires one to have some idea what you are talking about, and unsurprisingly most end users of the National Health Service  have absolutely no idea how it is organised or run. So what I am going to present here, courtesy of the notes of Lisa Langood and my own thinking, is a quick guide to the  organisation as it stands, so that when you read about the reforms you fully understand what is being suggested, and what is there already to be changed. I am sure this may count as the most boring thing I have ever written in many people’s eyes, but hell, I think it’s important. This is a rare thing, a CJ/Lisa Langood co-written piece, though Lisa is at work and does not know I have used her notes! 🙂

The National Health Service (henceforth NHS) came in to existence in England with the National Health Service Act of 1946, forever linked with Aneurin ‘Nye’ Bevan who fought to establish the service in a very limited time frame against initial opposition from large parts of the medical establishment (but mainly the GP’s who were at that time private practitioners You wanted a doctor, you paid for it, or went to a charity hospital). The Scottish NHS was brought in to existence by the National Health Service Act (Scotland) 1947, and after 1967 Wales came to organise its own NHS which became autonomous of the NHS England. Health and Social Care in Northern Ireland (HSC) has many similarities, but its structure is sufficiently different that I will not discuss it here at all. I will focus primarily on the NHS in England, with differences in the Welsh and Scottish mentioned passing.

nhs structure 2009

Figure 1. The Structure of the NHS – from Junior Doctor's Guide to the NHS (NHS, 2009)

OK, look complicated? I will briefly run through what each bit does…

The Department of Health

The overall responsibility for the NHS in terms of planning what it needs to do and meeting statutory requirements (making sure it obeys the law) and government policy is the Department of Health, a large Civil Service organisation, which deals with advising, formulating and implementing government policy and directives on matters of Health. The Department of Health is headed by the NHS Chief Executive, supported by the Chief Medical Officer, who advises the government on medical issues and public health policy and the Permanent Secretary, a civil servant who manages the Department of Health. A number of doctors are appointed to senior positions, acting as civil servants and serving successive governments. These include the Chief Medical Officer already mentioned, the NHS Medical Director, the Director General Research and Development and the Director of Medical Education.

Some government ministerial positions involve a role in the Department of Health, changing with each election as parties appoint their candidates to the roles. These are the Secretary of State for Health, who is a Cabinet member, and include the Minister of State for Health Services, Minister of State for Public Health, the Minister of State for Care Services, and the Parliamentary Under Secretary for Health Services. A Departmental Board of highly qualified individuals provides oversight, but the Department of Health’s main role is the implementation of legislation and creating of policy, as well as oversight of the Strategic Health Authorities. (see below).

Summary: The Department of Health consists of civil servants and politicians advised by high ranking doctors who set policy in line with the Government objectives. So this is the department of Government who has proposed the changes in line with Cameron’s vision for the NHS, a sone might expect and is their duty.

Strategic Health Authorities

There are ten Strategic Health Authorities (SHA’s) in England.  These regional bodies are tasked with oversight of performance of local NHS Trusts (but not Foundation Trusts, both explained in a minute!) and implementing national policies and directives at a local level, as well as ensuring that the correct decisions are made at regional level, taking in to account the different local context. So rather than have specialist care in every regional hospital, certain regional centres specialise – Frenchay in the Southwest for example for head and spine injuries. With a key objective of improving performance and staff development, (and checking all staff are properly trained to the required standards) they form a middle tier of authority between the Department of Health and the local Trusts.

“Created by the Government in 2002 to manage the local NHS on behalf of the Secretary of State, there were originally 28 SHAs. On 1 July 2006, this number was reduced to 10.” – from the Office of the Strategic Health Authorities Website (http://www.osha.nhs.uk/)

The ten SHA’s established in 2006 are (1) NNS East of England, (2) NHS East Midlands, (3) NHS London, (4) NHS North East, (5) NHS North West, (6) NHS South Central, (7) NHS South East Coast, (8) NHS South West, (9) NHS West Midlands and (10) NHS Yorkshire and the Humber. Gloucestershire NHS Trust is within the NHS Southwest Strategic Health Authority region.

Strategic Health Auhorities 2009

Figure 2. The Ten SHA's in England after 2006 from wikicommons

Primary Care Trusts

There are currently (2009) 152 Primary Care Trusts (PCT’s) in NHS England, which answer to their regional SHA; before  October 2006 there were 303, but the number was reduced for efficiency purposes and to redraw boundaries to match those of many local authorities.

A Primary Care Trust is a commissioning body, whose purpose is to ensure local health needs are met in  accordance with the targets and objectives set by the regional SHA, and each Trust has a smaller area which it is responsible for. PCTs manage their own budgets and set their own targets and strategies, in line with the directives from their SHA and the Department of Health. They are responsible for commissioning the provision of the full range of health services . These include hospitals, mental health services, ambulances and paramedic services, GP practices, opticians, community pharmacies, dentists etc. (McCay & Jonas, 2009)  They commission smaller NHS Trusts such as a Hospital Trust (see below) or from the private sector to meet these needs, and are responsible for allocating 80% of the NHS budget. (McCay & Jonas, 2009)

NHS Trusts & NHS Foundation Trusts

Within the area of a Primary Care Trust there will be a number of individual NHS Trusts, which are commissioned to provide one type of service to the region. These generally cover one area, such as a Hospital or Hospitals (Acute) , Mental Health, Ambulance and paramedic services, or Community Health Services such as district visiting, health visiting etc. There are two special kinds of Trust – Care Trusts, which are multi-agency task forces which only exist as partnerships between health and social care providers in a region, ensuring both services work fully together to provide a unified care plan. The second are Children’s Trusts which were created under the Children’s Act 2004, which again are multi-agency Trusts working to bring Education, Social Services and Health care provision together to address cases. (McCay & Jonas, 2009)

A Trust is managed by a board, often of eleven members, who provide direction, monitor performance, deals with the financial integrity and management of the Trust. Trust boards usually have a number of non-executive directors who may not be form a medical background but who bring other expertise or the public’s voice to the meetings, which are also open to the interested public if any wish to attend. Trusts have a legal requirement to break even financially, meet specified quality standards and meet other SHA targets.

A Foundation Trust is a newer initiative from the old New Labour government, designed to give increased local autonomy to the Trust.  Since 2005 Trusts who have met certain levels of financial and other target success are able to apply for Foundation status, which exempts them from SHA and Monitor control, and allows them to “run their own financial house”. They are able to set local wages and conditions, borrow money to meet short term needs under certain statutory limitations and  to manage how they meet targets and performance benchmarks in their own way, as long as they meet  the somewhat higher financial and quality control goal posts. They are regulated directly by a supervisory board called the Monitor which reports directly to Parliament. The aim is for all trusts to move towards Foundation Trust status, but as of August 2009 the number achieving this was 122 (the Reforms announced today will make ALL Trusts Foundation Trusts by 2013.)

A special type of Foundation Trust is the Foundation Trust equivalent, (FTe), all of which are specialist psychiatric trusts such as the one that covers Rampton Hospital for the Criminally Insane. They are still regulated by the SHA, but the Secretary of State has a personal remit to review cases and provide oversight to problems arising here.

Primary Care Providers

This group, often the first point of contact for patients, are businesses who work within the NHS structure but are privately owned and managed in accordance with legislation. They include GP’s surgeries, NHS dentists, optometrists, community pharmacies, etc. They are still subject to Primary Care Trust supervision and must work within constraints and parameters laid out to meet patient needs. It is for example not just possible to open a new pharmacy, especially in a rural area which may already have dispensers attached to a local GP’s surgery, but the new pharmacy must meet certain requirements to ensure it meets a perceived need in the neighbourhood and is properly run by a fully qualified pharmacist. Receipts, prescriptions and payments from the PCT and the constant supervision of the latter body mean that these primary care providers work closely alongside the licensing PCT in support of the local plan, at least in theory.  Also working in this area are Voluntary and Charitable groups and Social Enterprises who meet specific needs but work closely with the PCT to fulfil the overall health needs of the area.

Lisa wrote in 2009 “The NHS structures have evolved over time, with the creation of the NHS Trusts replacing the older Health Authorities and the introduction of SHA’s being major changes. Alan Milburn’s 2002 creation of Foundation Trusts, which came in to effect in 2005 have sparked considerable controversy, with opponents claiming that the setting up of the monitor and allowing them to stand outside the existing NHS plans of the Department of Health and SHA’s is a stealth move towards privatisation.  More importantly some claim this removes the cohesiveness of the National/Regional/Local plan, and reduces SHA’s ability to draw upon needed resources and create a regionally effective structure. Some of the heaviest criticisms have been directed at the financial targets which it is claimed may lead trusts to specialise in cost effective and profitable health care options, leaving expensive but necessary services underfunded and pushed out to other providers. As with any complex management structure there are obvious issues when the various Trusts and commissioned Primary providers must engage in multi-agency work, such as in the case of children with severe mental health, family and  educational problems, and even within the NHS structure different trusts must create working guidelines for how to share information and responsibility on specific cases, while maintaining client confidentiality and abiding the  provisions of the Data Protection Act.

Any multi agency approach runs the risk of the “somebody else’s problem” issue, where the relevant organisations and individuals assume that the needs are being addressed elsewhere, but do not check that  this is actually occurring. Faced with busy case loads and many issues it has frequently occurred in the past as we see from many high profile cases which eventually became newspaper tragedies, where a lack of coordination led to unfortunate oversights. Communication between the parties involved is absolutely key. Many health care  authorities are working to create regional multi-agency teams to deal with exactly this sort of case, but this has led to new challenges.  For example, when one steps outside of sole practice and works as a team, where does accountability lie?  Who is ultimately responsible for the decisions taken by the team?  Some GP’s are already concerned about the professional repercussions of decisions made by multi-agency teams they comprise part of, and the GMC has issued guidelines –  http://www.gmc-uk.org/guidance/current/library/accountability_in_multi_teams.asp

These problems can plague the attempts for various Health Care Providers to provide a unified and consistent approach to a problem.”

So what is actually changing?

I still need to read the White Paper properly, but the Strategic Health Authorities and Primary Care Trusts are being abolished. So everything will devolve to local level, and the GP’s will be asked to form consortiums instead to run the local areas doing the work of the now defunct PCT. For this they are being granted an £80 billion pound budget, and the provision of services currently provided by the Primary Care Trusts will pass to the GP Consortiums. Overall responsibility for Public Health campaigns and services passes to the  Local Authorities (by which one assumes county and town councils, and hence one might cynically assume, our Council Tax bills). ALL NHS Trusts are to become Foundation Trusts by 2013. To allow this to occur the current caps on Trusts taking on fee paying private patients are to be lifted, and Trusts which fail to achieve profitability and go bankrupt will be allowed to go under, not be bailed out. (So yes, hospitals can now go bust and be closed down, if they fail to break even.)

I am unsure if the new GP consortiums will consist of solely NHS employed doctors, or include GP’s in the private practices that treat NHS patients and are paid by the NHS for providing that service currently by the PCT’s. If the latter, it means that the doctors consortiums will be able to award contracts to their own practices, set their own fees etc, etc? I really need to read this paper! I’ll write more once i have properly read and digested it in a future post.

Anyway I appreciate this has been a bit dull (understatement I guess!) but hopefully if you took the time it read it you have a little more idea of the background, and a better understanding of the news coverage of the NHS reforms announced today.

cj x


About Chris Jensen Romer

I am a profoundly dull, tedious and irritable individual. I have no friends apart from two equally ill mannered cats, and a lunatic kitten. I am a ghosthunter by profession, and professional cat herder. I write stuff and do TV things and play games. It's better than being real I find.
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3 Responses to Dying by inches?: Understanding our NHS as it is now.

  1. The idea of making public health the responsibility of local councils is truly frightening. Tewkesbury Borough Council don’t even provide a pest control service, let alone have the ability to control viral outbreaks. In fact TBC are technically breaking the law by not providing wasp nest removal services to those with sting allergies. http://www.tewkesbury.gov.uk/index.cfm?articleid=417

  2. Chris Jensen Romer says:

    I’m still looking at exactly how it all works, but I guess I had best ask Councillor Paul Wheeldon round for a quick game of Pandemic so he can brush up on his epidemiology skills for when CBC have to save us from a new flu strain! The tragic thing is, I’m not entirely joking, as far as I can see Public Health does transfer now to Local Authorities, and yep that includes vermin control and epidemiology. 😦

    cj x

  3. Chris Jensen Romer says:

    OK, what will Local Authorities be up to?

    “We will strengthen the collective voice of patients and the public through arrangements led by local authorities, and at national level, through a powerful new consumer champion, HealthWatch England, located in the Care Quality Commission.” p.4

    “To strengthen democratic legitimacy at local level, local authorities will promote the joining up of local NHS services, social care and health improvement.” p.4 (that’s public Health I guess?)

    “PCT responsibilities for local health improvement will transfer to local authorities, who will employ the Director of Public Health jointly appointed with the Public Health Service. The Department will create a ring-fenced public health budget and, within this, local Directors of Public Health will be responsible for health improvement funds allocated according to relative population health need. The allocation formula for those funds will include a new “health premium” designed to promote action to improve population-wide health and reduce health inequalities.” – p.10

    So Public Health moves to the Local Authorities, but they will have a public health centrally provided budget – that bit’s good news – administered by a new Director of public Health in the County Council I presume.

    “Local Involvement Networks (LINks) will become the local HealthWatch, creating a strong local infrastructure, and we will enhance the role of local authorities in promoting choice and complaints advocacy, through the HealthWatch arrangements they commission.” p.19

    “Local authorities will be able to commission local HealthWatch or HealthWatch England to provide advocacy and support, helping people access and make choices about services, and supporting individuals who want to make a complaint. In particular, they will support people who lack the means or capacity to make choices; for example, helping them choose which General Practice to register with; Local HealthWatch will be funded by and accountable to local authorities, and will be involved in local authorities’ new partnership functions, described in chapter 4. To reinforce local accountability, local authorities will be responsible for ensuring that local HealthWatch are operating effectively, and for putting in place better arrangements if they are not.” p.20

    So the new oversight group is to be funded by local authorities – lucky old us. 🙂

    on Public Health

    “The Secretary of State, through the Public Health Service, will set local authorities national objectives for improving population health outcomes. It will be for local authorities to determine how best to secure those objectives, including by commissioning services from providers of NHS care.” p.22

    Presumably by letting people deal with their own vermin in Tewkesbury! 🙂 Note the including by – there is no requirement to use NHS services, your local authority can now set whoever they like to do this stuff. I might become a pest exterminator. 🙂

    “Consortia of GP practices, working with other health and care professionals, and in partnership with local communities and local authorities, will commission the great majority of NHS services for their patients.” p.28

    “GP consortia will need to have a sufficient geographic focus to be able to take responsibility for agreeing and monitoring contracts for locality-based services (such as urgent care services), to have responsibility for commissioning services for people who are not registered with a GP practice, and to commission services jointly with local authorities.”

    Interesting. While the press emphasis has been on GP consortiums (I refuse to use a Latin ending needlessly for a term used in English – stadiums not stadia!) what we are seeing here is actually a COLLABORATION between the gP consortiums and the Local Authority replacing the PCT’s and SHA’s. Maybe people are less enthusiastic if they realise their Health Care will be council driven?

    “GP consortia will have the freedom to decide what commissioning activities they undertake for themselves and for what activities (such as demographic analysis, contract negotiation, performance monitoring and aspects of financial management) they may choose to buy in support from external organisations, including local authorities, private and voluntary sector bodies.” p.29

    Here is the vital bit

    “To realise administrative cost savings, and achieve greater alignment with local government responsibilities for local health and wellbeing, the Government will transfer PCT health improvement functions to local authorities and abolish PCTs ” p.34

    “Building on the power of the local authority to promote local wellbeing, we will establish new statutory arrangements within local authorities – which will be established as “health and wellbeing boards” or within existing strategic partnerships – to take on the function of joining up the commissioning of local NHS services, social care and health improvement. These health and wellbeing boards allow local authorities to take a strategic approach and promote integration across health and adult social care, children’s services, including safeguarding, and the wider local authority agenda.

    4.18 We will simplify and extend the use of powers that enable joint working between the NHS and local authorities” p.34

    “These arrangements will give local authorities influence over NHS commissioning, and corresponding influence for NHS commissioners in relation to public health and social care.” p.35

    “Local authorities’ new functions
    Each local authority will take on the function of joining up the commissioning of local NHS services, social care and health improvement.
    Local authorities will therefore be responsible for:
    • Promoting integration and partnership working between the NHS, social care, public health and other local services and strategies;
    • Leading joint strategic needs assessments, and promoting collaboration on local commissioning plans, including by supporting joint commissioning arrangements where each party so wishes; and
    • Building partnership for service changes and priorities. There will be an escalation process to the NHS Commissioning Board and the Secretary of State, which retain accountability for NHS commissioning decisions.
    These functions would replace the current statutory functions of Health Overview and Scrutiny Committees. “p.36

    We are due in April 2012 to have “Public Health Service in place, with ring-fenced budget and local health improvement led by Directors of Public Health in local authorities” I[‘m going o resist cheap jokes about the Mayan Calendar!

    “NHS services will continue to be funded by the taxpayer. The Department of Health will receive funding voted by Parliament, and will remain accountable to Parliament and HM Treasury for NHS spend.”

    What interests me is to what extent Local Authority funding will meet the requirement, or if we are just seeing a shift from central taxation to council tax? We will see…

    cj x

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