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NHS White Papers - …

RESEARCH paper 98/1526 JANUARY 1998 The NHS White PapersOn 9 December 1997, the Department of Health andthe Scottish Office published White Papers , The newNHS, modern, dependable and Designed to care, onhow the "internal market" in the NHS was to beabolished. The Welsh Office brought out the equivalentpaper for the NHS in Wales, NHS Wales: puttingpatients first on 15 January 1998. This papersummarises the main proposals in the three WhitePapers and discusses some of the comments made byinterested parties to date. Legislation will be needed toimplement some of the changes, and this is expected inthe parliamentary session 1998 WrightSOCIAL POLICY SECTIONHOUSE OF COMMONS LIBRARYL ibrary Research Papers are compiled for the benefit of Members of Parliament and theirpersonal staff.

The NHS White Papers On 9 December 1997, the Department of Health and the Scottish Office published White Papers, The new NHS, modern, dependable and Designed to care, on how the "internal market" in the NHS was to be abolished. The Welsh Office brought out the equivalent paper for the NHS in Wales, NHS Wales: putting patients first on …

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1 RESEARCH paper 98/1526 JANUARY 1998 The NHS White PapersOn 9 December 1997, the Department of Health andthe Scottish Office published White Papers , The newNHS, modern, dependable and Designed to care, onhow the "internal market" in the NHS was to beabolished. The Welsh Office brought out the equivalentpaper for the NHS in Wales, NHS Wales: puttingpatients first on 15 January 1998. This papersummarises the main proposals in the three WhitePapers and discusses some of the comments made byinterested parties to date. Legislation will be needed toimplement some of the changes, and this is expected inthe parliamentary session 1998 WrightSOCIAL POLICY SECTIONHOUSE OF COMMONS LIBRARYL ibrary Research Papers are compiled for the benefit of Members of Parliament and theirpersonal staff.

2 Authors are available to discuss the contents of these Papers with Membersand their staff but cannot advise members of the general Library Research Papers include:98/14 Private Hire Vehicles (London) Bill 1997/98 Bill Rights (Dispute Resolution) Bill [HL] 1997/98 Bill Processions in Northern by Constituency - December Government in Barnett Development Agencies Bill [Bill 100 of 1997/98] Scotland Bill: the Scottish Parliament and Local Scotland Bill: tax-varying Scotland Bill: Some Constitutional and Representational Scotland Bill: Some Operational Aspects of Scottish Scotland Bill: Devolution and Scotland's Changes after English White structure of the NHS91. Primary care groups92. Health Authorities113. The successor to the internal market124. Resource and performance and Scottish White paper : Designed to Welsh White paper : NHS Wales: putting patients first22 IVReactions to the White care groups251.

3 GP incentives262. Management273. Structure and accountability274. Primary care of with other paper 98/155 SummaryIn 1991, the Conservative Government introduced major changes to the management of theNHS through the National Health Service and Community Care Act 1990. This Act created a"purchaser/provider split" in the NHS between Health Authorities (responsible for assessingthe health needs of their local populations and commissioning appropriate health services forthem) and NHS trusts (responsible for providing those services). The concept of "GPfundholders" was also introduced, allowing GP practices to hold budgets and hence haveconsiderable independence from their local Health Authority. Health Authorities and GPfundholders were at liberty to purchase services from whichever NHS trusts, or privateproviders, they wished, with the aim that the competition created by this "internal market"would both drive up standards and improve efficiency.

4 A more detailed summary of the mainaspects of the changes introduced by the 1990 Act is given in Library Research paper 93/109,The NHS reforms - the developing their election manifesto, the Labour party promised to retain this "purchaser/provider split"but to abolish the internal market which they believed had led to both waste and Government's proposals to achieve this were set out recently in three White Papers : Thenew NHS (England), Designed to care (Scotland) and NHS Wales: putting patients first . PartII of this paper summarises the proposals for England. Changes include: the creation of "primary care groups" of GPs and community nurses to take on the role ofcommissioning care from NHS trusts, with the ultimate aim of becoming free-standing"primary care trusts" Health Authorit ies to be given a more strategic role the system of annual contracts between purchasers and providers to be replaced bylonger-term "service level agreements" budgets for hospital and community services, GP prescribing and GP infrastructure to bemerged a new framework to be introduced to monitor NHS trusts' performance, with emphasis onquality and accessibility as well as finance a new "National Institute for Clinical Effectiveness" and a "Commission for HealthImprovement" to be set up.

5 The former to disseminate good practice guidelines and thelatter with the powers of intervening where quality standards are inadequate three specific initiatives: a 24 hour telephone advice line, "NHS Direct", for patients; theconnection of all GP surgeries to the NHS's information superhighway; and a guaranteeof a maximum 2 week wait to see a cancer specialist after referral by a GPPart III of this paper describes the proposals for Scotland and Wales. Although the broadprinciple, that of abolishing the internal market, is the same across all three countries, thereare significant differences in detail. In Scotland, GPs and other community staff will combinewith NHS trusts providing community services to become "primary care trusts", but theseResearch paper 98/156trusts (unlike the primary care groups in England) will not be responsible for commissioninghospital care from "acute" trusts.

6 In Wales, "local health groups" of GPs, other healthprofessionals and representatives from social services departments and the voluntary sectorwill be responsible for commissioning care but will remain sub-committees of HealthAuthorities and will not have the option of become free-standing bodies as in IV of the paper brings together some of the comments made to date on the three WhitePapers. In general, the response from health service professionals, academics and the generalpress has been positive, although there has been a lot of discussion as to how "primary caregroups" and their Scottish and Welsh equivalents will work in practice. Particular issues thathave been raised include the question of what incentives GPs will have to join primary caregroups, how the groups will be managed, to what extent they will be accountable to theirlocal populations and whether GP fundholders will accept their lessened independence.

7 Themerging of the hospital and community services, GP prescribing and GP infrastructurebudgets has been welcomed, as have the proposals to give a greater emphasis to quality ofcare. Many commentators, though, have expressed concerns that the White Papers do nothingto address the question of the adequacy of the existing funding of the paper 98/157I IntroductionIn its 1997 manifesto, the Labour Party promised to make major changes to the NHS, stating:"There can be no return to top-down management, but Labour will end the Conservatives'internal market in healthcare. The planning and provision of care are necessary and distinctfunctions, and will remain so. But under the Tories, the administrative costs of purchasingcare have undermined provision and the market system has distorted clinical priorities.

8 Labourwill cut costs by removing the bureaucratic processes of the internal market. The savingsachieved will go on direct care for patients. As a start, the first 100 million will treat an extra100,000 patients. We will end waiting for cancer surgery, thereby helping thousands ofwomen waiting for breast cancer recent years, GPs have gained power on behalf of their patients in a changed relationshipwith consultants, and we support this. But the development of GP fundholding has alsobrought disadvantages. Decision-making has been fragmented. Administrative costs havegrown. And a two-tier service has resulted. Labour will retain the lead role for primary carebut remove the disadvantages that have come from the present system. GPs and nurses willtake the lead in coming together locally to plan local health services more efficiently for allthe patients in their area.

9 This will enable all GPs in an area to bring their combined strengthto bear upon individual hospitals to secure higher standards of patient provision. In makingthis change, we will build on the existing collaborative schemes which already service 14million current system of year-on-year contracts is costly and unstable. We will introduce three tofive-year agreements between the local primary care teams and hospitals. Hospitals will thenbe better able to plan work at full capacity and co-operate to enhance patient services."1 Two White Papers were published on 9 December 1997, setting out how the Governmentintends to fulfil these promises: The new NHS: modern, dependable,2 covering England, andDesigned to care,3 covering Scotland. A further White paper , covering Wales, was publishedon 15 January 1998: NHS Wales: putting patients first4 and a consultation paper for NorthernIreland, has been promised for the near future.

10 This paper will summarise the main points ofthe English, Scottish and Welsh White Papers , together with a discussion of the responses tothe proposals which have been made so Labour Party, New Labour: because Britain deserves better, 19972 Cm 3807, 9 December 19973 Cm 3811, 9 December 19974 Cm 3841, 15 January 1998 Research paper 98/158II The English White PaperThe Department of Health sets out six key aims which it believes underlie the proposedchanges. These are set out in the White paper , The new NHS: modern, dependable, asfollows:" first , to renew the NHS as a genuinely national service. Patients will get fair access toconsistently high quality, prompt and accessible services right across the country but, second, to make the delivery of healthcare against these new national standards amatter of local responsibility.


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