1 Date of preparation: May 2011. [AXHUR102574m]

Jane Salvage Chair designate, Queen’s Nursing Institute

Editor, NMC Review

Visiting professor, Florence Nightingale School of Nursing, KCL

work@janesalvage.me.uk

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2 Date of preparation: May 2011. [AXHUR102574m]

Session objectives

1. Summarize key changes in the NHS

2. Highlight the implications for practice nursing

3. Discuss how practice nurses can face the challenges and make the most of the opportunities

“There is nothing around us to reverse the direction of development and change … thus we are posed with the question of being the

master of these changes or their servant.”

Mo Im Kim 2003

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4 Date of preparation: May 2011. [AXHUR102574m]

Government proposals and timescale

• Equity and Excellence: Liberating the NHS published July 2010

• Health and Social Care Bill presented to Commons, January 2011

• Secretary of State announced two-month ‘pause’, April 4

• Critical report by Commons health committee, April 5

• Government launched 'listening exercise’, April 6

• Government promises to amend Bill

• Bill now at committee stage, House of Lords

5 Date of preparation: May 2011. [AXHUR102574m]

The rhetoric

• The White Paper set out the government’s long-term vision for the future of the NHS

• It says its vision builds on the core values and principles of the NHS – a comprehensive service, available to all, free at the point of use, based on need not ability to pay

• The government says it will:

– put patients at the heart of everything the NHS does, and make the NHS more accountable to them

– focus on continuously improving the outcome of their healthcare

– empower and liberate clinicians to innovate and focus on improving services

– free staff from excessive bureaucracy and top-down control

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Key proposals

• Power and responsibility for commissioning services devolved to GPs, working in clinical commissioning groups (60% of NHS budget)

• Local authorities to lead joining up NHS, social care & health improvement

• Independent NHS Commissioning Board to lead on quality & access

• All NHS trusts to become foundation trusts with greater freedoms

• Many more employee-led social enterprises

• Monitor to become economic regulator

• Care Quality Commission inspectorate role strengthened

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Employment issues

• Implementation of Boorman report on occupational health

• Service providers to pay education and training costs

• Individual employers to determine local pay

• Pay frozen for 2 years for those earning over £21,000

• Pensions review

• Review of regulation to reduce burden and cost

8 Date of preparation: May 2011. [AXHUR102574m]

Health and Social Care Bill 2011

• Establishes an independent NHS board to allocate resources and provide commissioning guidance

• Increases GPs’ powers to commission services on behalf of their patients

• Strengthens role of Care Quality Commission

• Develops Monitor, the body that currently regulates NHS foundation trusts, into an economic regulator to oversee aspects of access and competition in the NHS

• Abolishes 152 PCTs and 10 SHAs by 2013

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The context: ‘Cutting bureaucracy and improving efficiency’

•Government promises small real-terms rise in NHS funding •Spiralling costs, rising inflation •The ‘Nicholson challenge’ – up to £20bn efficiency savings in NHS in 2011–2014 •45% cut in management costs, 2011–2014 •Thousands of job losses, including front line •Demand for skilled care outstripping supply •Massive reorganisation & abolition health bodies •Department of Health NHS functions will focus on public health, inequalities, adult social care

10 Date of preparation: May 2011. [AXHUR102574m]

Timetable – subject to change!

NHS Commissioning Board established in shadow form as a special health Authority; statutory body in 2012

NHS Outcomes Framework fully implemented by 2012

PCT commissioning and provision separated by April 2011 > ‘any willing provider’ Comprehensive system of GP consortia in place in shadow form during 2011/12, taking on increased delegated responsibility from PCTs Following passage of Health & Social Care Bill, consortia to take on responsibility for commissioning in 2012–13 NHS Commissioning Board to make allocations for 2013–14 directly to GP consortia in late 2012

GP consortia to take full financial responsibility from April 2013

Local authorities’ new functions – no date given

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NHS Future Forum report, June 2011

People accept need for change but ‘want the changes to be the right ones and to feel ownership of them’

The current model of care cannot be sustained

GPs ‘must be required to obtain all relevant multi-professional advice to inform commissioning decisions & the redesign of patient pathways’ – ‘strong role for clinical and professional networks’ – establish ‘multi-specialty clinical senates to provide strategic advice’

Competition should be a tool supporting choices, promoting integration and improving quality’ – not an end in itself

The pace of the reforms must ‘vary’

More time is needed to get workforce education and training right

12 Date of preparation: May 2011. [AXHUR102574m]

Government response, June

Promises key changes – some but not all require Bill amendments

NHS Constitution upheld + NHS free at point of use

Greater assurance that commissioning will ‘involve’ nurses, patients etc

Every clinical commissioning group to have governing body with decision-making powers, with at least 1 RN, 1 medical specialist, 2 lay members

PCTs cease to exist next April, SHAs to be clustered then abolished

All CCGs to be established by then, but can only start commissioning when they are ‘ready and willing’

Clinical networks to be strengthened, with stronger commissioning role

Formal role of clinical senates in authorising CCGs

‘Any Qualified Provider’ unchanged, just slowed down a bit

Safeguards against privatisation

Most trusts to be foundation trusts by April 2014

More work to be done on education and training esp CPD

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The implications for nursing – negatives

• Unprecedented change

• More to do with fewer staff and less resources

• Damage to nursing leadership, at least in short term

• Fight to maintain and enhance nursing voice at all levels

• Threat to specialist posts

• Much will depend on local structures and relationships

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The implications for nursing – positives

• Unprecedented change

• Much will depend on local structures and relationships

• Opportunities to be seized

• Growing recognition of the need for skilled care, especially for long-term and complex conditions

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Preparation for change and delivery of future services

• Understand policy-making

• Effective leadership in senior roles

• Networking

• Mobilise grass roots

• Alliances with communities and patients

• Developing our evidence base

• Creating and sharing good tools and processes

• Better processes to thrash out differences and present united front

• Need to be more proactive and savvy

• Put nursing on the radar – policy with us rather than about us

• Alignment with overall health policy

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Face the challenges, seize the opportunities

We must become policy activists and entrepreneurs:1,2

• Position yourself to influence policy

• Bring together problems, policies and politics into a novel amalgamate: new policy

• Soften up the system by presenting participants in the network (visible and invisible) with alternative representations of their realities

• This leads to opening a window of opportunity – potential for a truly new policy perspective

References 1.Kingdon, J.W. (1995). Agendas, Alternatives and Public Policies; 2nd ed. Harper Collins College Publishers, New York 2.De Leeuw E. Five books that shaped my view of health policy, Reviews of Health Promotion and Education Online, 2003. http://rhpeo.net/reviews/2003/1/index.htm

17 Date of preparation: May 2011. [AXHUR102574m]

Which kind are you?

• those who watch things happen

• those who wonder what happened

• those who make things happen

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