Contents
Forewords 6
NHS Confederation 8
Introduction: one system – four structures 9
01 The new structure of the NHS in England
Parliament 12 Department of Health 15 Other government departments 17 Arm’s-length bodies 17 NHS Commissioning Board 18 Clinical commissioning groups 20 Health and wellbeing boards 22 Foundation trusts 23 Independent providers 25 Managing the transition 30
02 Commissioning
The basics 34 Clinical commissioning groups’ role 35 NHS Commissioning Board’s role 38 Health and wellbeing boards’ role 39 Commissioning and competition 42 Public health 45
03 Providing services
Primary care 60 Community health services 69 Integrated care 72 Secondary care 77 Urgent and emergency care 84 Maternity services 91 Mental health 92 Care for special groups 99
04 Policy and strategy: creating a ‘vision’ for the NHS
The planning framework 106 Equality and diversity 110
05 Quality and safety
Ensuring quality 116 Ensuring patient safety 127
06 Accountability and regulation
The role of boards and governing bodies 132 Engaging patients and the public 137 Complaints 143 Regulation and inspection 147 Professional regulation 150
07 Financing the NHS
Sources of funding 158 Resource allocation 161 Capital 163 NHS spending 166 Buying goods and services 169
08 Staffing and human resources
Workforce planning 176 Pay and pensions 180 The NHS as an employer 183
09 Evidence, research and development
Government, strategy and infrastructure 188 Funding R&D 193 Research organisations 194 Nurturing innovation 195
10 Information technology
IT policy and the information strategy 200 IT infrastructure 202 Collecting and using data 206
11 The NHS in Scotland
The structure of NHSScotland 210 Strategy and policy 218
12 The NHS in Wales
The structure of NHS Wales 222 Strategy and policy 227
13 The NHS in Northern Ireland
The structure of the NHS in Northern Ireland 232 Strategy and policy 236
14 The NHS in Europe
EU health policy 243 Cross-border healthcare 244 Current EU policy initiatives 246
Acronym buster 248
Index 259
Acknowledgements 267
Please contact us on 0870 444 5841 for more information about the versions of The NHS handbook 2012/13 suitable for those with a visual impairment.
Foreword The NHS has changed so significantly in recent years that the traditional model of NHS care is, in many cases, no longer recognisable. Our healthcare system is more fluid and diverse than ever before and the NHS needs to continually adapt to meet the changing needs and expectations of patients and taxpayers. The NHS handbook 2012/13 is the must-have guide to help you navigate and make sense of the changing shape of the NHS. With the Government’s Health and Social Care Bill receiving royal assent in spring 2012, we have updated the guide to cover: • the structure of the NHS • clinical commissioning groups • the changing provider landscape • the NHS Commissioning Board • health and wellbeing boards. There’s also a handy acronym buster to help you find your way around the names of the new organisations, which is also available online at www.nhsconfed.org/nhshandbook The NHS handbook is supported by advertising from a number of organisations we work alongside, and I am particularly grateful to NHS Professionals for kindly agreeing to support this landmark edition. I hope you find this timely guide invaluable in 2012/13. At the NHS Confederation we will continue our work to join up the views, perspectives and opinions of each and every part of the healthcare system over the coming year. If you have any comments or suggestions for future editions of The NHS handbook, please contact our publications team on 020 7074 3200 or email publications@nhsconfed.org Mike Farrar CBE Chief executive NHS Confederation
foreword
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Who we are The NHS Confederation represents all organisations that commission and provide NHS services. We are the only membership body to bring together and speak on behalf of the whole of the NHS. We have offices in England, Wales (the Welsh NHS Confederation) and Northern Ireland (Northern Ireland Confederation for Health and Social Care) and provide a subscription service for NHS organisations in Scotland.
What we do We work with our members and health and social care partners to help the NHS guarantee high standards of care for patients and best value for taxpayers by: • making sense of the whole health system • influencing health policy • supporting our members to share and implement best practice • delivering industry-wide support functions such as the NHS Employers organisation and the NHS European Office. We represent the NHS as a whole and have a range of networks and forums to support our members on issues of specific concern to their part of the NHS. Ambulance Service Network • Primary Care Trust Network • NHS Partners Network • Mental Health Network • Community Health Services Forum
We also offer the opportunity for organisations working across the wider health and social care industry to be a part of the NHS Confederation as associate partners. Further information To find out more about the NHS Confederation, please visit our website at www.nhsconfed.org
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04 Policy and strategy: creating a ‘vision’ for the NHS
The planning framework 106 Equality and diversity 110
Making and implementing policy is a key strand of the Department of Health’s work, and during a government’s term of office it will publish a plethora of major policy documents designed to improve health and social care, turning political vision into action. Policy and strategy are aimed both at the long term – for example, setting out a ‘vision’ of how the NHS might look in five or ten years’ time – the medium term, such as the three-year cycle of the NHS’s operational plans, and the short-term, such as the annual operating framework. And apart from initiatives specific to the health and social care system, the NHS is influenced by cross-government policy and strategy frameworks such as the spending review and structural reform plans.
The planning framework The Government set its long-term strategy for public services in the 2010 spending review. It also decided the financial settlement for every government department and published structural reform plans that contain its priority outcomes for the spending review period. In turn, the DH published its priorities in its business plan, while the NHS operating framework outlines priorities for the health service over a three-year planning cycle. Spending reviews Every government carries out a long-term and fundamental review of all its expenditure soon after coming to power. The spending review is a Treasury-led process to allocate resources across all departments, according to the Government’s priorities. Spending reviews set firm and fixed budgets over several years for each department. It is then up to departments to decide how best to manage and distribute this spending within their areas of responsibility. Before spending reviews were introduced in the 1990s, departmental budgets were set on a year-by-year basis, making multi-year planning more difficult. The previous Labour Government held comprehensive spending reviews in 1998 and 2007. Following the coalition Government’s first Budget in June 2010, setting out the overall level of public spending until 2014/15, it announced details of its spending review in October 2010, fixing budgets for each government department for the four years to 2014/15. The NHS settlement is contained within the DH’s budget.
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Key text: Liberating the NHS Two months after the coalition Government came to power it published its first health white paper, Equity and excellence: liberating the NHS, together with a suite of complementary documents. The white paper outlined the far-reaching structural reorganisation now underway (see chapter 1), reinforced the importance of the market in the NHS in England and announced that the DH’s role would be reduced. On its launch, Liberating the NHS was greeted as representing potentially the most significant change in the NHS’s history. It contained the promise: ‘In the next five years, the coalition Government will not produce another long-term plan for the NHS’. Principles underlying the white paper include: • the Government is committed to an NHS available to all, free at the point of use and based on need, not ability to pay • health spending will increase in real terms annually for five years • the Government’s vision for the NHS is rooted in the coalition’s ‘core beliefs of freedom, fairness and responsibility’ • while the Government will be clear about what the NHS should do, it will not stipulate how to do it • funding must be used efficiently: ‘the single greatest priority for the next Parliament will be to reduce the deficit’. It aimed to empower clinicians while rendering the NHS free from frequent and arbitrary political interference. Such was the scale of public and professional disquiet about the white paper that the Government held a ‘listening exercise’ led by the NHS Future Forum (see page 108) to consult on the changes as the Health and Social Care Bill was passing through Parliament. After some adjustment, the bill resumed its passage and has since become the Health and Social Care Act 2012. Further information Equity and excellence: liberating the NHS, DH, July 2010. Liberating the NHS: legislative framework and next steps, DH, December 2010.
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Key organisation: NHS Future Forum By early 2011, concern among the public, healthcare professionals and MPs about the Government’s plans for reorganising the NHS led ministers to resume consultation on the proposals while the bill intended to make them law was still being considered by Parliament. The Secretary of State announced that the Government was ‘to take advantage of a natural break in the legislative process to pause, listen and reflect’. The NHS Future Forum, a group of 45 senior professionals from health and social care, was set up to carry out an intensive eight-week ‘listening exercise’ during April and May. Its brief was to act as an independent advisory panel noting people’s concerns, reporting on what was heard and offering advice to the Prime Minister, Deputy Prime Minister and Secretary of State on how the plans might be improved. Its four core themes were: • choice and competition • public accountability and patient involvement • clinical advice and leadership • education and training. Forum members attended 250 events and heard opinions from over 8,000 people, including 250 organisations. The Government accepted its recommendations and altered the Health and Social Care Bill accordingly. The Government then asked the Forum to continue its conversations with patients, service users and professionals to provide independent advice on how to: • make information improve health, care and wellbeing • develop the healthcare workforce • ensure the reorganisation leads to better integration of services • ensure the public’s health remains at the heart of the NHS. For this, the Forum held more than 300 events, which attracted 12,000 people. Once again, the Government accepted its recommendations. The Forum also influenced the 2012/13 NHS operating framework (see page 110). Further information Summary report on proposed changes to the NHS, NHS Future Forum, June 2011. Government response to the NHS Future Forum report, DH, June 2011. Summary report – second phase, NHS Future Forum, January 2012.
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The scale of the deficit provided the main context for the 2010 spending review, prompting the Government to take radical action to limit public expenditure. However, to honour its commitment to protect health spending, the NHS budget is planned to increase by 0.4 per cent in real terms to 2014/15 (see page 168). The Chancellor’s Autumn Statement in 2011 implied that the NHS would not see higher spending for a long time, with current funding levels set to persist into the next Parliament. Further information Spending review 2010, HM Treasury, October 2010. Autumn Statement 2011, HM Treasury, November 2011.
Structural reform plans Until the 2010 general election, the DH’s medium-term objectives were defined by its public service agreement (PSA) made with the Treasury. The coalition Government abolished PSAs, replacing them with structural reform plans (SRPs). The DH’s SRP is included in its business plan for 2011–15. Its five main priorities are to: • integrate health and care systems around the needs of patients and users • promote better health outcomes • revolutionise NHS accountability • promote public health • reform social care. The DH also agreed four ‘major responsibilities’ to: • maintain performance on waiting times • run an efficient and effective department of state • help prepare for emergencies • devolve leadership of information technology development. A monthly report on progress in meeting the SRP commitments appears on the DH website. Further information Business plan 2011–2015, DH, July 2011. Department of Health annual report and accounts 2010–11, TSO, September 2011. www.dh.gov.uk
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NHS operating framework The annual operating framework sets out the business and planning arrangements for the NHS for the coming year. The framework for 2012/13 describes the national priorities and system levers the NHS needs in order to change services while maintaining and improving quality and finance. It assigns four ‘key themes’ for all NHS organisations during the year: • putting patients at the centre of decision-making • completing the last year of transition to the new system • increasing the pace of the quality, innovation, productivity and prevention (QIPP) challenge (see page 170) • maintaining and improving performance, including ensuring the NHS Constitution right to treatment within 18 weeks is met. Key areas for improvement are dementia and care of older people, carers support and military and veteran health. Allocations to primary care trusts will grow by at least 2.5 per cent in 2012/13, while the running cost of clinical commissioning groups will be £25 per head of population. Further information The operating framework for the NHS in England 2012/13, DH, November 2011. Briefing 232: Operating framework for the NHS in England 2012/13, NHS Confederation, December 2011.
Equality and diversity Eliminating discrimination and disadvantage in the healthcare workforce and reducing health inequalities in the population are major policy aims of the DH and the NHS. Like all other public bodies, both have a legal duty to eliminate discrimination, harassment and victimisation, advance equality of opportunity and promote good community relations. Equality Act 2010 The Equality Act 2010 outlaws discrimination on grounds of: • age • disability • gender reassignment • marriage and civil partnership • pregnancy and maternity • race • religion or belief • sex • sexual orientation.
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The Act includes a new public sector equality duty, which demands equality issues be taken into account when developing policy. DH officials must analyse all available evidence to establish whether their policies or practices meet the aims of the public sector equality duty. Boards of NHS organisations are required to explicitly provide assurance, and disclose any non-compliance with equality legislation, through their annual statement on internal control. The DH’s equality and human rights assurance group has set up a twoyear transformation programme to develop a long-term cultural shift in the health and adult social care system with the aim of embedding equalities across policies, programmes and service delivery. Further information Briefing 74: The Equality Act 2010: employment implications for the NHS, NHS Employers, October 2010.
NHS Equality and Diversity Council The NHS Equality and Diversity Council (EDC), set up in 2009, has a strategic role to help the NHS comply with the Equality Act 2010, ensuring services and workplaces are fair and diverse, with equality of opportunity and treatment for all. Its vision is: ‘a personal, fair and diverse health and care service that draws the best from its communities and understands, respects and caters for all using and working within it’. Its aims are that: • services focus on improvements in health outcomes and experiences, for all their community • services are held to account by their communities for responding to the differing needs of all within them • talent flourishes, free of discrimination with everyone having fair opportunities to progress • all staff feel their contributions are recognised and that they count as part of their organisations • services are demonstrably compliant with statutory duties, in letter and spirit, striving to go beyond these. Membership includes representatives from the NHS, DH, trade unions, patient groups, regulators and voluntary sector.
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Key text: NHS Constitution ‘The NHS belongs to the people...’ The NHS Constitution, which applies only to the health service in England, comprises: • seven key principles that govern how the NHS operates, such as providing a comprehensive service and value for money • rights and pledges to patients and the public about matters such as access, quality, respect, choice and complaints • responsibilities that patients and public owe the NHS, such as keeping appointments and treating staff with respect • staff rights concerning issues such as working environment, fair pay, representation and equal treatment • staff responsibilities, including patient confidentiality and professional accountability • six values, including respect and dignity, commitment to quality and compassion. The Constitution attempts a balance between the need for clarity and avoiding litigation, between enshrining enduring values and principles while ensuring the NHS has flexibility to change. The Health Act 2009 placed a duty on all NHS organisations, private and third sector providers in England to take account of the Constitution. By law the Government must renew the Constitution every ten years, so that changes cannot take place without debate. In its Liberating the NHS white paper (see page 107) the coalition Government pledged: ‘We will uphold the NHS Constitution’, although it has introduced several changes: • NHS staff are expected to raise concerns about safety, malpractice or wrongdoing at work that may affect patients, public, other staff or the organisation as soon as possible • the NHS will support all staff who raise such concerns, responding to and investigating concerns • highlighting the Constitution’s existing legal right for staff to raise such concerns without suffering any detriment. Staff with concerns about patient care can call a free whistle-blowing helpline on 08000 724 725 weekdays between 8am and 6pm, with an out-of-hours answering service.
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Further information The NHS Constitution for England, NHS, March 2012. The handbook to the NHS Constitution for England, DH, March 2012. The NHS Constitution and whistleblowing – consultation report: September 2011, DH, October 2011.
Equality Delivery System The EDC initiated the NHS Equality Delivery System. Launched in 2011, its purpose is to help the NHS deliver personal, fair and more diverse health services, and ensure staff from all backgrounds can thrive and develop. EDS is a framework tool that will enable NHS organisations to: • prioritise better access to screening and other services for disabled people • provide better primary care experiences for people from black and minority ethnic backgrounds • ensure everyone, no matter what their sexual orientation or religious beliefs, can talk in confidence to clinicians about their identity • make adjustments in the workplace for staff who need support in caring for younger and older dependants. EDS supports NHS organisations in meeting various equality requirements, including those of the public sector equality duty, the NHS Constitution and the NHS outcomes framework (see page 126).
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