NHS Reform 2012-2022 PDF

The Health and Social Care Act 2012 introduced the most wide-ranging reform to the structure of the NHS since it was established in 1948. The Government aims were to: Reduce central control of the NHS Engage doctors in commissioning Give patients greater choice Many of the provisions came into forc...

The Health and Social Care Act 2012 introduced the most wide-ranging reform to the structure of the NHS since it was established in 1948. The Government aims were to: Reduce central control of the NHS Engage doctors in commissioning Give patients greater choice Many of the provisions came into force on 01 April 2013, including: NHS England and Clinical Commissioning Groups (CCGs) assumed statutory responsibility for commissioning services Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) were abolished Local Authorities (LAs) took on new public health responsibilities Local Healthwatch organisations came into being Part 3 of the Care Act 2014 established Health Education England (HEE) and the Health Research Authority (HRA) as statutory non departmental bodies (NDPBs). More recent changes introduced by the Health and Care Act 2022 have included: NHS and local government coming together legally as part of integrated care systems Repealing S75 of the Health and Social Care Act 2012, meaning NHS commissioners will no longer be compelled to put services out to competitive tender Placing a new ‘duty to collaborate’ on all NHS bodies Formal merger of NHS England and NHS Improvement. The new organisation is NHS England NHS Digital and Health Education England have been merged into NHS England Expanding the power of the Secretary of State for Health, including increased power to direct NHS England, create new NHS Trusts, intervene in reconfiguration disputes and amend/abolish Arms Length Bodies (ALBs) Healthcare Safety Investigation Branch (HSIB) to gain statutory footing, tasked with encouraging the spread of a culture of learning within the NHS through promoting better standards for investigations into safety incidents The UK Secretary State for Health and Social Care has a duty to promote a comprehensive health service in England and has responsibilities for the work of the UK Department of Health and Social Care. The UK Department of Health and Social Care has an overall responsibility for healthcare provision in the UK, and specific responsibility for organising the NHS in England. The work of this department is mostly scrutinised by the House of Commons’ Health Committee. The Department of Health and Social Care (DHSC) retains its responsibility for overall stewardship of the system, but manages the NHS using Arms Length Bodies (ALBs), who commission and regulate care. One of the stated aims of the 2010 Government’s health reforms was to end political interference in the NHS. Under the Health and Social Care Act 2012, the Secretary of State sets the strategic direction for the NHS in England through a ‘mandate’ to NHS England. However, the Health and Care Act 2022 has given the Secretary of State additional powers to direct NHS England, to intervene regarding service reconfiguration and to merge or abolish healthcare regulators. The Secretary of State sets the overall budget for NHS England. NHS England then sets the budget for CCGs.Integrated Care Boards. The Chief Executive of NHS England is accountable both to the Department of Health and Social Care and to Parliament. Parliamentary select committees examine the policy, administration and expenditure of the DHSC and its associated bodies. Overall responsibility for commissioning healthcare in England rests with NHS England. The Kings Fund has produced a video explaining the structure of the NHS in England, however, it should be noted that there have been some changes since this was last updated. It is available at: https://www.kingsfund.org.uk/audio-video/how-does-nhs-in-england-work NHSE - STRUCTURE NHS England is an executive non-departmental public body (i.e. an Arms Length Body). Services are commissioned by Integrated Care Bodies, overseen by NHS England on a regional and national level. NHS England directly commissions the following services: Armed forces Health and justice Primary care commissioning (although some ICBs are direct commissioning responsibility for primary care) Specialised services NHS England works closely with UK Health Security Agency and the Department of Health and Social Care to provide and commission a range of public health services. NHS seasonal flu vaccination programme NHS seasonal flu vaccine programme – advice and reimbursement guidance NHS Breast Screening Programme (NHS BSP) NHS England and NHS Improvement Diabetic Eye Screening Programme (DESP) NHS England and NHS Improvement Abdominal aortic aneurysm (AAA) screening programme NHS Cervical Screening Programme NHS Bowel Screening Programme NHS Antenatal Newborn Screening (ANNB) NHS Newborn Hearing Screening Programme (NHSP) Newborn and Infant Physical Examination (NIPE) Screening Programme Infectious diseases in pregnancy screening programme (IDPS) Fetal anomaly screening programme Down’s syndrome, Edwards’ syndrome and Patau’s syndrome screening pathway 20-week screening scan pathway NHS England has seven regional teams. The NHS Constitution The NHS Constitution for England sets out: the principles and values of the NHS rights, pledges and responsibilities for patients and staff in the NHS Patients’ legal rights are protected by law, however, the pledges are commitments that the NHS aims to achieve. Principles include: The NHS provides a comprehensive service, available to all Access to NHS services is based on clinical need The NHS aspires to the highest standards of excellence and professionalism The patient will be at the heart of everything the NHS does The NHS works across organisational boundaries and in partnership with other organisations in the interests of patients, local communities and the wider population The NHS is committed to providing best value for tax payer’s money The NHS is accountable to the public, communities and patients that it serves. Rights include: to receive NHS services free of charge, with some limited exceptions (e.g. dentist, prescription charges etc.) to be treated with a professional standard of care, by appropriately qualified and experienced staff, in a properly approved or registered organisation that meets required levels of safety and quality not to be unlawfully discriminated against when receiving NHS services to access certain services commissioned by NHS bodies within maximum waiting times, or for the NHS to take all reasonable steps to offer a range of suitable alternative providers if this is not possible access to drugs and treatments recommended by NICE if clinically appropriate to accept or refuse treatment The Secretary of State for Health and Social Care, all NHS bodies, private and voluntary sector providers supplying NHS services, and the local authorities in the exercise of their public health functions are required by law to take account of the NHS Constitution in their decisions and actions. The Constitution sets out that patients have the right to access certain services within maximum waiting times or be offered alternatives. The Handbook to the NHS Constitution gives details of what patients, the public and NHS staff can do if they think these rights are not upheld. The DHSC is required to renew the NHS constitution at least every 10 years, with the involvement of the public, patients and staff. The NHS Constitution is available at: https://www.gov.uk/government/publications/supplements-to-the-nhs- constitution-for-england/the-handbook-to-the-nhs-constitution-for-england The Long Term Plan (10 year plan), was published in January 2019. This builds upon the Five Year Forward View and subsidiary strategies covering general practice, cancer, mental health and maternity services. Some of the key clinical priority areas addressed in the Plan include cancer, cardiovascular disease, maternity and neonatal health, mental health, stroke, diabetes and respiratory care. There is also a strong focus on children and young people’s health. More information is available at: https://www.longtermplan.nhs.uk The Long Term Plan sets out a “Triple Aim” which is now a legal duty on NHS bodies requiring them to consider the effects of their decisions on: 1. the health and well-being of the people of England (including inequalities in that health and well-being) 2. the quality of services provided or arranged by both themselves and other relevant bodies (including inequalities in benefits from those services) 3. the sustainable and efficient use of resources by both themselves and other relevant bodies. Key areas addressed include: Funding commitments include: The funding settlement applies to NHS England’s budget only. It is a plan for the NHS, not the whole Health and Social Care system. The Spending Review was published in Dec 2021. It is available at: https://www.gov.uk/government/publications/autumn-budget-and-spendingreview-2021-documents In recognition of the additional pressures due to the pandemic, a 3-year funding settlement was announced in September 2021, this includes an average resource budget rise by an average of 3.8% each year until 2024/25. More information is available at: https://www.gov.uk/government/publications/build-back-better-our-plan-forhealth-and-social-care Integrated Care Systems A key tenet of integrated care systems is that commissioning to tackle inequality and improve population health, should be undertaken by collaborative planning over smaller areas. We now have the “systems, places, neighbourhoods” approach, although the scheme of delegation is not as yet clear. Systems – covering populations of 500,000 – 3 million people. Health and care partners collaborate to set overall system strategy, manage budgets and performance, plan specialist services and drive improvements. Places – covering populations of 250,000 – 500,000 people (often based on local authority boundaries). Partnerships of health and care organisations in a town or district collaborate to join up the planning and delivery of services, engage local communities and address health inequalities. Neighbourhoods – covering populations of 30,00-50,00 people. Primary Care Networks are an example – where groups of GP practices work with NHS community services, social care and other providers. The Health and Care Act 2022 has placed a duty on the CQC to review health care and adult social care in each ICB including looking at how partners in the ICS are working together. Integrated Care Boards Clinical Commissioning Groups (CCGs) were created by the Health & Social Care Act 2012, replacing Primary Care Trusts (PCTs). They were clinically-led statutory NHS bodies responsible for the planning and commissioning of health care services for their local area. The Health and Care Act 2022, replaced CCGs with Integrated Care Boards. Their role is to allocate the NHS budget and commission services for the population. The ICB is directly accountable to NHS England. Each ICB must prepare a 5-year plan setting out how it will meet the needs of the population, having regard to the partner ICP’s integrate care strategy and the joint health and well-being strategy published by the local health and well-being board. ICB membership includes – a chair, chief executive officer and at least 3 other members from NHS trusts and foundation trusts, general practice and local authorities within the relevant area. One member must have knowledge and expertise in mental health. There is a requirement to involve patients and communities in the planning and commissioning of services. ICBs have taken on some commissioning responsibilities from NHS England including commissioning of primary care and some specialised services. Integrated Care Partnerships These have arisen out of the Sustaining and Transformation Plans (STPs) but how have a statutory basis. The ICP is a statutory joint committee of the ICB and local authority within the area. Involivng a wide range of “system partners” the ICP develops an “integrated care strategy” to address the relevant population’s wider health care, public health and social care needs. ICP membership includes one member appointed by the ICB, one member appointed by the relevant local authority and flexibility with regards to other members. National Institute for Health and Care Excellence (NICE) This was established in April 2013 as an executive non-departmental body by the Health and Social Care Act 2012. Prior to that, it was a Special Health Authority. It also acquired responsibility for providing guidance for social care. The NHS Constitution states that patients have the right to drugs and treatment that have been recommended by NICE for use in the NHS, if the doctor believes they are clinically appropriate. NHS organisations in England are legally required to make funding available for treatments that NICE recommends following a Technology Appraisal or Highly Specialised Technology evaluation, no later than 90 calendar days (30 calendar days for Fast Track appraisal or Early Access to Medicines Scheme) of final guidance being published. Early Access to Medicines Scheme (EAMS) – The scheme aims to give patients with life threatening or debilitating conditions access to medicines that do not yet have marketing authorisation. NICE facilitates engagement meetings for developers of pharmaceutical products to apply for a “promising innovative medicine” (PIM) designation. The Medicines Healthcare Regulatory Agency (MHRA) will give a scientific opinion on the benefit/risk balance of the medicine. The opinion lasts for 1 year and can be renewed. The Technology Appraisal process involves considering: Evidence from clinical trials and peer reviewed research, considering likely impact on mortality and quality of life Economic evidence on how much it costs to the NHS Views of clinicians, patients and other stakeholders In addition to looking at clinical effectiveness of a treatment, technology appraisals assess a treatment’s cost effectiveness. This is usually measured in terms of the cost per additional Quality-Adjusted Life Year (QALY) that the treatment provides. QALYs are a measure of the years of life remaining for a patient, weighted on a quality of life scale. One QALY is equal to one year of life in perfect health. NICE does not decide on topics for guidance and appraisals. These are referred to NICE by the Department of Health and Social Care. There are three processes for assessing technologies: Single technology appraisal Multiple technology appraisal Fast track appraisal In 2017, NICE announced a fast track process for approvals. Essentially this includes the ability to fast track drugs which represent exceptional value for money and budget impact test for drugs if: The company’s base-case incremental cost-effectiveness ration )ICER) is less than £10,000 per quality-adjusted life year (QALY) gained. It is likely that the most plausaible ICER is less than £20,000 per QALY gained, and it is highliy unlikely that it is greater than £30,000 per QALY gained. OR A cost comparison case can be made that shows it is likely to provide similar or greater health benefits at similar or lower cost than technologies already recommended in technology appraisal guidance for the same indication. NICE also publishes advisory clinical guidelines and public health guidelines. Commissioners are not required to follow these. In the absence of guidance, NHS organisations can determine their own policy on funding, but cannot have a blanket ban policy and must consider individual cases. The Health and Social Act requires commissioners to have due regard to NICE Quality Standards. Public Health England (PHE) PHE has been replaced by UK Health Security Agency (UKHSA) and the Office for Health Improvement and Disparities (OHID). UKHSA was announced in March 2021. It is an executive agency. The OHID is located within the DHSC and has taken over PHE’s functions regarding wider public health including public improvement and population health. It is jointly accountable to the Secretary of State for Health and Social Care and the Chief Medical Officer (England). Regulation See section on Regulation. In England, the key regulators are the Care Quality Commission (CQC) and NHS England.