Briefing in full

How the Forum approached the listening exercise

The 45 members of the Forum attended 200 events and received responses from around 30,000 individuals and organisations, a response described as 'staggering' in the report. The Forum looked at the key elements of the reform programme from the perspective of their potential impact on delivering high quality healthcare and improved outcomes for patients. The report recommends changes to address areas of weakness, further clarification where there was a failure to explain, greater safeguards against unintended consequences and further work where there was insufficient evidence for change.

The chair of the forum indicates that this has been a destabilising period for the NHS and it is now time to act on the recommendations and move forward to build the NHS of the future.

Recommendations

1. To ensure the values and principles in the NHS constitution are protected and promoted, the Bill should include a new duty for the NHS Commissioning board and consortia to actively promote the constitution. Along with Monitor and the Care Quality Commission they should set out how they are meeting their duty to have regard to the constitution in their annual reports.
2. The Bill should make it clear that, while the NHS should be free from political interference, the Secretary of State remains ultimately accountable.
3. The Bill should include stronger and clearer duties of involvement for patients and carers, focused on the principles of shared decision making – 'no decision about me, without me'.
4. To ensure that decisions are transparent, the Bill should require commissioning consortia to have a governing body that meets in public and has effective independent representation to protect against conflict of interest. Members of the governing body should abide by the Nolan principles for conduct in public life. All commissioners and major providers of NHS funded services should be required to publish board papers and minutes and hold their board meetings in public. Foundation Trust governors must receive training and support to oversee their Trust's performance, with Monitor's compliance role in place until governors are sufficiently skilled.
5. The Bill should require commissioning consortia to obtain relevant multi-professional advice to inform commissioning decisions. There should be a strong role for clinical and professional networks and multi-speciality clinical senates should be set up to provide strategic advice to local commissioning consortia, health and wellbeing boards and the NHS Commissioning Board.
6. Experienced managers are crucial and must be retained to support clinical leaders through transition and to ensure efficiency savings.
7. There should be a comprehensive system of commissioning consortia, but they should only be authorised to take on the full range of responsibilities when they are ready to do so. The national board should commission on their behalf until they are ready, while supporting them to take on powers as soon as possible.
8. Choice and control for patients should go much further than just choice of provider – following public consultation the Secretary of State should give a 'choice mandate' to the NHS board setting out the parameters of choice and competition. Healthwatch England should have a citizens panel reporting to parliament and there should be a strengthened 'right to challenge' poor services and lack of choice.
9. Competition should be used to support choice, integration, and improved quality and never as an end in itself. The Bill should be amended so that the role of Monitor is to support choice, collaboration and integration, with the primary duty to promote competition removed.
10. Additional safeguards should be in place to prevent private providers cherry picking patients; the government should not seek to increase the role of the private sector as an end in itself.
11. The duty on the Secretary of State, the NHS board and consortia to reduce health inequalities is welcome and all elements of the new systems must be used to achieve this.
12. The Bill should strengthen the role and influence of health and wellbeing boards so they have stronger powers to promote integration and meet local health needs, and to hold local commissioning consortia and social care to account if commissioning plans are not in line with the local health and wellbeing strategy.
13. Better integration across health and social care should be a key aim and to support this boundaries of local commissioning consortia should 'not normally cross those of local authorities, with any departure needing to be clearly justified'. Joint commissioning demonstration sites in health, social care and public health should be set up and evaluated.
14. There are concerns about insufficient detail on changes to workforce training and education (which stem from the abolition of strategic health authorities). The professional development of staff is critical, but 'is not being taken seriously enough'. The National Quality Board should urgently examine this issue.
15. Improving public health is everyone's business, and must be supported by independent, expert public health advice at every level. The Forum advises that Public Health England should not be set fully within the Department of Health.
16. The NHS Commissioning Board should be established as soon as possible to ensure that the priorities of quality, safety and meeting the financial challenge are addressed in the transition to the new system.

The Government Response

The government has agreed to implement the Forum's recommendations. In addition it has described some of the changes it intends to make in more detail. Some of these will require amendments to the Health and Social Care Bill and the government intends to 'recommit' the relevant parts of the Bill to a Public Bill Committee for scrutiny, the details of which will be announced shortly. The Future Forum will continue to lead listening on the NHS, focusing on education and training, patients' rights and public health.

Some of the key points in the government's response are as follows.

GP consortia will now be known as clinical commissioning groups to reflect wider clinical involvement. Commissioning groups will all be established by April 2013; some will be authorised and fully operational, some will operate in shadow form with the local arms of the NHS Commissioning Board commissioning on their behalf until they are ready to take over responsibility. Authorisation will be run by the NHS Commissioning Board with input from health and wellbeing boards and local clinicians. No individual GP will need to get involved in the work of a commissioning group if they do not want to do so.

PCTs will be abolished by April 2013, and primary care cluster arrangements will be in place by that time to provide local arrangements for the NHS Commissioning Board. Strategic Health authorities will remain in place until April 2013 but will be formed into smaller number of clusters for management purposes as has happened with PCTs.

Commissioning groups will have governing bodies involving at least two lay members and at least one nurse and one specialist doctor.

Existing clinical networks advising on areas such as cancer, and multi-professional clinical senates (including social care) will advise on commissioning plans in each area of the country. These will be hosted by the NHS Commissioning Board.

Health and wellbeing boards will have a stronger role in promoting joint commissioning and integrated provision and, although they will not have a veto, they will have the right to refer plans back to the commissioning group or the NHS Commissioning board if plans are not in line with local health and wellbeing strategies. Health and Wellbeing Boards will operate as local government executive bodies.

Patient and public involvement will be strengthened throughout the system, with, for example, a new duty on Monitor to carry out patient and public involvement in the exercise of its functions.

There will be stronger duties for clinical commissioning groups and the regulator to promote care integrated around the needs of users, e.g. extending personal health budgets and joint health and social care budgets. The NHS Commissioning Board will promote innovative ways to integrate care for patients.

There will be extensive measures to safeguard against privatisation and to ensure competition is only used for the benefit of patients, such as the role of Monitor being limited to tackling unjustifiable restrictions that demonstrably act against patients' interests.