Three interesting bits of context for the second day of the Alliance conference:

A report that NICE is to use other forms of evidence in its assessments of cost-effectiveness than the randomised control trial

The Association of British Insurers eyes an attractive new market if top-ups are sanctioned by the Richards review, as expected

and the House of Commons Health Select Committee has found a lack of evidence around foundation trusts - a quote from the summary follows:

"FTs have some proven strengths. They have performed well financially and generated surpluses. They have been high performers in routine NHS process quality measures. However, much is unknown. It is not clear whether their high-performance is the result of their changed status, or simply a continuation of long term trends, since the best trusts have become FTs. Key aims of FTs were the promotion of innovation and greater public involvement. While we were provided with examples of good practice in both of these areas, again there was a lack of objective evidence. We therefore recommend that the Government commission research to assess all aspects of FTs’ performance objectively so that best practice can be shared with other FTs, and with the NHS more widely.

"It seems that some of the fears about FTs’ impact on local health economies have not been borne out; however, they have made little contribution towards the Government’s aim of
delivering more NHS care outside hospitals with the interesting exception of mental health
trusts. This situation is not solely attributable to FTs themselves; rather it is a consequence of the introduction of Payment by Results and inadequate collaboration between PCTs and FTs to manage demand for acute care. FTs’ slowness to innovate and invest was ascribed by many to failure on the part of PCTs to provide strategic guidance.

"The Government is clearly aware of these deficiencies and has announced plans to strengthen PCTs’ commissioning skills through its World Class Commissioning programme; however, it is unfortunate that this has come after the establishment of powerful FTs in the acute sector and not before.

"While FTs do not appear to have yet exploited the full potential of their autonomy, witnesses from FTs told us that the ability to make decisions more quickly was important and made a ‘tangible’ difference to the dynamic of their organisations, which we welcome.

"Unfortunately, concerns persist about what level of Government intervention in FTs’ affairs is legitimate, and the Government must clarify what the appropriate levels of intervention are.

"Finally, Monitor’s application process and regulatory regime seems to be well regarded.
However, a complex regulatory environment of other organisations also surrounds FTs, and in particular there is potential duplication between the Healthcare Commission and Monitor both of which evaluate the quality of FTs’ services".

The report issues a fascinating and key conclusion:

"The ability to retain surpluses was a key element of the FT reform, and FTs are now building up surpluses. FTs report that they are looking to PCT commissioners to collaborate on how these surpluses should be reinvested to improve patient care, but that PCTs are not in a position to give this guidance.

"We did not see any evidence that PCTs are thinking strategically about how FT surpluses might best be reinvested in their local health communities, a situation which we find extremely worrying.

"We recommend that the Department of Health takes steps to ensure that PCTs are able to play the strategic planning role urgently required of them; without this, public money risks sitting idle or being invested without proper strategic planning".