The NHS Confederation's response to the White Paper Equity And Excellence is published today.

In common with most of the responses so far, it opens with a statement of support for the aims of focusing on quality and empowering patients, and for greater clinical involvement in commissioning decisions.

However, the document goes on to warn that the implementation and transition to the new system pose significant risks. It warns that "it will be exceptionally difficult to deliver major structural change and make £20 billion of efficiency savings at the same time".

"Significant risks, worrying uncertainties and unexploited opportunities"
Among the potential challenges to success, the Confed's document lists the following:
• Market mechanisms alone will not be adequate to manage the system
• GP consortia do not appear to be clearly accountable to patients and the public
• Achieving integration for patients requires a whole system approach
• GP consortia need more influence on primary care and health inequalities
• Overlapping outcomes frameworks for health, public health and social care are needed

It suggests that Confed members' key concerns about the transition to the new system include:
• GPs need capacity and capability to take over commissioning
• Skills and experience from PCTs are likely to be lost
• The management burden needs to be reduced from now
• Barriers to trusts achieving foundation trust status may remain
• The scale of the cultural change needed has been underplayed

It offers ten recommendations for dealing with the transition period:
• providing clarity about GP consortia
• keeping hold of expertise and knowledge
• establishment of consortia
• capability and capacity
• workforce
• management costs
• encouraging GPs to engage quickly
• moving to foundation trust status
• managing expectations
• communications.

One of the dominant themes running through the response's more detailed proposals is the need for an element of system planning (for such areas as mental heath services, or the networks for cancer and other specialist care) and appropriate integration.

Integrated care needs the government to:
• review the current incentive structures to encourage hospitals to create more integrated care between primary and secondary care, including mental health, by more readily working with local authority partners as well as healthcare colleagues
• ensure when drafting legislation and regulations that instructions to the competition regulator allow providers to develop integrated patient care solutions
• ensure when drafting legislation and regulations that the obligation to cooperate that is part of the current set of market rules is not lost.

It also highlights the need for a population health viewpoint, noting that the outlined architecture of the new system "does not explain how this will be provided".

While it notes the extension of 'any willing provider' markets under economic and competition regulator Monitor, it adds that "other market models including competition for the market and planned provision of emergency services are also appropriate in many circumstances ... we welcome a clear rules-based system but the rules should not inhibit cooperation where appropriate, for example in coordinating clinical networks and integrating care pathways".

Management costs and 'right-pricing'
The response also raises the need for GP consortia to get "confirmation of the management cost limits they will have to operate within", adding that "micromanaging expenditure on leadership and management within the consortia is inappropriate. We are concerned that the white paper makes the presumption that management is a cost rather than an investment ... GP consortia should be held to account for how they spend the totality of their resources".

It also observes that while price-setting in competitive markets tends to see purchasers (commissioners) drive provider productivity via lower price paid, "price competition ... has particular risks in healthcare markets ... (and) is likely to lead to declining quality where quality is harder to observe than price".

Preparing to fail
A DH insider (who didn't realise he was talking to a journalist) recently told me that one of the key objectives of the current reforms was "to finally sort out the persistent overspenders". Failure has been the Nelson's eyepatch of the NHS: the telescope is raised, but we can see no ships.

In a White Paper future, this is clearly no longer an option. Accordingly, while there has been limited description of how providers might fail, the Confed's response correctly analyses that "it is not clear what the mechanisms will be for dealing with consortia that consistently fail to provide high-quality outcomes or to manage their financial responsibilities. The balance between a sufficient incentive to avoid failure and creating a major obstacle to participation is a difficult one. The extent to which there is collective responsibility for the failure is also difficult, particularly where failure may be the result of the action of a relatively small number of practices. We believe the Government should spell out how it will deal with GP consortia that fail, and ensure that the rewards of success and the consequences of failure are proportionate and significant enough to have an impact on their behaviour".

The corrolary of that is the need for performance management of primary care, of which it queries "whether the NHS Commissioning Board will be able to do this from a
distance and whether it will have the appropriate expertise ... We believe the Government should give the NHS Commissioning Board the power to delegate responsibility for practice performance and contract management of General Medical Services (GMS) contracts to GP consortia where appropriate. The distribution of any performance payments related to commissioning should be the responsibility of the consortia.".

This is an interesting idea: peer pressure within each consortia as the driver of behavioural change by GPs and the primary care team. The evidence that GPs have high levels of willingness to act corporately, and to make difficult and unpopular decisions about rationing or even closing services, could best be characterised as incomplete.

Accountability forms a significant section of the response, with suggestion that much greater clarity is required about the accountability arrangements between Parliament and the National Commissioning Board; between the National Commissioning Board and GP consortia; between GP consortia and their member practices; and between local government health and wellbeing boards and GP consortia.

National Commissioning Board - 8,000 contracts light
The Health Secretary's plan for the National Commissioning Board to be a light and lean organisation may not quite be appropriate. The document notes that while the Confederation "support the Board being a small tightly-focused organistion ... it must also have the capability and support in place to deal with the scale and complexity of the task".

This task includes managing the contracts with 8,000-odd GP surgeries, as well as with pharmacists and opticians.

The response also notes, "it would be highly regrettable if commissioning standards were to deteriorate in the new system and we have concerns that the NHS Commissioning Board may, by default, take on a range of functions which mean it will either have to become large and unwieldy or alternatively that it may not have capacity to deliver. We also have concerns about its accountability arrangements ... The NHS Commissioning Board will retain a very significant commissioning remit and it is important that in exercising this it is subject to the same procurement and competition regimes as the rest of the system".

The networks' responses
The obvious interest, given the suspension of FT network director Sue Slipman, is to see what the FT network's response is. It welcomes the "radical proposals", especially "the fact that they will no longer be constrained by the cap on earning income from non-NHS sources".

However, in the press release, it quotes Sue Slipman as saying, "there are tough times ahead and we cannot ignore the risks that are present in the proposed changes to the stability and effectiveness of the whole health system. FTs are the stable heart of the NHS and will play a crucial role in working with commissioners, other providers and local communities to deliver joined–up healthcare to the highest standards“.

The NHS Partners Network
The press release for the Confed's private sector providers' section reads as follows:
• For the NHS to be able to truly deliver benefits to patients and taxpayers, government policies must deliver genuine freedom for patients to make informed choices; fairness in economic and clinical regulation; non-discrimination in tendering and commissioning and equitable access for any provider meeting NHS standards and tariffs.
• We strongly support and welcome the approach to economic regulation. A statutory, independent economic regulator is essential to enable the provider market to develop as a sustainable, pluralist component in the UK health economy. Establishing such a regulator will in time give confidence to investors and allow the long-standing problems of the unlevel playing field and anti-competitive practices to be addressed.
• The proposed new commissioning model will need to have the strongest safeguards to ensure that GP Commissioners are not inappropriately influenced and are not able to undermine plurality, patient choice and the investment environment. They must fully understand their legal obligations to comply with procurement and competition law.
• A possible consequence of the transition is that a vacuum could develop in the ability of the NHS to continue to drive plurality and market development. This could mean private sector investors avoid the UK health market at just the moment when severe public expenditure constraints mean other sources of funding are most needed.

David Worskett, director of the NHS Partners Network, said, “The independent sector has long played a role in the provision of healthcare in the UK. The last five years especially have seen a growing acceptance that NHS care should be delivered by organizations that offer the best combination of quality and value, irrespective of whether they are public, private or third sector.

“We believe that one of the key issues for the transition period is how to retain investor and provider confidence and ensure the momentum towards a pluralist market that drives quality up and gives patients real choice is not lost. This will be integral to creating a sustainable and stable market, to which organisations and investors will be happy to commit”.