Commissioning a Patient-Led NHS

'Commissioning a Patient-Led NHS' outlines potentially major changes to the configuration of Primary Care Trusts (PCTs) in England and to the future provision of PCT-managed services such as physiotherapy. Use the links in the list below to find out more about this initiative, including the CSP's response and policy position, links and relevant downloads:

Commissioning a Patient-Led NHS: background

'Commissioning a Patient-Led NHS' was published on the Department of Health's website www.dh.gov.uk on 28 July 2005 with little fanfare or consultation. The guidance outlines potentially major changes to the configuration of Primary Care Trusts (PCTs) in England and to the future provision of PCT-managed services such as physiotherapy.

In brief, Commissioning a Patient-Led NHS sets a target of 15% cuts in administration and management costs, and makes clear that mergers and reconfigurations will reduce significantly the number of PCTs by October 2006. Under the same initial proposals, PCTs would cease being direct providers of services, and hence employers of clinical staff in most cases, leaving staff to be transferred to private sector and other, undefined, providers by 2008.

To help shape the Society's response to the proposals the CSP's Council has established a reference group, comprised of officers and members in England across the NHS, private and independent sectors. A copy of a CSP policy statement produced by the reference group is reproduced below. (It can also be downloaded as a Word document by clicking on the appropriate link at the foot of this page).

As you will see, the CSP has expressed strong criticism of many aspects of Commissioning a Patient-Led NHS, in particular the rationale for wholescale outsourcing of PCT services. The CSP has also made its position known to Sir Nigel Crisp, Chief Executive of the NHS, directly in a letter from Chair of Council (the letter to Nigel Crisp can also be downloaded by clicking on the appropriate link at the foot of this page).

The proposals, once they appeared on the DH's website in July 2005, provoked a significant outcry over the lack of consultation involved and over the merits of the proposals themselves. Early day motions in Parliament accompanied intensive lobbying of the Health Secretary, Patricia Hewitt, by MPs and others concerned at the impact of the proposals on primary care services and staff. CSP Employment Relations and Union Services (ERUS) director, Lesley Mercer, was able to put the CSP's concerns directly to the Secretary of State at a meeting of the NHS Social Partnership Forum in October 2005. In response to these pressures, the Health Secretary issued a statement in the House of Commons on 25 October which appeared to backtrack a little on the scope of the proposals. The statement is reproduced below.

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Health Secretary Patricia Hewitt's statement to the House of Commons on Commissioning a Patient-Led NHS of 25 October 2005

"In Commissioning a Patient-Led NHS, we described the need to strengthen commissioning through the development of PCTs and increased GP engagement in decision-making in order to drive forward the creation of a patient-led NHS.

SHAs and PCTs have since been developing their plans for the future, based upon looking at the appropriate structure for their organisations and responsibilities that they will take on."

Restructuring

"The design of the new, stronger PCTs is not a top-down reorganisation. We have asked SHAs and PCTs to develop a plan that will work for their area.

The proposals are now in and the department is assessing them against the published criteria. There is no standard, national template. The proposals could be based on large or small PCTs, providing they deliver strong patient representation through their commissioning function.

Where the proposals fit the criteria, local areas will be able to go out to three months consultation in the usual way.

If I am not happy that a proposal both meets our criteria and demonstrates extensive stakeholder consultation, I will send it back for reconsideration."

Staff

"Our goals are clear. We want to deliver the best possible health and healthcare for all patients in each local area.

There are a variety of services models already in operation around the NHS including those run by the voluntary sector and new NHS initiatives like walk-in centres. We want to build on the strengths of what is already happening and best practice from around the NHS.

The policy framework for developing primary and community services will be set out in the forthcoming White Paper Your Health, Your Care Your Say on which we are currently consulting.

District nurses, health visitors and other staff delivering clinical services will continue to be employed by their PCT unless and until the PCT decides otherwise. The terms and conditions of staff will of course be protected. The decision would be driven locally, following our White Paper deliberations, and only be implemented following full local public consultation."
Ends

A Legal Challenge to Commissioning a Patient-Led NHS

In November 2005, the Royal College of Nursing (RCN) began proceedings against the Health Secretary by applying for a judicial review of the government's proposals for primary care. A judicial review is effectively legal action. The CSP supported the call by the RCN for a judicial review. CSP Chief Executive, Phil Gray, said:

"Thousands of physiotherapy jobs are affected by plans to restructure Primary Care Trusts and Strategic Health Authorities. Currently they are in limbo, not knowing if they have a future in the NHS. The determination that PCTs cannot provide primary care services after April 2008 threatens the jobs of up to 230,000 NHS staff. The lack of consultation would be outrageous if a private sector employer were involved, but for the Government to expect dedicated healthcare professionals to sit back and wait while existing NHS services are fragmented and distributed around the public and private sector is appalling. Patients deserve better than this. The CSP supports the RCN's legal challenge over the Government's failure to carry out public consultation and is urging the Health Secretary to have the courage to re-think the impact of these plans."

Due to be heard on 9 December 2005 in the High Court, the judicial review was shelved at the 11th hour following a last minute settlement between the RCN and the Department of Health. For more information on the RCN's application for a judicial review of Commissioning a Patient-Led NHS see RCN Judicial Review: Settlement Reached.

House of Commons Health Select Committee Enquiry into Reform of Primary Care

MPs on the House of Commons Health Select Committee were told in November 2005 that NHS staff in primary care are in danger of losing their focus with all the uncertainty surrounding the Government's reforms contained in 'Commissioning a Patient-Led NHS'.

The Health Committee's enquiry into the reform of Primary Care Trusts (PCTs) heard evidence on Thursday 10 November. Among those giving evidence were Lord Warner, Minister of State for NHS Delivery; John Bacon, Director of Health and Social Services Delivery at the Department of Health and several representatives from PCTs themselves.

Lord Warner told the Committee that the directive to PCTs to 'divest' themselves of their service provision capabilities, issued by NHS Chief Executive Sir Nigel Crisp on 28 July, was too prescriptive". All changes to PCTs will be subject to local consultation, the Minister insisted, although the aim of the reforms is to 'rebalance' the health service by strengthening the commissioning function of PCTs.

When probed by MPs on workforce issues, John Bacon acknowledged staff concerns over pensions and possible transfers to new employers, but said that staff affected would be protected by existing 'transfer of undertaking' (TUPE) arrangements.

The Committee also heard from several PCT chairs that the identified savings of £250m earmarked in CPL-NHS were unrealistic, but what was real was the risk of losing the engagement and focus of clinicians as they seek to leave behind the uncertainty of primary care for pastures new. One PCT Chair said the drift of staff away from primary care was "only a matter of time".

Lord Warner sought to reassure the Committee that changes to PCTs would not happen without the involvement of local service users, saying that there was still a three month consultation to come on any proposed changes to individual PCTs. The government would publish more proposals in early December he said.

Several witnesses who gave evidence to the Committee highlighted how key the White Paper is. The Committee's report, which is written in a general tone of censure of the Government for its handling of Commissioning a Patient-led NHS, can be downloaded as a PDF file from the UK Parliament website: www.publications.parliament.uk.
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Health Secretary apologises for uncertainty

The Health Secretary, Patricia Hewitt, told NHS managers at a conference in Harrogate on 11 November 2005 that she was 'really sorry' for the uncertainty that had been created for PCT staff. On the same day, her junior minister, Liam Byrne, told BBC Radio 4 listeners that trusts would be free to decide that services could be provided by 'direct delivery', using their own staff. He added that it would be wrong to 'write a blueprint' in Whitehall.

The CSP's policy position on Commissioning a Patient-Led NHS

A major new policy initiative for the NHS was launched on 28th July 2005 entitled Commissioning a Patient-Led NHS. The document requires Primary Care Trusts in England to reconfigure their boundaries by October 2006 in order to achieve financial savings and a better alignment with local authorities. By 2008, PCTs are also required to outsource the majority of the clinical services they currently provide in order to concentrate on their commissioning role. Potential alternative providers of these services include foundation, acute or children's NHS trusts, local authorities, voluntary organisations or independent companies.

The Chartered Society of Physiotherapy is deeply disappointed that Commissioning a Patient-Led NHS was launched without any kind of advance consultation, despite its profound implications for members and patients alike. We do not see the logic of producing such a strategy before the publication of the forthcoming White Paper on care outside hospitals. We also believe that after many years of almost continual change, what the NHS needs most is a period of stability and consolidation, so that current structures can bed down and produce the further improvements needed.

Of concern to the Society is the limited evidence base to support the contention that introducing contestability or competition improves the quality of public services. It also seems illogical to suggest that it is inappropriate for PCTs to continue to both commission and provide services, when GPs will be doing precisely this under practice based commissioning. We recognise the desire to strengthen the commissioning role of PCTs, but it is important to recognise too that some PCTs have already developed excellent models where there is a clear split between provider services and commissioners. These models can be built upon and extended to other areas as an alternative to hiving off all provider functions.

A further inherent contradiction in Commissioning a Patient-Led NHS lies in the possibility of community services being taken over by acute trusts. This is difficult to reconcile with existing policy to develop as much care as possible in integrated primary care settings and organisations. Overall, while the Society is keen to develop opportunities for all members around the delivery of health care, we believe that the potential risks of dismantling current PCT services and outsourcing them to alternative providers outweigh any potential benefits. In our view, these potential risks include:

  • Destabilisation and fragmentation of services
  • 'Cherry picking' of the most profitable parts of services, leaving other services more vulnerable and potential gaps in services for some client groups
  • An increase in health inequalities due to a lack of interest by alternative providers in areas of social deprivation where profit margins would be reduced or non existent
  • Less opportunity for members to influence commissioning decisions, as the involvement developed in PCTs over recent years, including on Professional Executive Committees, is potentially devalued by the changes is potentially devalued by the changes and lack of clarity of the policy
  • An undermining of the real achievements of PCTs to date in developing services, driven by the process of modernisation and service improvement which the Government has supported and facilitated in recent years
  • Diminishing of key partnerships and collaborations which have been created by PCTs and which have been proven to offer value to patient care and quality, especially focussing on working across patient pathways
  • The potential for services to retract into acute provision, thereby hindering service development in health promotion, admission avoidance etc
  • Increasing the difficultly for new graduates to find jobs and physiotherapy students (via higher education institutes) to find placements
  • Undermining staff terms and conditions, job security and development opportunities, which will be difficult to maintain if staff end up being employed in much smaller professional groups, across a wide range of different service providers
  • Poor staff morale, with the potential for this to impact on recruitment and retention within community areas, should these changes be driven through as they stand with little effective choice given to those directly affected.

Physiotherapy staff across the NHS, private and independent sectors have led and embraced innovation and modernisation, and have pioneered many new ways of delivering faster and more cost effective services. The Society is not therefore opposed to change. However, what we cannot support is the whole-scale dismantling of existing services where these are already based on effective local partnerships, effective engagement of clinicians in commissioning, and are delivering the modernisation agenda.

The Society therefore calls on members and representatives to use every opportunity locally, to press for a rethink of the basic premise in Commissioning a Patient-Led NHS that PCTs should no longer both commission and provide services. We also advise members, both in the NHS and independent sectors, to be extremely cautious about entering into alternative models of service provision without a full evaluation of the potential gains from these models compared to the existing provision.

In terms of PCT reconfiguration, while the Society recognises the potential economies of scale from rationalising the number of PCTs, we believe that the focus should be on encouraging co-terminosity with local authorities and integrated working. We also believe that there should be maximum transparency around the proposals being drawn up by PCTs and Strategic Health Authorities, and a timetable which allows meaningful consultation to take place. We call on Society members across England to take part in these local consultation processes in order to ensure that the voice of physiotherapy is heard.

The Society will continue to monitor developments on Commissioning a Patient-Led NHS and will review this policy statement as needed.

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Strategic Health Authority Consultations

On 1 December 2005, all 28 Strategic Health Authority areas in England were given the go-ahead by the Department of Health to begin local consultations on boundary changes. Health Secretary, Patricia Hewitt, confirmed that no decisions on boundary changes would be taken until these local consultations had been completed and their outcomes considered. The views of stakeholders, including NHS staff, will be crucial in shaping the plans in each local area, she added. This decision meant that SHAs were able to start consulting locally on the future shape and, where relevant, the number of their local PCTs and SHAs. The local consultation exercises began on 14 December 2005, running for fourteen weeks. Outlining her hopes for the outcome of this process, the Health Secretary, Patricia Hewitt, said:

"Through this process of local decision-making we will end up with organisations that are fit for purpose in the new NHS and which are able to secure good value services for their local populations through strong commissioning. We anticipate that boundary changes and a new focus on commissioning for primary care trusts will enable local NHS organisations to make substantial savings by reducing management costs. As a result of these changes we expect upwards of £250 million in management costs to be invested back into local frontline services."

SHAs have received technical guidance, including a Human Resources (HR) framework (see below), on how to conduct the local consultation to ensure that all interested parties and stakeholders have an opportunity to participate and that all options proposed for each area are given equal weight.

A Human Resources framework for Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs)

A Human Resources framework for Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) has been produced jointly by NHS Employers and the NHS Staff Side. The aim of the framework is to try to ensure that the workforce changes arising from implementation of Commissioning a Patient-Led NHS are managed consistently and equitably across England. The framework was sent out to SHAs and PCTs by Sir Nigel Crisp on 1 December 2005.

The document needs to be read as a whole, but the following sections are particularly important:

  • paras 13-15: spelling out the role of trade unions at both local and SHA 'cluster' level
  • paras 43-46: on the future of PECs
  • paras 69-71: on the process to be followed for dealing with managerial posts below Director level
  • paras 75-77: on the requirement for all NHS trusts to restrict advertisements for permanent management posts in order to minimise redundancies among staff affected by PCT mergers etc
  • para 85: giving all substantive staff at risk in PCTs guaranteed employment until the end of June 2007
  • para 125: on the support every manager at risk is entitled to expect from their employer

The Framework can be viewed as a PDF download via the Department of Health website.

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This text on this page was last updated on 22 Oct 2007.