An overview of recent NHS reform in England April 2013 Review date: October 2013

Introduction This presentation provides a synopsis of the main changes brought about by the Health and Social Care Act 2012 and contained in the draft Care and Support Bill. These apply to England only. It is designed to help RCN members understand the reforms and how they will affect patients and nursing practice.

Contents  History of the reforms.  Changes brought about by the Health and Social Care Act 2012, including:  changes to commissioning  changes affecting providers  the changing role of Monitor.  The draft Care and Support Bill  What the RCN is doing on behalf of members.

History of the changes  NHS White Paper published in July 2010  Health and Social Care Bill published in January 2011  The Bill was passed and became the Health and Social Care Act in March 2012  Draft Care and Support Bill 2012 currently going through Parliament (as of April 2013)

The Government’s aims for the Health and Social Care Act  A stronger voice for patients:  Patient-centred care – “No decision about me without me”  Creation of Healthwatch England within the CQC and Local Healthwatch organisations to represent the voice of service users  Focus on patient outcomes rather than processes  Extend choice and competition  Overhaul of the commissioning structure  Increase autonomy of providers with all NHS trusts becoming foundation trusts (FTs)  New approach to provider regulation – creation of a licence issued by Monitor

The RCN and the Health and Social Care Bill The RCN welcomed:The RCN was concerned by: The focus on improving patient outcomes No introduction of mandatory nurse staffing levels to act as a safeguard Increasing patient choiceReforms acting as a distraction from the “Nicholson Challenge” to save £20bn from the NHS budget by 2015 Reducing inefficiencyHigh cost of implementation Increased complexity of the new structures with barriers to co- operation Increased competition could lead to fragmentation of services and integrated care provision

The RCN and the Health and Social Care Bill  Because of these concerns, the RCN moved to oppose the Bill in January  As the Act has now passed, the RCN is committed to help make the reforms work for the benefit of patients and our members.

What is commissioning? Commissioning is the process through which NHS health care services are “purchased” on the behalf of service users. It is a continuous cycle made up of:  strategically assessing population needs  prioritisation  procuring services from providers  monitoring the performance of providers.

Changes to the commissioning system – from April 2013  Abolition of primary care trusts (PCTs) and strategic health authorities (SHAs)  NHS England (previously known as the NHS Commissioning Board) established – provides leadership for the NHS in England and commissions primary and specialist care. Has regional and local offices throughout the country.  Clinical commissioning groups (CCGs) commission the majority of local health services  Transfer of public health from the NHS to local authorities, with a new body - Public Health England - taking a national leadership role.  Creation of Health and Wellbeing Boards at local level, bringing together people from commissioning, health care, social care and public health to develop Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies.  Healthwatch – the independent ‘consumer champion’, replacing the patient representative bodies Local Involvement Networks (LINks)

How do they fit together? NHS England Local Authorities CCGs Health and Wellbeing Boards Local Healthwatches Providers FTs regulated and licensed by Monitor (economic) and all providers regulated by CQC (care quality) Public Health England Department of Health

Who commissions what? New organisationsServices NHS Englandprimary medical services dental services community pharmacy specialised services offender health care health care of the Armed Forces and their families CCGsplanned hospital care rehabilitative care urgent and emergency care most community health services mental health and learning disability services Local Authoritiespublic health services

The role of nursing in commissioning  NHS England has a Chief Nursing Officer with responsibility for quality assurance and patient experience. Each of the organisation’s regional and local offices also has a chief nurse  Each CCG must have at least one nurse on their governing body  Public Health England has a professional lead for nursing who is also Director of Public Health Nursing at the Department of Health.

Changes affecting providers  All NHS trusts will be expected to become FTs, with a new Trust Development Agency set up to help them achieve this safely.  Providers will be allowed to fail if they cannot remain financially viable or provide safe care, though the provision of essential services they provide will be maintained so that patients being treated are unaffected.  The private income cap for FTs has increased to 49%.

The changing role of Monitor  Monitor will act as the economic regulator for FTs. NHS Trust Development Agency will cover trusts until they can achieve FT status. CQC will remain as the quality regulator.  Has a duty to protect, promote and improve the provision of health care services.  Tasked with “tackling anti-competitive behaviour” and promoting integration.  Will set prices and tariffs for NHS-funded care in conjunction with NHS England.  Will license FTs and other providers of NHS-funded health services.  Will scrutinise commissioner requested services (essential services) to provide an early warning system in the case of trust failure.

Care and Support Bill 2012 Proposed changes to social care include:  establishing national eligibility criteria to reduce local variation in access  introducing a code of conduct and minimum standards for care workers  establishing a capital fund to develop specialised housing for older and disabled people. However, does not reform the way social care is funded, and does not stipulate the need for qualified staff or multidisciplinary teams

Draft Care and Support Bill 2012: Social care reform The RCN welcomes:The RCN is concerned by: National eligibility criteria to reduce local variation in access Fails to address the urgent and long overdue issue of social care funding. Introduction of a capital fund to develop more specialised housing for older and disabled people Without funding reform, many of the Bill’s intentions are at risk (i.e. prevention) Aims to create a greater focus on preventive and integrated social care Absence of recognition of importance of registered staff input into assessment and MDT working. Plus lack of incentives to encourages integrated care. A new code of conduct and minimum standards for care workers Failure to regulate care workers

Care and Support Bill 2012 Changes to health care education:  Responsibility for health education and training moving from SHAs and Medical Education England to new bodies - Health Education England (HEE) and local education and training boards (LETBs)  HEE will provide national leadership for education, training and workforce development  LETBs will bring together health care and public health providers, the professions, local government, and the research sector to plan and commission education in the local area  The RCN has raised concerns about accountability and transparency in the new system, and called for multi- professional workforce planning over the longer term rather than an annual cycle.

What the RCN is doing The RCN continues to monitor the impact of the reforms and advocate on behalf of patients and the nursing family to help them deliver safe, high quality care. The RCN is leading discussions and negotiations with employers (old and new) and the Department of Health to ensure that through this challenging period of change, workforce and staffing issues are dealt with quickly and effectively through partnership and that there are transparent processes and systems supporting staff throughout the change.

More information  The Navigating the new NHS section of the RCN website has briefings, fact sheets and an archive of our work on the reforms:  If you have any concerns about the reforms and how they affect you and your patients, please let us know so we can take them forward on your behalf. Contact us via  The RCN has produced a resource on clinical governance to help members sustain and improve high standards of patient care:  If you are an RCN member and you are being directly affected by the reforms, you can access advice and support from RCN Direct on