1. Working in rapid political change Case study: NHS White Paper - 'Equity and Excellence: Liberating the NHS' Presentation by Leela Barham, Policy Unit Exeter 18 th May 2011

2. Objectives  To reflect on a recent political change  To understand how the RCN policy unit analysed this political change  To understand how the RCN policy position was formulated  To understand the timescales involved with policy announcement, analysis and RCN response  To explore how RCN regions can influence organisational direction in rapid political change

3. Proposed approach  Case study of White Paper  Questions as we go through  Group discussion on case study  Current state of play  Group discussion so I can learn from you:  What worked well?  What would you change?  Working together in the future

4. Why this case study?  Reforms to NHS stem from change in Government  Unprecedented political environment with Coalition  Unprecedented financial challenge for UK plc  Nicholson Challenge (identified back in May 2009)  Uncertainties in direction for reform because of need to bring together 2 political viewpoints into 1 plan for the NHS in England  Reforms were not fully trailed in Manifestos

5. 2010 timetable  6 th May General Election (new Coalition Government)  13 th May Initial Coalition Agreement (promised real terms funding increase for NHS)  21 st May Final Coalition Agreement  13 th May Andrew Lansley New Secretary of State for Health in England (shadow since June 2004)  21 st June NHS Operating Framework  22 nd June Emergency Budget  28 th June RCN briefing on Emergency Budget and Coalition Programme  12 th July NHS White Paper (and 8 related Consultations over the next weeks)  26 th July RCN briefing on White Paper  3 rd September RCN Breakfast Roundtable  6 th September RCN Evening Seminar with Nurses in Commissioning  17 th September close date for members comments on White Paper  4 th October RCN response to NHS White Paper (and 8 related Consultations over the next weeks)  20 th October Comprehensive Spending Review  12 th November RCN Frontline First Interim Report

6. 2011 timetable  17 th January joint letter to the Times with others (e.g. UNISON, BMA and others)  19 th January Draft Health and Social Care Bill  31 st March Bill finished Committee stage  4 th April ‘Pause’ announced  21 st April first meeting of NHS Future Forum  13 th April RCN congress vote of no confidence in Lansley

7. NHS White Paper  Main NHS White Paper ‘Equity and Excellence: Liberating the NHS’  Supporting consultation documents:  Transparency in outcomes  Commissioning for patients  Local democratic legitimacy in health  Regulating healthcare providers  Achieving equity and excellence for children  Greater choice and control  An information revolution  Developing the healthcare workforce  Healthy lives, healthy people

8. Approach to analysis  Policy unit has leads on key areas e.g. system regulation, competition  Leads reviewed relevant sections and separate consultation documents  Often, leads also reviewed the whole reform proposals  Team discussions  Linked into broader discussions (e.g. with ERD) and into key internal working groups (e.g. HSCPG)  Identified opportunities, threats and risks and compared to evidence base and RCN principles  Papers and presentations to support discussions  Internal working drafts of response by individual Chapter leads  Final response was a composite and with separate Editors to ensure the whole read together  Final sign off from Exec Team

9. What the white paper said… Chapter 1: ‘Liberating the NHS’- Key themes  ‘Empowering’ frontline clinicians  Government to ‘uphold’ the values & principles of the NHS  Commitment to increase health spending in ‘real terms’ in each year of the current Parliament  Decentralisation and significant reduction in size of DH  Responsibility for local health improvement to transfer to Local Authorities Chapter 2: ‘Putting patients and the public first’- Key themes  Patient focus and shared decision-making: “ no decision about me, without me.”  New independent consumer champion: Health Watch  More information for patients (as part of ‘information revolution’)  Patients to rate services provided

10. Chapter 3: ‘Improving healthcare outcomes’- Key themes  Outcome measures, not process targets  NHS Outcomes Framework will include a set of national outcome goals against which the NHS Commissioning Board will be held to account  Health Bill will strengthen NICE and extend its remit to include social care  Incentives for quality improvement  Commissioners will be able to impose contractual penalties on providers delivering poor quality care  From April 2011 a new Cancer Drug Fund will operate What the white paper said…

11. Key themes  Pay and pensions:  Pay will be frozen for 2 years for those earning more than £21,000  Fundamental structural review of public service pension provision  Workforce planning and training:  Employers given the freedom to plan and develop their workforce locally  Role of DH in deciding and allocating resources for training and education reduced  Care Quality Commission as the system regulator for providers and new Economic Regulator (new Monitor) Chapter 4: ‘Autonomy, accountability and democratic legitimacy’  Commissioning:  Creation of GP commissioning consortia  Independent Board to oversee commissioning process  Foundation Trusts:  Every NHS Trust to become a Foundation Trust, with extended freedoms and autonomy  Abolition of trusts’ private income cap trusts  Pro-market:  Focus on competition  A role for ‘any willing provider’ in delivering health care What the white paper said…

12. Chapter 5: ‘Cutting bureaucracy and improving efficiency’- Key themes  Abolition of PCTs and SHAs  Review of arms length bodies  Acknowledgment that overall changes will cause significant disruption and loss of jobs  Efficiency savings of £20 billion, which includes significant reductions (up to 45%) in NHS management costs.  Government will not bail out commissioners who fail What the white paper said…

13. New structure Source: http://www.bbc.co.uk/news/health-10647910

14. RCN’s own consultation  Dedicated section on RCN web site  All member email and online member survey  Film (to support survey)  RCN briefing for members  PowerPoint presentation (for RCN Boards, activists and groups of members), policy presentations in person when invited  Website story – Peter Carter’s message to members  Nursing press articles, features and news reviews  RCN Bulletin stories - asking for member feedback and link to resources on website  Blogs for RCN web site  Podcast  RCN round table breakfast meeting with royal colleges and RCN evening meeting with commissioning nurses  Webcast Over 1000 members responded to inform the RCN response to the White Paper and RCN materials reached over 175,000 members

16. Group discussion  What did you see?  What did you think of it?  What else would you have wanted?

17. Forming the RCN position  Policy unit supports formulation of position  Informed by responses and discussions  In conjunction with others within RCN including:  Nursing Dept  Employment Relations Dept  Legal Dept  Parliamentary Dept  RCN Institute  RCN England  Exec Team  Formal positions discussed and agreed via NPPC and then Council  Then positions disseminated via number of routes (e.g. Policy web pages, submissions to Health Select Committee etc), led by Comms with support from many others (e.g. Parliamentary briefings to MPs)

18. Key RCN concerns  Fragmentation concerns/need for co-operation  Nursing representation on consortia and NCB  Impact of forced competition and maximum tariff price on quality of patient care  Public and Patient Involvement  Role of Monitor and EU competition law  Private Income Cap and bonuses  Opposition to localised pay structures  Health inequalities  Piloting and evaluation

19. The 18 assurances we seek… In our response to the NHS White Paper we asked for 18 assurances. Key examples include:  Structural reforms should be piloted and only introduced if they work  No move away from national pay or undermining AfC  Nursing leadership must be protected  National oversight of nurse education and training  Nursing must be represented in commissioning regimes  The risks of system reform must be managed in the interests of the NHS, staff and patients

20. Are changes possible? RCN and others raising serious concerns about impact of NHS Reforms on safety of services A ‘fluid’ situation with increasing media attention (Lib Dem Spring conference, BMA meeting etc) Nurse leadership beginning to win support – nursing representation on NCB, mentions in parliament and by Prime Minister. Concessions on price competition Govt pause for ‘listening’ and Forum RCN Congress – no confidence in the Sec of State’s management of reforms

21. Current state of play  Currently in a ‘pause’  Number of groups looking at reforms and changes needed to the Bill  NHS Future Forum  Special Number 10 Group  DH running listening events  Stakeholders putting forward their ideas (e.g. UNISON, RCGP)  But changes on the ground  PCT Clusters (and redundancies in PCTs, SHAs etc)  Frontline First suggests cuts and more cuts  But some things stay the same  Agencies e.g. CQC  Drive for quality  Need to make efficiency savings

22. Pathfinder Programme On 21st October 2010 the Department of Health announced a Pathfinder Programme to identify and support groups of GP practices who would like to make faster progress in taking on the new commissioning roles:  On 8 th Dec the first GP consortia under the Pathfinder Programme were announced  On 17th Jan 2011 a second wave of GP pathfinder consortia were announced. This took the total to 141 groups of GP practices of various shapes and sizes from across England  On 2nd March the Govt announced a third wave with the names of 40 more GP consortia, predominantly in the East of England, East Midlands & London  On 1st April DH announced a fourth wave of GPs to join the Programme The total programme now covers 90% of the total population in England that have come forward. This means that 45.7 million people around the country are covered

23. Links to ongoing work  Frontline first  Continuing ‘usual’ work  Informal discussions with stakeholders on the future and policy directions

24. What next? 2011  New Outcomes framework  NHS National Commissioning Board begins (in shadow form)  First GP Consortia start work in shadow form 2012  NHS National Commissioning Board established  New local health and well-being boards established  SHAs abolished 2013  New Public Health Service to be in place  GP consortia fully operational  PCTs abolished  All trusts become, or are part of a foundation trust * Subject to passage of Health and Social Care Bill through the Lords

25. Group discussion  What worked well?  What would you change?  Working together in the future

26. Thank you!  Read the RCN Policy Unit website for more…www.rcn.org.uk/policy  And please do call (020 76473723), email (policycontacts@rcn.org.uk), or if you’re in London pop in to Room 204 at HQ