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The times we are working in now need a great deal of accelerated change and there must be no negotiating that down. So my mission statement for this part of my consultancy career is to be clear that there needs to be and will be a lot of change from the work that I do with individuals and organisations and if organisations don’t want that, then it is probably best to go somewhere else.

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The White Paper – some issues. 3. Who is providing health care and how are they organised?

Filed Under (Health Policy, Reform of the NHS, White Paper) by Paul on 29-07-2010

One of the most striking phrases in the White Paper comes on page 36

“Our ambition is to create the largest and most vibrant social enterprise sector in the world”

I am always excited by ambition in a Government White Paper.

My initial reading of this was a referral to potentially hundreds of social enterprises led by GPs who would become commissioning consortia. But we know from elsewhere in the White Paper for that sector the Government ambition is the largest and least vibrant nationalised organisation of GPs in the world

The social enterprises that the Government talks about are in the field of the provision of NHS care and it looks as if the White Paper is talking about potential FTs. This is a very large aim indeed.

It contains two considerable aspects of ambition:

First to create such a large social enterprise sector in a country that has no track record of scaling up the social enterprise sector

The second is to achieve this in the NHS where the majority of provision is within either the public sector, in terms of secondary and community care, or the private sector in terms of GP care.

The rest of this paragraph refers to developments within the Foundation Trust model.

Here there are two significant changes.

Firstly they will consult on changing the governance model. Some Foundation Trusts find the existing model, with its emphasis on a variety of stakeholder’s involvements, cumbersome. Specifically the White Paper says that FTs “could be led only by employees, whilst others may want to remain with a wider membership”. This would be a significant shift in the model.

The Government will also consult on removing the constraints on FT freedoms. If this were to include a much greater ability to borrow on their assets this could lead to a considerable increase in their ability to develop new services.

Secondly whilst they restate the goal of all trusts becoming Foundation Trusts within 3 years, the new policy is to abolish the organisational form that non-FTs trusts have. This is a real end date for prospective FTs since if they no can longer exist as an organisation that is NOT an FT then by definition they cannot exist.

The problem for such a policy is how they can get some 30-40 existing trusts through to FT status when it is difficult to see how they could ever be responsible for their own future. Long term debt and structural problems mean that it is difficult to see how these trusts will ever make it.

A new unit will be set up in the Department to drive progress, but in truth these 30-40 trusts will only become FTs if they are taken over by existing FTs. This will only happen if they as organisations know that there is no alternative for them. For as long as a Government is committed to Conserving inefficient hospitals then the bung culture in the NHS always means that there is an alternative.         

The White Paper uses the language of extreme dread to describe how in the end they might have to deal with failing hospitals:

“In the event that a few NHS trusts fail to agree credible plans, and where the NHS trust is unsustainable, the Secretary of State may as a matter of last resort apply the trust administration regime set out in the Health Act 2009” Para 4.23

(In what field of endeavour is going bankrupt anything but a measure of last resort?)

Across the country we know that there are a considerable number of trusts that will not pass Monitor’s hurdles of entry. If the current Secretary of State wants these to become FTs they will have to first agree they have failed and can be taken over. If he doesn’t do this because he is committed to Conserving hospitals at all costs then his pledge to make all hospitals FTs will be as successful as his predecessors.

The other main pledges in the White Paper are about making it easier for new entrants into the quasi markets that it hopes will emerge. A lot will depend upon the capability of the new commissioners to commission new approaches to care. If state run GP Commissioners want to let contracts for NHS health care that encourage new entrants into the market for, say, long term conditions, then I am convinced that in this area alone there will be very many new integrated care organisations.

But if GP commissioners follow the lead given by the BMA and they do not develop new entrants, then the flowering of new social enterprises will remain a long way off.

Comments:

One Response to “The White Paper – some issues. 3. Who is providing health care and how are they organised?”


  1. Thanks for these rolling reflections – they are thoughtful and appreciated. I think I’m beginning to see the proposals as consisting of three imperatives – partnership, predation (NHS taking over social care) and privatisation (the 3 Ps). What is unclear is how these will interact and with what outcomes. About to write something along these lines for publication.

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