How NHS leaders reacted to the health White Paper

Responses from the main NHS bodies broadly support the White Paper's plans to hand commissioning to clinicians.

Andrew Lansley: has pledged not to back down on reform plans (Photograph: Pete Hill)

The most hostile opposition has come from the public sector unions, with Unison taking health secretary Andrew Lansley to court to block the plans and warning of privatisation.

Some, like the King's Fund and the NHS Confederation, believe the reforms should be introduced more gradually.

Of the GP organisations, the National Association of Primary Care and NHS Alliance are the most enthusiastic, having championed clinical commissioning for years. The BMA is more cautious; recognising the chance for GPs, but concerned about workload, privatisation, funding and the doctor-patient relationship.

There are divisions too over whether GP consortia should hold practice contracts.

GPs should not be the only clinicians running commissioning and all clinicians must be involved for the scheme to work, the BMA warns.

The White Paper's 'any willing provider' policy could destabilise local health economies by replacing large NHS providers with multiple small-scale providers, which may cost more.

The BMA questions the overall value for money of changes at a time when the NHS is targeting £15-20 billion of savings.

It adds that PCTs and SHAs should not be scrapped until new NHS organisations are ready to operate, and warns that GP commissioning consortia should not inherit PCT debts. Inheriting PCT debt would prevent consortia from operating to their full potential and GPs may be put off, the BMA says.

Success should not be measured just in outcomes - process targets that are proven to be of value work.

The college is confident GPs can 'rise to the challenge' set out in the White Paper. GP commissioning should cut unnecessary referrals and allow clinicians to improve services.

But RCGP members expressed concern over the pace and cost of the reforms, fearing the GP workforce could be 'stretched to breaking point' unless the DoH provides an adequate management fee. They call for greater clarity on which PCT roles will transfer to consortia, and for GP training to be updated.

The 'any willing provider' rule could 'undermine the essential ethos of the NHS - to provide equitable, high quality healthcare for all, free at the point of use', the RCGP warns. It fears a commissioning role could undermine doctor-patient relationships, because financial role clashes with previous clear GP role as patient advocate.

National association of primary care
Argues that the NHS Commissioning Board would be too bureaucratic if it holds GP contracts as proposed in the White Paper. The association says practice contracts should instead be held by GP consortia.

It adds that for consortia to build patient-centred services around a population, they will need to be able to commission primary care services, along with other services in primary care including dentistry, pharmacy and optometry.

Commissioning consortia should develop into 'managed care organisations', developing integrated care around population groups, the NAPC says. It backs a shift to outcomes, but warns some process targets may need to remain.

Urges GP consortia to share budgets with local authorities and believes the relationships with local authorities through health and well-being boards can boost transparency.

NHS Alliance
The Alliance believes the timescale for GP commissioning can accommodate both the 'fast movers' and 'those falling behind', and sees the White Paper as a huge opportunity. It would like to see budgets shifted to GP consortia that are ready as soon as possible. The Alliance is also championing PCT managers and executive committee chairmen as valuable assets in the transition and is keen to see power and budgets totally devolved to local clinicians.

Its response says: 'The White Paper will only be successful if it brings a major change of behaviour and culture in the NHS. The risk is that we might simply see changes to the structure and little else.' The Alliance says GP consortia should not hold GP contracts, but calls for maternity services to be commissioned by GPs.

It wants a statutory duty for consortia and local authorities to collaborate and for consortia to be represented on the NHS Commissioning Board.

NHS Confederation
Questions the scale and cost of the reforms, and fears they will distract the NHS from overcoming huge financial challenges ahead. Another concern is the loss of 'organisational memory', knowledge and skills as the number of NHS managers is drastically cut. It also suggests GP consortia's reduced management allowance will not be sufficient to commission properly. Despite its concerns, the confederation has published comprehensive responses to the four-part consultation, setting out hundreds of practical suggestions.

It says GP consortia should hold GP provider contracts, and there should be 'open book' accounting to trace income practices receive from their own consortia.

Specialised services could be commissioned by 'federations' of consortia, and maternity services should be commissioned by GP consortia, not centrally, it argues.

King's Fund

King’s Fund chief executive Chris Ham: warning over pace of reform (Photograph: Jason Heath Lancy)

Calls to reconsider the pace and scale of reforms attracted enough media attention to provoke the health secretary into publicly ruling out a U-turn.

The King's Fund wants PCTs' abolition delayed and thinks GP commissioning should be piloted. It wants 'balanced regulation' to both promote competition and encourage collaboration, and has called for the NHS Commissioning Board to establish regional offices to support consortia.

Patients Association
The association warns that because GPs are generalists some may lack the skills to commission specialist services for patients with long-term conditions.

It also warns that the White Paper reforms could worsen the NHS postcode lottery and that the 'skills, expertise and services offered by one GP consortium may be very different to those offered by a GP consortium down the road'. Believes consortia should have patient participation groups.

The Royal College of Paediatrics and Child Health warns that 'some services may require a more strategic view than can be offered by GP consortia yet are not a specialised service that might be overseen by the NHS Commissioning Board'.

The college wants 'arrangements to help sub-groups of the National Commissioning Board or clusters of GP consortia to consider commissioning requirements'.

Local Government Group
Wants local authorities to be 'lead commissioners' for a range of services GP consortia may also want to control: long-term conditions, mental health and HIV/AIDS clinics. It says health and well-being boards which bring GPs and local authorities together should sign off commissioning plans.

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