NHS reforms: White Paper response from national diabetes nursing groups

The NHS is facing the most radical reforms since its inception following the publication of the White Paper Equity and Excellence: Liberating the NHS (Department of Health [DH], 2010a) on 12 July 2010. Under the Government’s plans, NHS management costs will be reduced by more than 45% (DH, 2010a). In addition, all strategic health authorities (SHAs) and PCTs in England will be abolished in the next 4 years. In their place, hundreds of GP consortia will be created and given responsibility for 80% of the entire NHS budget (Roland, 2010). 

The White Paper was accompanied by four supporting documents that formed a public consultation on specific aspects of the reforms: 

• Liberating the NHS: Commissioning for Patients (DH, 2010b).
• Liberating the NHS: Transparency in Outcomes – a Framework for the NHS (DH, 2010c).
• Liberating the NHS: Increasing Democratic Legitimacy in Health (DH, 2010d).
• Liberating the NHS: Regulating Healthcare Providers (DH, 2010e).

We appreciated the opportunity to respond to the White Paper and organised a diabetes nurse working group discussion that took place in London on 30 September 2010. The aim of the meeting was to discuss key issues in the first two consultation documents, and to form a formal response on behalf of the following organisations:

• Training, Research and Education for Nurses in Diabetes-UK (TREND-UK).
• The National Diabetes Nurse Consultant Group.
• The Diabetes Inpatient Specialist Nurse Group.
• The Royal College of Nursing (RCN) Children and Young People’s Diabetes Community.
• RCN Diabetes Nursing Forum.
• Diabetes Nurse Facilitators Group.
• The Primary Care Diabetes Society (nurse representatives).
• The Practice Nursing Forum.

We summarised comments from all meeting participants and submitted our full response to the DH on 11 October 2010. This article outlines the main outcomes from the meeting and discusses our concerns regarding the NHS reforms.

General comments
Implementation of the reforms
We warmly welcome and share the Government’s commitment and its key principles, but are concerned by the lack of detail addressing how these principles will be implemented in practice and how they would interact with existing NHS initiatives. Clarification is also needed on the commissioning of specific services, such as diabetes care, and related outcome measures.

Multidisciplinary team working
High-quality patient care relies on successful partnership working from the whole multidisciplinary team. Although vast and diverse, the NHS is an organisation with a cohesive and unifying ethos. The reforms set out in the White Paper may fragment the present service into many different and competing services. We are concerned about how collaboration and sharing of knowledge will be supported in an increasingly competitive healthcare market. Clarification is needed on how care providers at different levels, from those working in the communities through to specialist centres, will be empowered to work in a coordinated way to provide truly integrated care.

Workforce competency
In order to achieve the Government’s ambition to move care closer to home and to ensure continuous delivery of high-quality care in the community, it is vital that healthcare providers have the necessary skills and competencies. The White Paper has not addressed how to prepare staff for the dramatic changes and how to assess essential workforce competencies. We would like to see professional standards being developed to ensure proper investment in an appropriately skilled and sustainable workforce.

The role of nurses in the new NHS
Nurses have an invaluable insight into the practical issues of service delivery and their unique perspective of patient experience is vital to any reform of the NHS. Over the years, the role of the nurse has evolved to encompass greater responsibility in many areas, including making treatment decisions. Moreover, nurses have also taken a decisive role in hospital administration and hospital and community service redesign, and as such they can positively or negatively impact the way health care is provided. As a result, nursing expertise must be recognised and utilised during the new commissioning process. However, we are gravely concerned that the Government failed to explicitly mention within the White Paper the role of nurses, who make up some 70% of the NHS workforce (RCN, 2010). We are keen to see genuine involvement and input of nurses in the future NHS.

Financial concerns
The implementation cost of the reorganisation set out in the White Paper has been estimated at £2–3 billion (Walshe, 2010). At a time of financial austerity, we are unconvinced that each GP consortium will have ring-fenced funding for necessary professional training for staff and various support materials for patients.

Our response
Below is an overview of our response to two of the four consultation documents that accompanied the White Paper: Commissioning for Patients and Transparency in Outcomes – a Framework for the NHS. We chose these two documents because they are most pertinent to nurses working in diabetes care.

Commissioning for patients
The consultation document Commissioning for Patients provides information on the Government’s intended arrangements for GP commissioning and seeks views on a number of specific questions (DH, 2010b).

Commissioning responsibilities have for some years largely rested with PCTs and to some extent the primary care groups that preceded them. In a bid to “shift decision-making as close as possible to individual patients”, the coalition Government has proposed to “devolve power and responsibility for commissioning services to local consortia of GP practices” (DH, 2010a). Under this plan, GP consortia will commission the great majority of NHS services, including out-of-hour emergency care, elective hospital care, rehabilitative care, most community health services, mental health services and learning disability services. To provide overall leadership on commissioning, the Government will create an NHS Commissioning Board, which will calculate practice-level budgets and allocate them directly to consortia. Consortia will be responsible for managing these budgets and the Board will in turn hold consortia to account for their performance.

We appreciate the principle of cutting bureaucracy and empowering healthcare providers who are working close to patients. However, we feel that it is essential for GPs to actively engage with specialists in order to successfully deliver the extra services proposed in the White Paper. During the roundtable meeting, we raised a number of general questions regarding GP commissioning, which are listed in Table 1. We also answered some of the questions brought up in the consultation document. Key points from our response can be found in Table 2.

Transparency in outcomes
The consultation document Transparency in Outcomes – a Framework for the NHS provides information on proposals for developing an NHS Outcome Framework and seeks views on some specific aspects (DH, 2010c). Here, we summarise our discussion during the meeting regarding proposals for the development of the framework. Readers should note that following the consultation period, the DH has recently published this document entitled The NHS Outcomes Framework 2011/12 (DH, 2010f).

As stated in the original White Paper consultation document, the NHS Outcome Framework is intended to “sharpen the accountabilities in the system for delivering better and more equitable outcomes” (DH, 2010c). The framework is made up of a set of national outcome goals that provide a means by which patients, the public and Parliament can hold the Secretary of State for Health to account for the overall performance of the NHS. The framework has been developed with the following key principles in mind:

• Accountability and transparency.
• Balance.
• Focus on what matters to patients and healthcare professionals.
• Promotion of excellence and equality.
• Focus on outcomes that the NHS can influence but working in partnership with other public services where required.
• That it would be internationally comparable.
• That it would evolve over time.

In terms of the structure of the NHS Outcome Framework, it was proposed that the framework should be developed around a set of five outcome domains (see Table 3) that attempt to capture what the NHS should be delivering for patients, and indeed the subsequently published document reflects this (DH, 2010f). Each of the domains is covered by one or more overarching outcome indicators, five to eight improvement areas and a suite of supporting quality standards, most of which are in development.

During our discussion, we agreed with the key principles and the structure of the framework. However, we felt that there was a lack of detail regarding outcome measures for specific services. Some of the indicators proposed may not be applicable to diabetes services and clarification would be needed when measuring the quality of diabetes care. Key points from our response to some of the consultation questions can be found in Table 3.

In the newly published NHS Outcome Framework, we are pleased to see that NICE quality standards for diabetes that are relevant to domain 1 and 2 are due for publication by June 2011 (DH, 2010f); however, the other domains do not appear to provide sufficient clarification for diabetes.

Conclusions
The principles driving the White Paper – removing unnecessary bureaucracy, empowering healthcare professionals working close to patients, focusing on clinical outcomes and providing greater transparency of data – are commendable and welcome. However, a lack of detail is notable throughout the proposals. In our view, the White Paper fails to provide sufficient evidence about why the Government believes this is the right action to take now.

We are concerned about how GP consortia will link with other organisations to ensure similar levels of engagement from all parties in the multidisciplinary team. We also feel that the nursing profession, which is vital to high-quality patient care, is inadequately represented in the current proposals for the commissioning and delivering of services. As nurses working in diabetes care, we would like some clarification on how the reforms will affect diabetes services and we look forward to making our best contribution to the new NHS.

Acknowledgements
The authors are grateful to Zhizhi Chen, SB Communications Group, for writing assistance and editorial support.

This article is based on a diabetes nurse working group discussion that took place in London on 30 September 2010. Novo Nordisk provided an educational grant to support the meeting and this article. Novo Nordisk have had no input into the content of the meeting or this publication.