It is publishing its response to the white paper Equity and Excellence – Liberating the NHS on behalf of 95 per cent of organisations in all parts of the NHS, the result of a major consultation exercise.

The NHS Confederation makes clear that its members support the government’s objectives of empowering patients and involving clinicians more closely in decision making.  It stresses that they are firmly committed to working positively to achieve ministers’ ambitions. They have significant knowledge and experience to contribute to help make the new system work.

But the NHS Confederation also indentifies “significant risks, worrying uncertainties and unexploited opportunities” that need addressing if the plans are to work as intended.

Nigel Edwards, Acting Chief Executive, said: “Empowering patients is clearly the right thing to do.  And there are strong arguments for involving clinicians more closely in decisions about the design of care and the management of resources. But these reforms mean radical change, requiring a major shift in culture and the way the NHS does business, as well as a shake up of institutions.

“It is imperative that the government does everything possible to address what is a significant list of uncertainties about how the new system will work. The fact of the matter is that the government is planning to build a very big new machine - at great pace - but no one can be quite sure what will happen when it is switched on.” 

Mr Edwards added: “Ministers also need to ease the very deep worries that people feel about the transition. This is the area where people’s concerns have been greatest because there is a real danger of failures in quality of care or finances. We are about to embark on a hazardous journey at a time when resources are hugely stretched. The risks are very real indeed.”

The Confederation makes 40 suggestions for improving the new system and proposes a ten-point action plan for managing the transition.  It urges the government to tackle the issues, either by making changes to national policy or by enabling local solutions. 

Key concerns about the proposed new system include:

GP consortia do not appear to be clearly accountable to patients and the public

Clarification is needed on their relationships with member practices, the NHS Commissioning Board and health and well-being boards. These relationships have the potential to be hugely productive, but GPs need to be fully engaged in commissioning, and accountable to the populations they serve.

Market mechanisms alone will not be adequate to manage the system
There needs to be a way to encourage GP consortia to work together and help providers adjust to changes in demand. The new system will need to make sure patients in unpopular markets receive the services they need, ensure quality and encourage innovation and change.

Achieving integration for patients requires an whole system approach

There is a need to promote better integration between primary and secondary care; and between health, social care and public health. But some of the incentives and structures in the proposed system could act against this. In particular, the omission of any consideration of the role of specialists in the new system could push different parts of the system further apart. Improving integration will require co-ordinated planning across systems and incentives for commissioners and providers to work together.

GP consortia need more influence on primary care and health inequalities
The proposals do not make the most of the potential of GP consortia to drive health improvements. Giving consortia the power to performance manage primary care and make the tough decisions needed to get the best value for public money could make a big difference in these areas.

Overlapping outcomes frameworks for health, public health and social care are needed

These frameworks should be developed against a co-ordinated timetable to ensure that the content is consistent and professionals from different sectors are working together to achieve shared outcomes.

The Confederation’s submission describes the transition period as the area of greatest area of risk. 

It warns of potential for failures in the quality of patient care and in financial control.  It says it will be exceptionally difficult to deliver major structural change and to make £20 billion worth of efficiency savings at the same time. 

Key concerns about the transition include:

GPs need capacity and capability to take over commissioning
Commissioning health services is a complex task and GPs will need to quickly develop the capacity and capability to do this effectively. Our members have major concerns that this will not be possible with 45 per cent management cost reductions over the next few years.

Skills and experience from PCTs are likely to be lost
Primary care trusts have built up a wealth of expertise that will be vital to the success of the new consortia. Urgent action is needed to retain good staff and preserve organisational memory.

The management burden needs to be reduced from now
Strategic health authorities and primary care trusts have amassed a large number of management responsibilities at the request of the Department of Health, some of which may not be continued in the new system. The Government needs to urgently review which activities it does not wish to continue so that savings can be made immediately.

Barriers to trusts achieving foundation trust status may remain
The reasons for trusts failing to make the transition to foundation trust status are many and varied. These need to be correctly diagnosed, and solutions found, if the system is to succeed.

The scale of the cultural change needed has been underplayed

Most of the consultation and documentation focuses on the mechanics of the new system and immediate next steps. However, it is clear that the culture change being proposed is at least as important and, based on health reform elsewhere, will take many years to have an impact. There is insufficient focus on explaining this, which is a hazard given the long-standing view that the Department of Health and ministers run the NHS and should intervene when things go wrong. The NHS itself is also accustomed to a top-down management approach. More needs to be done to explain the shift away from top-down management and to help the public, the NHS, media, and MPs to understand its implications.