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Promoting efficiency
6.21
Efficiency will be enhanced through incentives at both NHS Trust and clinical team
level. Many NHS Trusts already devolve budgetary responsibility to clinical teams
and involve senior professionals from them directly in the management of the NHS
Trust. All NHS Trusts should be developing these approaches. Increasingly, clinical
teams will develop and agree the new longer term service agreements with Primary
Care Groups. Clinician to clinician partnership will focus service agreements on
securing genuine health gain. The efficiency incentives that come with budgetary
responsibility will be reinforced by longer term service agreements that allow a
share of any savings made to be redeployed by the clinical teams, in a way consistent
with the NHS Trust's priorities and the local Health Improvement Programme.
6.22 Partnerships between secondary and primary care clinicians and with social services
will provide the necessary basis for the establishment of 'programmes of care', which
will allow planning and resource management across organisational boundaries.
Programmes of care
An example is services for patients with diabetes covering support both in primary
care and from specialist hospital services, planned as an integrated whole to meet
patients' needs over time.
6.23
The requirement for benchmarking will encourage rigorous scrutiny of NHS Trusts'
costs and performance. All NHS Trusts will in future publish the costs of the treatments
they offer, so that inefficient performance can be identified and tackled. Further
details are in chapter 9. The new performance framework described in chapter 8 will
ensure over time that data are available locally on the areas that matter most to
patients as a basis for planning change and measuring progress.
6.24
Efficiency will also be achieved by bearing down on bureaucracy. The abolition of
the internal market will mean a significant reduction in transaction costs, the end
of extra-contractual referrals and progressive improvements in efficiency. Together
these changes will make it possible to redeploy £1 billion into patient care
over the lifetime of this Parliament.
6.25
The move from the market will allow NHS Trust managers to refocus their efforts on
the core purposes of the NHS. They will have a critical role in leading the developments
set out in this White Paper. The Government wants to see less bureaucracy and administration,
but more good management. They are quite different things.
6.26
The Government certainly does not want to see reorganisation for the sake of it.
Given the intended integration of primary and community health services, merging
community with acute NHS Trusts will not generally be encouraged. Nor will amalgamation
of smaller community NHS Trusts be encouraged if this inhibits closer working with
local primary care teams. Other mergers arising from local decisions will be considered
on their merits, on the basis of demonstrable benefits in health and healthcare,
and savings in administration.
Involving staff
6.27
To succeed in the NHS of the future, NHS Trusts will need to develop and involve
their staff. In the past this has not been a high priority. In the new NHS it is
- for one simple reason. The health service relies on the commitment and motivation
of its staff. That is why there will be a new approach to better valuing staff and
NHS Trusts will spearhead it.
6.28
NHS Trusts will retain their role as local employers within the NHS. In a national
health service, the current mix of national and local contracts is divisive and costly.
The Government's objective for the longer term is therefore to see staff receive
national pay, if this can be matched by meaningful local flexibility, since current
national terms of service for a multitude of staff groups are regarded as inequitable
and inflexible. Exploratory discussions on these issues are already under way with
staff organisations and NHS employers.
6.29
Pay is but one factor in how staff are rewarded. The Government will work with the
NHS to give a higher priority to human resource development. We are currently consulting
on a new direction for human resources to encompass action on all issues that affect
the quality of the working lives of NHS staff. It will particularly emphasise the
need to bring equality and development issues into the mainstream work of the NHS.
6.30
The NHS Executive has already asked NHS Trusts to tackle a range of immediate human
resource priorities. These include measures to promote health at work, through strategies
to minimise accidents, avoid violence, and address stress; to recognise and deal
with racism; to develop flexible, family-friendly employment policies; to ensure
junior doctors have reasonable standards of food and accommodation when on call;
and to make sure that staff can speak out when necessary, without victimisation.
6.31
Involving staff in service developments and planning change, with open communication
and collaboration, is the best way for the NHS to improve patient care. In the future,
NHS Trusts will be expected to be open with and involve their own staff. Open communication,
including early discussion of any changes, is part of good management, and all staff
should have greater opportunities to contribute their ideas for service improvement.
All NHS Trusts should work imaginatively through staff consultative committees and
other local arrangements to improve dialogue about decisions affecting local health
services.
6.32
Nationally, the Government will establish a Taskforce on improving the involvement
of frontline staff in shaping new patterns of healthcare. This will identify and
explore new approaches and examples of good practice within the NHS and elsewhere.
The Taskforce will involve NHS staff, unions, professional bodies, employers and
others. It will provide targeted support and advice, and help developing networks
of NHS Trusts interested in taking forward this approach locally. It will not duplicate
established NHS industrial relations processes.
6.33
There will be two further changes:
- NHS Trust Boards will be required to review regularly
whether they are doing enough to involve staff
- in their annual reports, NHS Trusts will outline
their local policy on staff involvement and include the outcome of any negotiations
or local initiatives which have been undertaken throughout the year.
6.34
The best NHS Trusts are already promoting greater involvement of clinical professionals
in their management. In the future it will be essential for the professional and
managerial environment in every NHS Trust to support clinical behaviour which maximises
the quality of care patients receive, minimises waste in the way care is offered
and makes best use of the skills of nurses, consultants, junior doctors, and other
clinical professionals and support staff.
6.35
It will be important for the right information to be made available to clinicians
and for high professional standards to be set and monitored. Equally that the substantial
sums invested in education and training support the service objectives of the NHS,
and that contractual obligations and incentives support quality, efficiency and effectiveness.
6.36
The NHS Executive and its Regional Offices will provide support through a specific
development programme to support the changes set out in this White Paper. The Regional
Education Development Groups and local Education Consortia will need to ensure that
connections are made between personal and organisational development, and that local
and national programmes are complementary.
Regional Education Development Groups
Regional Education and Development Groups bring together the key human resources
interests at regional level. They advise Regional Offices on the coherence of consortia
workforce plans and on the strategic direction of education and training, and ensure
that education responds to service needs and developments.
Rebuilding public confidence
6.37
Greater involvement among staff in NHS Trusts will help rebuild public confidence
in the NHS. That confidence was badly dented by the sense that the ethos of the internal
market was at odds with health service values.
6.38
In the internal market, NHS Trusts were established as independent statutory corporations,
owning assets, and with a financial regime modelled on the private sector. In abolishing
the internal market, the Government will amend the NHS Trust financial regime to
make it more transparent and more suitable for a public service based on partnership.
Control of the estate, comprising land and property, will be retained by NHS Trusts,
but Health Authorities will be responsible for monitoring its utilisation to ensure
consistency with Health Improvement Programmes and locally agreed estates strategies.
The Government will take reserve powers to ensure that the estate is managed in ways
which are consistent with local strategies and the broader requirements of the NHS.
6.39
In addition, the Government will make NHS Trusts more open and accountable. Already
action has been taken to ensure that NHS Trusts hold their meetings in public and
that Board membership is more representative of the local community. To buttress
these changes, no management information in the future will be classified as 'commercial
in confidence' between NHS bodies. Such a classification is simply not appropriate
for organisations that are publicly funded and accountable and are expected to operate
as trusted partners working together to the common goal of better health and healthcare
for local people.
6.40
Finally NHS Trusts will be expected to publish annually details of their performance,
explicitly reflecting the six new dimensions of performance outlined in chapter 8.
From 1999 - 2000, their annual accounts will have to include a statement detailing
their clinical governance arrangements, drawing on the approach above.
Making it happen
6.41
The new arrangements go with the grain of what NHS Trusts and their staff want. The
expectations laid on NHS Trusts are challenging, requiring good leadership and a
positive approach to partnership. The commitment of all concerned will be needed
to develop their new role as full participants in the local health service. Formal
changes in duties will be introduced through legislation but the new approach to
partnership is already developing (for example in the 1998-99 commissioning round)
and will continue to grow.
Milestones
1998
- new partnership arrangements will develop, and
NHS Trusts will participate in preparation of the first Health Improvement Programmes
- a strategic plan for improving human resource
management in the NHS will be published
1999
- (subject to legislation) the new framework of
statutory duties will be put in place
- new clinical governance arrangements will be put
in place to the same timetable
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