Evidence of widespread conflicts of interest among NHS commissioners has prompted calls from the BMA and the Labour Party for tighter regulation.

A BMJ study found that more than a third of GPs on the new CCG boards had a financial interest in private providers of healthcare, either as shareholders or as directors.

The NHS Commissioning Board stated that transparency over potential conflicts of interest would enable CCGs to self-regulate effectively.

Shadow Health Secretary Andy Burnham commented: “There is a real risk that the doctor-patient relationship will be corroded and public trust in the NHS lost.

“At the very least, ministers must bring in new rules to ensure that no GP takes part in any decision in which they could be perceived to have a financial interest.”

The BMA expressed concern that the reputation of GPs was at risk. Laurence Buckman, Chairman of its General Practitioners Committee, said: “In our view, GPs who are directors of, or who have significant financial interests in, companies who might be awarded contracts to provide services should seriously consider their membership of CCG governing bodies. Alternatively, they should consider their position within provider companies.

“We support the principle of greater clinician involvement in commissioning, but it must not come at the expense of the trust of patients.”

According to an NHS Commissioning Board spokesman, “it is vital that everyone working for a CCG or serving on its governing body declares any interests they have. This allows the CCG to put arrangements in place to ensure that those individuals are not involved in any decisions that would give rise to a conflict.”

The Department of Health has agreed to withdraw and revise the current secondary legislation on competition in NHS commissioning.

New regulations, tabled in Parliament a month ago, appeared to give Monitor the power to enforce private sector tendering of virtually all NHS services.

Following protests from the Academy of Medical Royal Colleges (AMRC) and over 1,000 GPs, the DH has claimed any difference between this and the former regulations was purely “inadvertent”.

Allowing CCGs to decide which services would be put out to competitive tender was one of the modifications to NHS reform agreed following the ‘listening exercise’.

However, the new secondary legislation appeared to override the ‘discretionary’ powers of CCGs and enforce competition in all areas of care, potentially driving the contracting out of most NHS services to the private sector.

Monitor would be empowered to enforce competitive tendering except where only one qualified provider existed, which is rarely the case.

Last week, a letter signed by over 1,000 GPs was sent to the Daily Telegraph urging a full Parliamentary debate on the new regulations, which will become law by default unless actively opposed.

This weekend, the AMRC wrote to Health Minister Earl Howe expressing “considerable concern” that the regulations disregard assurances formerly given by the DH and would drive a “dangerous” fragmentation of the NHS.

The situation recalls former Health Secretary Andrew Lansley’s statement that the listening exercise had not significantly altered any aspect of the NHS reform.

However, following the protests, Health Minister Norman Lamb (pictured) said the DH had “inadvertently created confusion and generated significant concerns”, and would revise the secondary legislation to show that it was in line with existing rules.

The revised version will be “fully in line with the assurances given” to the medical professions, he said, and will confirm the power of CCGs to decide which services go out to tender.

Shadow Health Secretary Andy Burnham said the revision of the secondary legislation, less than a month before it comes into force, shows that “Coalition policy on competition in the NHS is in utter chaos.”

The Labour Party has outlined plans to integrate health, mental health and social care in a single system, ultimately run by local government.

Shadow Health Secretary Andy Burnham has argued that such a ‘whole person care’ approach is the only way to meet the challenges of chronic illness and the ageing population.

The current system, he argued, merely sees patients slipping in great numbers from primary care to hospital and hence to nursing homes.

Speaking to the King’s Fund health think tank, Burnham said a Labour government would legislate for “a one budget, one service approach”.

Health and social care would merge, he said, with the NHS providing social care and local authorities commissioning healthcare.

Echoing recent statements by NHS Confederation leader Mike Farrar, Burnham said that integrated care was the only way to meet the clinical and economic needs of the NHS.

To shift the balance of healthcare towards prevention, he argued, the Payment by Results tariff needed to be replaced by a ‘year of care’ payment system for patients with complex needs or chronic diseases.

The providers of integrated care might be either acute NHS trusts or primary care services, he said, but in either case both services would be combined – with mental health services brought under the same control.

Burnham said: “In the century of the ageing society the gaps are becoming dangerous. People are falling into the ever-expanding cracks between our three systems. We are paying for failure, allowing people to fail at home and drift into expensive hospital beds and from there into expensive care homes.”

However, critics will argue that local authorities lack healthcare expertise and are often the least responsible and reliable kind of politicians.

The Care Quality Commission (CQC) has warned 26 NHS provider organisations that they are not employing and training enough staff to operate safely.

A total of 17 NHS hospitals, eight mental health trusts and one ambulance trust have been recorded as non-compliant with staffing level regulations following CQC inspections up to 9 January 2013.

This represents an improvement on the figure up to March 2012, when 40 NHS providers were recorded as dangerously under-staffed.

The warnings – made public following a request from Shadow Health Secretary Andy Burnham – related to lack of staff training as well as numbers of staff.

The following providers have been warned by CQC about the dangers posed by their under-staffing:

• Hospitals – Scarborough Hospital; Milton Keynes Hospital; Royal Cornwall Hospital, Truro; Walton Centre, Liverpool; Queen’s Hospital, Romford; Stamford and Rutland Hospital, Stamford; Southampton General Hospital; Croydon University Hospital; Bodmin Hospital; Northampton General Hospital; St Peter’s Hospital, Maldon; Queen Mary’s Hospital, London; Chase Farm Hospital, London; Westmorland General Hospital, Cumbria; Pilgrim Hospital, Lincolnshire; St Anne’s House, East Sussex; Princess Royal Hospital, West Sussex.

• Mental health trusts – Ainslie and Highams Inpatient Facility, London; Campbell Centre, Bedford; Forston Clinic, Dorset; Cavell Centre, Peterborough; Bradgate Mental Health Unit, Leicestershire; Avon and Wiltshire NHS Mental Health Trust; Blackberry Hill Hospital, Bristol; Park House, Manchester.

• Ambulance trust – London Ambulance Service.

The list reflects the extent to which the ‘lean’ corporate paradigm has penetrated NHS organisations.

Health Secretary Jeremy Hunt commented: “There can be no excuse for not providing appropriate staff levels when across the NHS generally there are now more clinical staff working than there were in May 2010 – including nearly 5000 more doctors and almost 900 extra midwives.”

However, Burnham drew attention to the lack of hospital nurses: “Nurses will not be able to provide the standards of care we all want to see when they are so overstretched and the wards so short-staffed.”

Some hospitals have challenged the inspection reports. The Bradgate Mental Health Unit’s Chief Executive, John Short, said: “The temporary absence of non-nursing therapeutic staff when the CQC conducted its inspection did not and does not relate to patient safety.”

In addition, the Royal Cornwall Hospital and the Bodmin Hospital both noted that more recent CQC inspections had found their staffing levels acceptable.

NHS Chief Executive Sir David Nicholson has warned that the Government’s controversial health service reforms may end in “misery and failure”.

Sir David said that politically driven changes to any public sector body usually ends in disaster.

Speaking to doctors at the Royal College of General Practitioners conference, Nicholson said that “carpet bombing” the health service with private sector competition was not the right way to tackle rising costs.

The NHS’ leader said that the reforms would benefit patients by offering them increased choice and improved standards of care through competition. But he added that GPs would only benefit from the reforms if they are free from negotiating new services.

“If we are creating a system where general practitioners feel it is their job to do all that, then I think we have a massive problem,” he told delegates. “We need to create the right kind of people with the right kind of skills, which we are trying to do at the moment through commissioning support, to enable people to focus their attention on clinical decision-making.

“My advice to anyone – and I have been involved in the last five or six years with the national programme for IT, and I have, as they say, the scars on the back around all of that – is that big, high-profile, politically driven objectives and changes like this almost always end in misery and failure.”

Shadow Health Secretary Andy Burnham said Nicholson’s comments were a concern. “David Nicholson is a man who has the NHS at heart, so it is worrying to hear him talk in these terms,” he said. “He has put on a brave face in public, but clearly has private concerns about the real damage this reorganisation is doing.

“His open acknowledgment of the possibility of it ending in failure will send shock waves through the NHS and provide a stark illustration of the sheer scale of the gamble the Government is taking.”

A Labour Government will rebuild the NHS as “a national, planned, collaborative system”, according to Shadow Health Secretary Andy Burnham.

In a preview of his party conference speech, Burnham promised to end the ‘any qualified provider’ (AQP) policy, which he said is now causing wholesale NHS privatisation.

More controversially, he outlined plans to have local authorities lead NHS commissioning and NHS hospitals provide social and mental health care.

Pledging a return to the NHS as ‘preferred provider’ of services, he said the private and voluntary sectors would “play a supporting role to a publicly owned, publicly accountable NHS”.

Burnham noted, from information about NHS tenders obtained through freedom of information requests, that the AQP rules now in operation were leading to rapid privatisation of many NHS services.

“This week the AQP contracts are being signed with private companies,” he said. “It is very difficult to find out what is going on. Who they are, how much is being spent. They cite commercial confidentiality but that is not good enough.”

In particular, he argued, hospitals reserving up to 49% of their beds for private patients from 1 October will “damage the character and culture” of the NHS.

While Labour did not intend to exclude the private sector from NHS service provision, he stated, it would remove the new “competitive structure” that hospitals and providers “have to work within”.

To achieve this, it would replace the CCGs with a commissioning system led by local government – retaining local control but removing the commercial element.

In addition, instead of reducing the role of hospitals, Labour would involve them in providing social and mental health care for the most vulnerable people.

Labour leader Ed Milliband has already pledged to repeal the Health and Social Care Act.

Hospitals across England are struggling to deal with real term cuts in funding imposed by the Government as part of its efficiency savings, the NHS’ economic regulator has warned.

Trusts across England are forecasting cuts of more than 8% over the next three years as the Government attempts to meet its target of saving £20bn by 2015.

But following a review of trusts’ three year plans Monitor said that hospitals need to make “significant changes” beyond efficiency savings to remain financially sustainable.

The review found that hospitals may be forced to reduce services in an attempt to meet financial targets – despite being tasked with treating the same amount of patients.

Hospitals across England have started to reduce their cost base by an estimated £7bn to meet Government targets. However, Monitor expects trusts with hospitals built using private finance initiatives and small general hospitals to suffer the most when aiming to cut costs.

Andy Burnham, Labour’s Shadow Health Secretary, accused the Government of making a “major mistake” in imposing harsh savings targets instead of finding cost-savings efficiencies.

“Eyes were taken off the ball just when the NHS needed its full focus on the money and this report suggests the NHS has failed to get ahead of the problem,” he said.

“Senior civil servants complain of how hard they have found it to get the Secretary of State on the seriousness of the financial challenge – a damning indictment of his time in office. This failure to plan is resulting in an increasingly crude approach to reducing costs and panic measures. Ministers are in danger of losing control of NHS finances and urgently need to get a grip.”

The King’s Fund anticipates that the outlook for hospital finances are bleak over the course of the next three years but is unsure how the cuts will affect standards of care. “The question is to what extent that will translate into a cut in quality or in the amount of care hospitals provide,” said Professor John Appleby, Chief Economist at the King’s Fund

What priorities does Andrew Lansley’s draft mandate for the NHS Commissioning Board reveal?

The draft mandate for the NHS Commissioning Board (NHSCB), published on 5 July 2012, is a manifesto for the new NHS: the first clear public statement of the anticipated course of NHS reform since the Health and Social Care Act became law. It offers a snapshot of the emerging structure for local commissioning, and highlights the Government’s key priorities for an NHS reform that is now a reality.

Introducing Our NHS Care Objectives: A Draft Mandate to the NHS Commissioning Board to Parliament, Health Secretary Andrew Lansley said: “Today we will be laying the foundations of the new, more independent NHS.” By this, he explained, he meant an NHS “free from constant political interference” and “tasked with continuously improving the care that patients receive”.

Transfer of powers
A key background document to the draft mandate is Lansley’s letter to the new Chair of the NHS Commissioning Board Authority, Malcolm Grant, in April. The letter stated his primary objective as being
“to design the Board so it transfers power to local organisations”. Other priorities included integrating health and social care and promoting patient choice.

Another important background document is the NHS Outcomes Framework, published in December 2010 and updated a year later. This defines the patient outcomes the NHS has to work towards – a counterpart to the business processes defined by the reform agenda.

The draft mandate has been issued for consultation. The final NHSCB mandate will be published in October and will guide the Board when it assumes its full statutory authority in April 2013.

Improving healthcare outcomes
The draft mandate begins by setting the context: the NHS is facing “one of the tightest funding settlements in its history”, while elderly care, long-term conditions and mental health are growing priorities. It outlines 22 objectives for the NHSCB for the two years from April 2013, as well as ‘ambitions’ for the coming decade.

The first major section lists 11 objectives for improving outcomes. The first six relate to the NHS Outcomes Framework – one for each of the five domains and one for the whole – setting concrete targets in QALY and similar terms, but leaving the actual numbers to the final version.

While there are no objectives for specific conditions, this section refers to dementia and mental illness and notes the need for better integration of general healthcare with treatment of these conditions. The NHS should work towards treating mental health as “on a par with physical health,” it states. There are objectives for reducing health inequalities, including life expectancy at birth. However, the reference to “greater improvement in more disadvantaged communities” should be seen in the context of the planned shift of public health funding from the NHS to local government. Finally, there are objectives relating to service performance standards and support for patient self-care.

Patient choice and local control
While the first 11 outcomes are related to the agenda for NHS improvement defined by Lord Darzi in 2008, the last 11 belong wholly to the new reform agenda. One crucial objective relates to patient choice. The Board must ensure that people are “involved in decisions about their care and treatment”; that personal health budgets are available “to anyone who might benefit”; and that a patient who has waited 18 weeks for treatment is entitled to choose another provider.

The Board is required to develop integrated care through joint commissioning and other methods, particularly for “people with dementia or other complex long-term needs”. It should also improve the quality of NHS information, using IT to make the NHS “transparent” to patients and carers.

The Government’s innovation agenda is highlighted by an objective requiring the Board to “promote access to clinically appropriate drugs and technologies recommended by NICE”, as well as supporting the participation of NHS clinicians and patients in life science research.

The section on commissioning states that the Board should fully authorise “as many CCGs as are willing and able” by April 2013, and allow the CCGs “full control over where they source their commissioning support”. The new clinical senates and networks will provide advice, with CCGs “free to make their own arrangements”.

The Board must have a “transparent, principle-based system” for managing “poor performance” or “financial risk” by CCGs. It must “support a fair playing field between providers” and “ensure that financial incentives for commissioners and providers support better outcomes and value for money”. The latter objective includes the controversial Quality Premium, a bonus payment rewarding CCGs who achieve a surplus on their annual budget. This will be funded from within “the overall administration costs” available to CCGs.

Crucially for industry, there is an objective to support “changes in services that lead to improved outcomes for patients”. These must meet four criteria: support from clinical commissioners; strong patient engagement; a clear clinical evidence base; and consistency with patient choice.

On the critical issue of cost savings, the mandate says only that the Board must ensure that QIPP savings are made “in a sustainable manner” as dictated by the Treasury, but without reducing service quality.

Between the lines
Responses to the draft mandate have focused on its open-ended nature. Mike Farrar, Chief Executive of the NHS Confederation, commented: “Unlike documents that have gone before it, the mandate does not seek to develop an ever-growing ‘wish list’ of objectives. It rightly encourages commissioners to exercise their knowledge of the needs of their local communities to plan and deliver the best care.”

Shadow Health Secretary Andy Burnham argued that Lansley had missed an important opportunity to highlight the issue of healthcare rationing – which the Health Secretary had recently stated to be
“unacceptable”. The delegation of control to local commissioners, Burnham argued, was “a mandate for privatisation.”

Dr Richard Vautrey, Deputy Chairman of the BMA’s GP Committee, praised the mandate for not placing too many restrictions on GP-led commissioning. However, he was strongly critical of the Quality Premium, which he claimed would encourage rationing and increase health inequalities.

Whatever the consultation period delivers, the draft mandate for the NHSCB is a clear statement of the NHS reform agenda: to deliver improved patient outcomes through CCG autonomy and provider competition.

Labour plans to scrap the Government’s controversial NHS reforms if they win the next general election, Shadow Health Secretary Andy Burnham (pictured) has said.

Speaking in Parliament during a debate opposing the reforms, Mr Burnham insisted the changes open the door to privatisation within the NHS and undermine the health service in general.

He said that Labour will “repeal the bill” if elected claiming it to be a “defective, sub-optimal piece of legislation” that has left the NHS with a “complicated mess”.

The Shadow Health Secretary added that it would be “irresponsible” to leave the Health Act in place if Labour were elected and added that the “gap between ministers’ complacent statements and people’s real experience of the NHS gets wider every week”.

“They are in denial about the effects of their reorganisation in the real world, it is dangerous complacency and it can’t be allowed to continue.”

Health Minister Simon Burns countered Mr Burnham’s claims by reminding the Leigh MP that Labour leader Ed Miliband had previously said he would keep clinical commissioning in place if elected as prime minister.

But the former Health Secretary insisted “it’s not about the organisations, it’s about the services they provide”.

“The existing organisations can be asked to work differently, as I would ask them to work differently,” he said.

“I don’t want those NHS organisations in outright competition, hospital versus hospital. I want them working collaboratively.”

All Foundation Trusts will be able to increase the private healthcare proportion of their income to 49% from 1 October, the DH has confirmed.

The rule – included in the Health and Social Care Act but still controversial – may help NHS trusts that are currently struggling to achieve FT status.

However, it has been criticised as likely to increase rationing of NHS services.

Since their creation in 2002, FTs have not been allowed to increase the proportion of income they earn from private patients.

The Health and Social Care Bill originally removed all caps on private earnings for FTs. The current rule was a key House of Lords amendment.

A DH spokeswoman said that being allowed to receive almost half of their income from private patients will enable FTs to expand their NHS services. “Services for NHS patients will be safeguarded, because foundation hospitals will still have as their core legal purpose a duty to provide services to them,” she added.

However, Ron Singer, President of the Medical Practitioners’ Union, commented: “It is inevitable that when an NHS hospital gets into financial trouble it will try to increase its income from private patients, putting NHS patients at the back of the queue.”

Shadow Health Secretary Andy Burnham predicted “an explosion of private work in the NHS” arising from the new rule.