Health Secretary Jeremy Hunt has pointed the finger of blame at GPs for rising A&E admissions and the added pressure placed on emergency services.

Speaking to MPs, Hunt said that “poor primary care provision” was behind some four million additional people unnecessarily visiting accident and emergency services.

But the General Practitioners Committee called Hunt’s claims “nonsense”.

A Department of Health spokesperson played down Hunt’s accusations insisting the Health Secretary was “clearly not blaming GPs” and that he was referring to procedures set by the former Labour government.

Hunt was responding to figures published by Labour that showed the NHS had missed its national A&E waiting times each week for the past six months.

He claimed this was down to poor alternatives to primary care which was the result of changes introduced by Labour to the GP contract.

“The reason that there is so much pressure on A&E is because of the disastrous GP contract that was negotiated,” he told the House of Commons. “That is what is causing the huge pressure. That is what we are determined to put right.”

The Health Secretary said the solution to the rising number of A&E admissions was to analyse the GP contract, introduce alternatives to secondary care and integrate health and social care services.

A new House of Lords bill aims to restore the legal duty of the Health Secretary to “secure provision” of NHS services.

The National Health Service (Amended Duties and Powers) Bill, introduced by independent peer David Owen, would reverse the autonomy of the NHS – a key legal plank in its anticipated carve-up by the private sector.

According to Owen, the new bill would provide a Labour government with ready-made legislation to avoid “the worst ravages” of a healthcare market.

Since the establishment of the NHS in 1948, the Health Secretary has had a legal duty to ensure that health services are provided nationwide.

However, the Health and Social Care Act (2012) replaced this duty with a less specific “responsibility” for NHS management, with accountability for services passing into the remit of an “autonomous” NHS.

This transition, Owen claims, ensures that decisions about what services will be freely available to patients will be made by non-accountable bodies, including private companies.

Supporters of Owen’s bill include Clare Gerada, Chairwoman of the Royal College of General Practitioners, and Allyson Pollock, Professor of Public Health Research and Policy at Queen Mary, University of London.

“This bill, if it becomes an act in 2015, will come just in time to save [the NHS] from the worst ravages of an external and full blooded market,” Owen said.

As legislation, he added, it would enable a new government “to reverse the marketisation of health, the treatment of health as just another utility, and to reinstate not just its democratic base but its values.”

The Department of Health commented that clauses clearly stating the Health Secretary’s “responsibility” and “accountability” for the NHS were included in the Health and Social Care Act “after constructive cross-party discussion”.

The new chairs of the National Institute for Health and Clinical Excellence (NICE) and the Care Quality Commission (CQC) have been confirmed.

Following the announcement of David Haslam and David Prior as the Government’s preferred candidates for the two roles, both have been approved by the Health Select Committee.

New NICE chair David Haslam (pictured) is currently National Clinical Adviser to the CQC and chair of NICE’s Evidence Accreditation Advisory Board.

Haslam is a former GP, BMA president and chair of the Royal College of General Practitioners. His appointment can be seen as an attempt to give the GP profession a clearer voice in the NHS.

He will replace Sir Michael Rawlins, chair of NICE since its inception in 2000, in April 2013 – when NICE will extend its remit to social care.

Health Secretary Jeremy Hunt said that Haslam “will bring to this important role a wealth of skills and experience from his distinguished career as both a front line GP and a respected clinical leader.”

David Prior, who will take up the post of CQC chair at the end of January, is currently chair of Norfolk and Norwich University Hospitals NHS Foundation Trust.

He is a former Conservative MP for North Norfolk, and his appointment represents a consolidation of the NHS reform agenda.

Hunt commented: “David brings a wealth of experience to this significant position, as the chair of a foundation trust, a large comprehensive school, and experience in the private sector.”

Prior said: “I do not underestimate the scale of the challenge ahead but look forward to working with the chief executive, David Behan, and the whole of the organisation to ensure CQC is absolutely clear to the general public about the quality of services it inspects: when services are good and when they are not.”

The Care Quality Commission (CQC) was formed in 2009 to replace three separate inspection bodies: the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission. Since October 2010 all providers of healthcare and social care, whether in the public or private sector, have had to register with the CQC – which now regulates more than 21,000 providers.

This massive registration task was divided into phases: the Commission registered NHS secondary care providers, then re-registered adult social care and independent healthcare providers, then registered primary dental care and independent ambulance providers. Its next challenge is to register all GP practices. Most importantly, it will need to continue monitoring the quality and safety of all these providers’ services.

The CQC’s declared purpose is to eliminate poor quality care, defend patients’ rights and ensure that care is centred on people’s needs. Initially it adopted a ‘risk-based’ strategy of using evidence of potential danger to determine the frequency of inspections. In 2011/12 it shifted to annual inspection of all care providers. Next year, however, it will revert to a ‘riskbased’ approach – as well as participating in local Quality Surveillance Groups, alongside CCGs and local Healthwatch.

These changes follow a year in which the CQC has faced criticism of its leadership and its overall performance. The Mid Staffordshire Foundation Trust enquiry led to criticism (for different reasons) of its Chief Executive, Cynthia Bower, and its Chair, Dame Jo Williams. The recent scandal of sustained patient abuse at Winterbourne View Care Home led the CQC to be accused of failing to conduct regular inspections and respond to ‘whistleblowers’.

In March a Commons Public Accounts Committee concluded that the CQC had “a long way to go” before it could be considered an effective regulator. The recent resignations of Bower and Williams have reduced the shadow over the leadership. The new CQC Chief Executive, David Behan, has a background in social care rather than healthcare. But can the problems of regulating provider quality in the new health and social care system be solved by such changes, or are they systemic issues beyond the scope of the CQC?

In safe hands
The CQC’s annual report for 2010/11 noted that by April 2010 it had licensed all 378 NHS provider trusts, and had required 22 trusts to take specific actions to improve their services. By October 2010 it had re-registered 12,000 adult social care and independent health providers, and had required almost 1,000 care homes to put in place qualified managers. By July 2011 it had registered 18,000 dental care and independent ambulance providers. The inclusion of primary medical services will add 8,000 providers to the list.

Each provider is accountable for each separate ‘regulated activity’ it provides, and must show that the service meets acceptable standards of quality and safety. CQC standards cover these areas:

• Informing patients and involving them in decisions about their care.
• Personalised care, treatment and support.
• Safeguarding and safety of the care environment.
• Suitably qualified and capable management and staff .
• Risk management and incident reporting.

A further responsibility of the CQC is to respond to complaints about services – and in particular, to provide a safe and responsive port of call for ‘whistleblowers’: care provider staff who report failings in quality or safety.

Winter in social care
Financial pressure was a feature of the CQC’s role from the outset. Its initial budget was 30% less than the combined budget of the three organisations it had replaced. The Labour Government set a ‘light-touch’ agenda for inspection: unless there was evidence of risk, providers would be left uninspected for
up to two years.

The coalition Government’s review of arm’s length bodies in July 2010 reinforced the CQC’s role as regulator for health and social care. However, it was not exempt from the general requirement that the NHS ‘do more with less’. Its annual budget for 2010/11 was set at £16.4m – £10m less than it had told the DH it needed to cope with the combined task of registering and inspection.

As a result, the number of inspections carried out by the CQC fell by 70%. Concern over its performance came to a head in the Winterbourne View scandal, where action to stop the mistreatment of learning-disabled patients in a care home run by private firm Castlebeck had been unacceptably slow. The regulator had failed to act on information from a ‘whistleblower’, and only a BBC Panorama report had brought the abuses to public attention.

In the aftermath of the scandal, a Health Select Committee report accused the CQC of devoting too much of its resources to registration, a sign of “distorted priorities”. However, Kings Fund Director of Policy Anna Dixon observed: “It is no good preaching the virtues of light touch regulation, and then blaming the regulator for not taking a more interventionist approach when problems emerge.”

The later Commons Public Accounts Committee report highlighted several CQC failings: lack of inspections,
failure to fill key vacancies in its inspection team, and the decision to scrap a helpline for whistleblowers. The committee said the CQC risked becoming a mere “postbox” for complaints.

Jo Williams described the Winterbourne View case as a “watershed moment” for the CQC, triggering its abandonment of the ‘light touch’ approach. The regulator asked for – and got – a £10m increase in its budget for 2012/13 to increase its number of inspectors by 15%, enabling it to adopt a policy of inspecting each provider at least once a year.

Crisis of leadership
The issues affecting the CQC leadership reflect some of the conflicts of interest that can arise for care regulators. The Mid Staffordshire inquiry – the greatest hospital safety scandal in the NHS’s history – concerned events that took place before the formation of the CQC. However, Cynthia Bower was head of the West Midlands SHA at that time, and the inquiry was critical of her role.

The Healthcare Commission (HCC) had warned the SHA about the unusually high mortality rate at Stafford General Hospital. According to the Guardian, Bower responded by commissioning a known critic of the HCC at Birmingham University to write a report on the HCC’s methodology. When the CQC was formed, Bower disbanded the HCC’s inspection team.

The Mid Staffs inquiry led to severe damage within the CQC. Senior operations analyst Rona Bryce claimed the testimony of CQC Board members was “aspirational”. Board member Kay Sheldon contacted the enquiry to voice concerns she said she had raised internally without result. Dame Jo Williams then asked the Health Secretary to dismiss Sheldon, but he declined. Williams also commissioned a third-party investigation of Sheldon’s mental health.

The way forward
David Behan, who took over as CQC Chief Executive in July 2012, had been Director General of Social Care at the DH since 2006. His appointment suggests a shift towards greater focus on social care regulation. The DH has set three core goals for the CQC going forward: to become more strategic in its approach and define quality more clearly in terms of outcomes; to make its Board stronger and more accountable; and to make the regulatory process more systematic and proportionate to risk.

The reversion to a risk-based approach is clearly driven by the cost-cutting agenda. However, Behan promises a “more ambitious” use of performance data to highlight success as well as failure, helping to drive widespread improvements in care. He also plans a “differentiated regulation” of health, mental health and social care providers.

In addition, from April 2013 the CQC will work alongside CCGs and local Healthwatch to develop a network of local and regional Quality Surveillance Groups. According to the NHS Commissioning Board, this system will “act as a virtual team” across health and social care, and will “need to manage itself ” without governance. It will use a ‘risk summit’ model to deal with problems, but who takes primary responsibility will depend on the circumstances.

These changes show the CQC becoming more devolved, but also more able to assist the integration of health and social care. However, as providers become more diverse while funding both for inspection and for care becomes steadily tighter, the future is unlikely to be problem-free for the regulator. The CQC will need to continue walking a tightrope between a ‘light touch’ agenda and urgent reactions to healthcare disasters – its success will depend primarily on getting better at it.

Health Secretary Jeremy Hunt has said it’s “not possible to make a prediction” on whether the NHS budget will remain protected.

In his first interview in his new role, Hunt said that whether Lansley’s promise to ‘ring-fence’ the NHS budget could be honoured would depend on “the eurozone”.

Hunt also said the Government was trying to decide whether there was “any way at all” of following the Dilnot recommendations on social care reform, including cheaper variations on it.

Speaking to The Spectator, a strongly Conservative journal, he said his aim as Health Secretary was to “safeguard Andrew Lansley’s legacy”.

The shift in leadership at the DH was due to a need for it to communicate how the reforms will “make a difference to patients”, he said – confirming speculation that Hunt’s more ‘personal’ presentation style was a key factor.

While he said his “instinct” was to protect the NHS budget, Hunt insisted that it could no longer be a commitment due to economic “uncertainty”.

Asked whether the Dilnot proposals might be realised from the NHS budget (as the Treasury is said to favour), he said that would be “extremely difficult”. However, he said, “other versions” of the Dilnot plan with a lower cost would be considered.

In clinical terms, Hunt stated his priorities to be: care for the elderly and those with long-term conditions, dementia care and achieving “the best cancer, heart and stroke survival rates in Europe”.

Finally, he expressed the aspiration of delivering a “measurably better” NHS that patients would recognise as such.

The new ‘semi-disgraced’ Health Secretary arrives with trouble already packed in his suitcase. Does that mean he’s in for a difficult time? Not necessarily, says Maxine Vaccine.

Timing is a crucial factor in politics. If Andrew Lansley had been replaced as Health Secretary when the Health and Social Care Bill had not yet been passed, that would have been interpreted as an admission that the reforms were misconceived. If it had happened just after the Bill had become law, that would have been taken to mean that Lansley’s personal handling of the reforms had been poor. If it had happened shortly before the next General Election, that would have been a blatant electoral ploy to replace an unpopular veteran with a fresh-faced Cameron clone. Happening now, the replacement doesn’t exactly have any of those meanings. It gives Jeremy Hunt the opportunity, over nearly three years, to adapt his course according to how the wind is blowing.

From 1 October, the health service will be run by the NHS Commissioning Board, which in turn will entrust it to CCGs at a local level. Legislation is under way to make CCGs play the game according to the ‘any capable provider’ rules, ensuring that the role of the private sector in NHS service provision continues to accelerate. The public spending budget will continue to shrink as the second-wave recession deepens, ensuring that austerity is the name of the NHS game for another decade. The finely-tuned machinery of Lansley’s NHS revolution will continue to turn – and, as Lansley promised, it doesn’t need any Government intervention to ensure that it delivers a competitive healthcare market. All Hunt needs to do, safely domiciled in the house that Lansley built, is wave from the balcony.

The most important thing to understand about Hunt as Health Secretary is that he is a longtime opponent of the NHS. He was a contributor to Direct Democracy (2005), a book co-authored by 23 Conservative Party members that claimed the NHS was “no longer relevant” to modern society. Its problems was not “one of resources”, the book argued, but one of adherence to a public sector model. Its proposed solution was: “We should fund patients, either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice. Those without means should have their contributions supplemented or paid for by the state.”

That’s an accurate description of the ‘Panel’ health funding system that prevailed before the Second World War. Does the 21st century demand its revival? The Times reported back in July that Hunt, as Culture Secretary, had tried to get the NHS tribute taken out of the Olympic Games opening ceremony. However, it’s very unlikely that Hunt will start his time as Health Secretary by saying “It’s time to wave goodbye to the NHS.” Rather, he will put his weight behind the reforms and let the process take its course.

What Direct Democracy and its two sequels, which Hunt has endorsed, show is that the plan to ‘de-nationalise’ the NHS existed well before the 2010 election. Stripped of the stark phrasing that the Conservatives use when talking to each other rather than to the media, Direct Democracy predicts the Lansley reforms – and those steps immediately beyond it that the BMA and other clinician groups have warned against. The book cannot embarrass Hunt: there is nothing scandalous about it, unless your view of Conservative policy is based on the naïve assumption that the party supports the NHS.

The recent Leveson enquiry blighted public trust in Hunt to some extent – hence the recent description of him in the Guardian as ‘semi-disgraced’. But it also showed that he can walk through trouble without losing his cool or naming names. His statements in support of homeopathic medicine, however alarming to NHS and pharma industry professionals who believe in evidence-based medicine, also show that he is not afraid of controversy.

It’s a safe prediction, therefore, that opponents to the NHS reforms in the medical professions or the public sector unions will achieve little by dragging Hunt into the briar patch of controversy. He was born and bred in a briar patch. He will be passive or active on NHS reform depending on circumstances and the Government’s mood – but he will not backtrack on the reform agenda. While his gestures and hairstyle may suggest a genial public-school clown, only the most naïve critic would fail to take him seriously.

Mike Farrar, NHS Confederation Chief Executive, has warned the new Health Secretary Jeremy Hunt not to overlook the main challenges the NHS faces in the future.

Andrew Lansley’s replacement is tasked with continuing the transition of the health service conjured up by his predecessor.

While the NHS Confed leader realises the importance of the reforms, he advised Mr Hunt to keep an “eye on the long-term issues the NHS is facing”.

An ageing population and growing rates of obesity, plus the rising number of diabetes cases, could put the health service at breaking point in coming years.

Farrar said it is these challenges which Mr Hunt needs to pay attention to. “He is taking on a critical brief at a critical time,” he said.

‘Top of Mr Hunt’s in-tray will be making sure the NHS is financially sustainable for the future and fit to respond to the needs of our changing population. Driving change in these areas will be the big test of the success of this Government.”

The former SHA head thanked the departing Andrew Lansley for his “commitment to the NHS” during his time in office and in shadow government. “He has held his brief in health for almost a decade and that is something that not many other politicians can say they have done,” he said.

The appointment of Jeremy Hunt as Health Secretary has provoked a storm of controversy regarding his views on healthcare and the NHS.

Critics have noted his co-authorship of a 2005 book calling the NHS “no longer relevant” to the health needs of a modern society.

More recently, it was reported that he opposed the inclusion of a tribute to the NHS in the 2012 Olympic Games opening ceremony.

Hunt’s belief in the importance of homeopathic medicines has also been criticised as showing a poor understanding of scientific evidence.

Direct Democracy (2005) was co-authored by 23 Conservative Party members, including Jeremy Hunt, Michael Gove and MEP Daniel Hannon (who later called the NHS “a 60-year mistake”).

A chapter on health stated that the existing NHS structure was “no longer relevant” and that its problem was not “one of resources” but one of being a state-run and centrally organised healthcare provider.

“We should fund patients, either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice,” the book argued. “Those without means should have their contributions supplemented or paid for by the state.”

Hunt’s opposition to the NHS tribute in the Olympic Games opening ceremony was reported in July. According to the Times Hunt queried whether the tribute was “necessary”, but the Prime Minister overrode his objection.

Medical scientists have suggested that Hunt’s endorsement of homeopathy – he signed a Commons early day motion supporting it in 2007 – betrays a poor grasp of evidence-based medicine.

Professor Sir John Krebs, former head of the Food Standards Agency, said: “It would be a real blow for those who want medicine to be science-based if the Secretary of State were to promote homeopathy because of his personal beliefs.”

Health Secretary Andrew Lansley has been replaced by Culture Secretary Jeremy Hunt as part of David Cameron’s cabinet reshuffle.

Mr Lansley has been demoted to the role of Leader of the House after serving as Secretary of State for Health for two controversial years.

Mr Hunt said the new role was the “biggest privilege of his life” and that he was looking forward to starting work within his new department.

Lansley’s controversial reign will be remembered for the introduction of the Health and Social Care Act – which abolished Strategic Health Authorities and Primary Care Trusts in favour of GP-led clinical commissioning.

The move – which was which contested by a host of national organisations representing healthcare professionals – resulted in thousands of NHS workers losing their jobs during an era of austerity within the health service.

Dr Kaliash Chand, who was recently elected as BMA Deputy Chairman, welcomed Mr Lansley’s removal and hoped his replacement would end the marketisation of the NHS.

He commented: “He has done an utterly miserable job. Especially considering he was shadow health secretary for six years. He was unable to explain what he wanted to achieve. He was not a good communicator. In my view he has not been a very good health secretary. He epitomised everything that has gone wrong in the last two years in the NHS.”

Stephen Whitehead, ABPI Chief Executive, “welcomed” Mr Hunt to the new role and thanked the outgoing Andrew Lansley for his efforts over the last two years. “The NHS is highly regarded both here in the UK and around the world and Jeremy Hunt will face a number of challenges in not only safeguarding its short term success, but its long term future.”

Mr Whitehead said that one of the first challenges the new health secretary faces is getting the latest medicines to patients. He added that the pharmaceutical industry will continue to work closely with the DH to “design a pricing system” that provides value for money for taxpayers whilst “ensuring a healthy and productive environment for companies to research and develop the medicines of the future.”  

Mr Hunt, the MP for South West Surrey and the former Secretary of State for Culture, Olympics, Media and Sport, faced widespread criticism earlier this year when he urged David Cameron to support Rupert Murdoch’s bid for BSkyB – a month before he was due to decide whether the bid should be allowed.

What does the ‘single operating model’ for primary care commissioning mean for GPs?

The NHS Commissioning Board Authority’s ‘single operating model’ for primary care commissioning represents a major step in defining the relationship between GPs and the new NHS. As such, it is essential reading for anyone with a stake in prescribing behaviours and, more widely, in patient pathways.

A major question posed by the Lansley reforms is: who should commission the commissioners? If GP-led groups are responsible for commissioning secondary care, who can commission primary care? The answer, the NHS Commissioning Board, was greeted with mistrust by many GPs who asked why they needed some Big Brother watching over the job they had always done.

In addition, the passage of the Health and Social Care Act left a lot of broken glass scattered through primary care. The relationship between clinical outcomes and money, the involvement of the private sector in the NHS and the apparent fragmentation of the health service are issues that divided
the GP profession.

So the single operating model has the task not only of outlining new clinical and business relationships, but of building professional bridges. The Board tackles this challenge by saying up front that it seeks to
achieve “the right balance between national consistency and local decision making”.

Unlike earlier documents describing the infrastructure of the new NHS, Securing excellence in commissioning primary care does not list concrete developments to be in place by April 2013. Rather, it outlines a pattern of relationships that will develop from that date, when the new single operating model
for primary care commissioning becomes operative. It represents the parts of the new
NHS working together with a clear goal of outcome improvement.

The commissioning challenge
According to Dame Barbara Hakin, National Director for Commissioning Development, the new system aims to “tackle unwarranted variation and take positive steps towards raising the overall standard of primary care”. The document notes that primary care, while accounting for only 15% of the NHS budget, has a
profound role in making “preventative interventions” and influencing all the care patients receive.

The challenge of replacing “many different systems” for primary care commissioning with “a single national
operating model” without losing “vital local responsiveness”, the Board says, depends on “establishing relationships and arrangements across the new organisations” – including CCGs, whose health strategies
will set the context for primary care.

The NHSCB will be responsible for planning, securing and monitoring primary care services. Its local area teams will manage the performance of GPs and other primary care providers (dentists, community pharmacists and opticians), and will help to support providers in difficulty and deal with major emergencies.

The local area teams will support patient “choice and control in designing services that respond to their needs”, focusing on “the basic service offer” (such as early diagnosis) to reduce variations and health inequalities. Likewise, they will support the development of “local area clinical leadership teams” that draw on the expertise of all types of primary care clinicians. Finally, their focus on patient outcomes means they will look for “improvement strategies” at all times.

All together now
Most primary care commissioning will take place through the Board’s local area teams working with CCGs, local authorities and health and wellbeing boards. The Board as a central authority will “ensure consistency” and provide the framework for performance management and quality assurance. Crucially, this system involves “fewer managerial resources” and “larger geographical footprints” than the previous system. It does not remove local initiative: it just removes the SHA and PCT management layer.

At the heart of the model are the common operating procedures for local area teams, of which the most important is “to standardise the performance management frameworks and processes at practice, provider and individual levels”. Managing variability and the healthcare market are also key priorities.

Commissioning support services may also assist local area teams: emphasis is placed on the value of
business intelligence in providing “a single flow of standardised information”, and the potential for CCGs to share support for primary care development and redesign with local area teams.

Micro commissioning
CCGs themselves will work closely with the NHSCB to review the “micro commissioning decisions” made by
GPs in “each referral and prescription”. The Board says that its work with CCGs has shown they can progress effectively together towards “quality improvement” through benchmarking, data sharing and peer review. It notes further that CCGs will be able to commission integrated “wrap-around” community-based services in which GP practices can participate, with care taken to manage conflicts of interest.

The local area teams will establish relationships with a range of partners, including CCGs, Local Healthwatch, health and wellbeing boards, local authorities, Public Health England local units and the CQC. Clinical networks will feed into the primary care system “with a particular focus on early diagnosis and timely treatment”. Public health commissioners will advise local area teams on priorities for the local
population, and work with them to develop health improvement initiatives that may include primary care.

The Board concludes: “During the next three to six months, we will fully explore all the interdependent relationships critical for the operating model and take any action necessary to ensure that they will work effectively.” It encourages discussion of the model within PCT clusters and feedback on
potential improvements.

A business network
The single operating model for primary care commissioning is not so much a ‘one size fits all’ as an ‘all things to all people’. It shows the old hierarchical NHS giving way to something much closer to a business network, with shared rules and goals but different cultures. The imprecision of the arrangements described displays the will to promote clinical innovation and business
development.

The emerging structure is designed to give GPs more confidence that they will be neither isolated nor controlled. Those who need guidance and support will receive it, while others will have the freedom to change treatment pathways and business models. This will help to defuse opposition to reform in the
profession, while setting the stage for further changes.

For pharma, the new model points to the development of a complex and flexible customer network with many points of contact. Key account managers are much concerned with how primary care operates and the factors influencing it. This model shows primary care in a dynamic field of NHS and other stakeholders, responding to ideas from all sides: an exciting prospect for suppliers.