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.

Health Secretary Jeremy Hunt answers the questions you weren’t afraid to ask.

After the clinical waste left by Andrew Lansley, Secretary of State for Health, Jeremy Hunt, is keen to restore public confidence, establish clarity and, generally, galvanise a flagging NHS reform bill. In a Pf exclusive he takes his place on our imitation-leather hot seat, as readers (and writers) don ominous white outfits for a bit of ‘ultra-questioning’.

Since you took over the role as the ‘guardian’ of people’s health in the UK, what has surprised you most about the functionality of the NHS? – Iain Bate (Writer)
I’m very proud to be the Secretary of State for Health, and I know that a lot of people are incredibly passionate about our health service. The NHS is one of our greatest assets; it is admired around the world and has a reputation for excellence, but I want it to be even better.

The coming year will be an important one for the health service and my priorities are to improve care and nursing in the NHS; promote technology to make care more straightforward; and help people to feel in control of their health, supporting them to lead longer, healthier lives.

Given the rapidly expanding role of the private sector in the NHS, how will transparency in contracting be achieved? After all, business to business transactions are confidential. – Joel Lane (Writer)
We have always been clear that, whenever services are procured in the NHS, it should be through a fair and transparent process, judged on the quality of the care. This helps improve healthcare and enables patients to access the best possible services.

The Health and Social Care Act was the first piece of legislation to create rules and regulations around this process, making it more straightforward. It prevents discrimination in favour of private health companies over the NHS, and helps protect patients’ interests.

But it is worth remembering that charities, social enterprises and independent providers have played an important part in providing NHS care for some time. They offer patients more choice about how they are treated by the health service, and every year, a significant number of patients choose to be treated in independent hospitals, ‘on the NHS’.

The NHS is moving into an era whereby it will need to make decommissioning decisions which are unpopular, such as delivering services that patients will have to pay for. How do you aim to integrate this into the wider healthcare bill implementation? – Omar Ali (Pharmacist)
Let me be absolutely clear on this – the NHS will always be free at the point of delivery and no one will be asked to pay for its services. Yes, in the future, services will be provided differently – public health services will be organised by local authorities, for example – but the founding principle of those NHS services being free, for those who need it, will never change.

To some extent, the NHS remains a 1950s animal trying to survive in 2013. What are the challenges when it comes to changing an institution’s post war philosophies and encouraging it to embrace modern practices, without altering the fundamental concept? – John Pinching (Writer)
Of course the NHS has evolved over its 64 year history, and it continues to improve the lives of people up and down the country, but we have to guarantee that the founding principles of the NHS are protected.
I would like to see the NHS using technology more, while continuing to improve care and experiences for patients. That would mean people being able to book their GP appointments online, or those with long-term conditions managing their situation from home, digitally; saving time for both them and their doctor. Technology in the NHS is rapidly developing, and I would urge local doctors and nurses to embrace it.

Recently the Government announced that it will cap individual payments for social care at twice the Dilnot-recommended level, i.e. at about £70k rather than £35k. Will NHS funding for the less wealthy be increased, or will their suffering and avoidable death be allowed to escalate? – Susan Ranch (Key Account Manager)
This is incorrect. The Government has not said this and no decision has been made. I want this country to become one of the best places in Europe to grow old and make sure people can live independent and healthier lives into old age. As part of the care reforms, we committed to taking action: ensuring people do not have to sell their homes to pay for care. While we have also agreed that Andrew Dilnot’s model of the cap on care costs is the right basis for any new funding model. Given the current economic situation, we need to look carefully at how we can pay for this. 

You have acknowledged the differences within the UK of cancer survival rates and compared to other European countries. How can the pharmaceutical industry work with the NHS to help address these inequities? – Leigh Saunders (Key Account Manager)
The pharmaceutical industry already plays a vital role in improving the health of people with cancer. I want to improve mortality rates, where the targeting and development of medicines is becoming ever more important. I am sure the pharmaceutical industry will want to build on its work in this area and help improve cancer care.

Are you still encouraging British hospitals to sell their services abroad and, if so, what future plans do you have to support this? – Valerie Nolan (Clinical Nurse Specialist)
The NHS has many valuable assets, including products, technologies and knowledge. It makes absolute sense that the NHS should be able to use those assets to earn money, which it can reinvest back into patient care at home.

Through Healthcare UK – a UK government initiative in collaboration with UK Trade and Investment and the Department of Health – we are working on several very promising commercial opportunities to support those parts of the health service that can earn income abroad. Any investment generated will be put back into the NHS for the benefit of patients. Importantly, no part of the NHS will be forced to do this, and NHS patients will always come first.

At the current time, David Nicholson is praising the NHS for achieving a major reduction in referral rates, Diabetes UK, however, has noted that reducing referral rates has led to an increase in premature deaths and amputations in people with type 1 diabetes. Is this a case of cost saving targets being achieved at the cost of human lives?  – Nick Dawes (Sales Manager)
Patients should always get the care they need from the health service, and rationing services on the basis of cost alone is wrong and compromises that patient care. Decisions on treatments, including suitability for surgery, should be made by clinical experts taking the needs of each individual into account. We have already written to the NHS to set out clearly, that access to services should not be restricted on the basis of cost.

Should there be incentives in place for the private healthcare sector to expand and take on some of the load from the NHS, such as removing income tax on insurance payments? – Barry Rose (Independent Market Consultant)
The most important thing is ensuring everyone has access to the very best NHS care available and that those services are designed and provided to best meet the needs of the people who use them. This is why we are giving doctors, nurses and other health professionals more power to make decisions. They are the ones who know their patients best and will make sure that services meet the needs of their local communities.

Under this Government the NHS is performing well: waiting times are down, mixed sex accommodation has nearly been eliminated, we have the best ever record on hospital infections and access to dentistry has increased.

The NHS needs to involve the general public in making important decisions when managing their care and encourage greater interaction in their health and wellbeing, the NHS Confederation has said.

Mike Farrar, Chief Executive of the Confederation, said the NHS needs to go further to meet statements in its constitution to combat future challenges.

Farrar, writing in an editorial in The Guardian, said “NHS organisations need to do more to involve patients and the public” in how services are run.

The NHS Confed leader referred to the statement in the NHS Constitution that: the NHS belongs to the people.

But he admitted that the “daily reality for patients and the public” is somewhat different – and highlighted poor clinical practice and senior NHS leaders ignoring public opinion when making difficult decisions.

He said: “Take all this into account and you sense the NHS is a ‘public service’ with a long way to go.” Farrar added that the solution must change rapidly if the “NHS is to survive its next decade of challenges.”

Farrar pointed towards greater patient engagement in the future to obtain “faster and more sustainable results.” He said this was “business critical” if the NHS is to provide better standards of care and outcomes “for less money as healthcare demands grow”.

“There is no doubt that healthcare issues are complex,” he said. “But NHS managers and doctors do themselves no favours by their attitude of ‘arms around their work, no peeking’. We have to change.

“There is a huge need for more transparency, honesty and openness about why we need to modernise health services. There is an even bigger need for revealing to the public information about the economics, finances, and costs of health and social care.”

The new body tasked with championing standards of health and social care in England has been launched by the Department of Health.

Healthwatch England is the new national, statutory consumer body created to ensure the public’s opinion of health and social care services is reflected at a national level.

Health Minister Norman Lamb said the “consumer champion” plays a “vital part” in putting patients at the heart of health and care services.

The independent organisation has been tasked with creating a local Healthwatch network from April 2013 onwards. This will then be used to gather evidence based on real experiences to highlight national issues and trends.

Chair Anna Bradley commented: “Health and social care can be a complex world to understand, however our starting point is simple: it’s about people – their experiences, and needs.

“We will actively seek views from all sections of the community to build a national picture of what matters most to local people and make sure their views and experiences are really listened to, analysed and acted upon. Better health and social care services has to be the result.”

How will Public Health England bring together the NHS and local government?

Public Health England (PHE) is the national executive agency of the new public health system, which will be driven by local government. PHE will be responsible for improving public health and reducing health inequalities through a range of local policies aimed at reducing health risks to individuals and communities.

From 1 April 2013, when PHE becomes a statutory body, public health services will shift from the NHS to local government. PHE will take £4 billion (5%) of the annual NHS budget with it, and will form an economic and organisational bridge between health and social care.

Like the NHS Commissioning Board, PHE will provide national leadership and guidance for local organisations but will not control them. According to Duncan Selbie, its Chief Executive designate, PHE will combine “a national voice with local action”. It will bring together experts from newly-dissolved public health bodies such as the Health Protection Agency and the National Treatment Agency.

Local authorities will commission public health services, employing local Directors of Public Health as ‘health ambassadors’ to lead discussions on public health spending. To engage with this locally-controlled system, PHE will develop public health outcome indicators and a ‘public health premium’ incentive system.

PHE’s broad function has been defined as “helping people to lead healthier lives”. That covers a wide range of interventions, from driving health awareness campaigns to a more practical role in vaccination programmes. In terms of impact on behavior, PHE will follow the Nuffield ‘ladder of interventions’ model, which relies on using evidence-based arguments rather than regulatory controls.

Leaders, not bosses
PHE will operate through 15 centres across the four regions identified by the NHS CB: North, Midlands and East, London, and South. This structure articulates the national role of PHE with local authorities: the regional bodies have more responsibility for national initiatives such as health emergency response, while the centres are more involved with local initiatives such as specialised commissioning.

The senior leadership team of PHE, like that of the NHS CB, will combine medical and commercial expertise. The medical leadership will consist of a Director for Health Protection, a Director for Health Improvement and Population Health, and a Chief Knowledge Officer. These will be supported by a Chief Operating Officer and Directors for Strategy, Programmes, Finance and Corporate Services, and Human Resources.

Chief Executive designate Duncan Selbie promises that PHE will offer the new public health system “leadership without hierarchy”. Selbie is an experienced NHS leader who was recently Chief Executive of Brighton and Sussex University Hospitals NHS Trust. He has been described as ‘popular’ and ‘likeable’, despite being a man of relatively few words. Notably, he survived the 2005 crisis of NHS governance under Sir Nigel Crisp with his professional credibility intact.

PHE is currently engaged in setting up its board and management team, and in matching roles between the old and new public health systems.

Health of the nation
The underlying medical goals of the new system are defined by the Public Health Outcomes Framework (January 2012), which groups outcome indicators into four domains:

1. Improving the wider determinants of health – improving against wider factors that affect health and well-being.
2. Health improvement – helping people to live healthy lifestyles, make healthy choices and reduce health inequalities.
3. Health protection – protecting the population from major incidents and other threats.
4. Public health and preventing premature mortality – reducing the numbers of people living with preventable ill-health and people dying prematurely.  

Selbie’s document My vision for Public Health England (July 2012) states that the agency “will lead nationally and enable locally a transformation in the health expectations and, in time, outcomes of all people in England”. He promises a focus on “collaboration” to provide a national voice for local public health expertise in councils, and says PHE will achieve “transformation” by changing people’s behaviour.

PHE’s three directorates, described in a separate factsheet, indicate the agency’s chief responsibilities:

• Health protection – concerned with reducing infectious disease and environmental harm. PHE will lead the field epidemiology service, the national immunisation programme, and emergency preparedness, resilience and response. It will also be responsible for investigating and managing environmental hazards such as radiation and chemical exposures.
• Health improvement and population health – concerned with reducing health inequalities and improving preventative healthcare. PHE will advise NHS commissioners on policies for disease screening and specialised commissioning, and will use social marketing to achieve behaviour change. It will promote innovation in this area of public health, reaching out to all providers and commissioners of health and social care, with the long-term goal of achieving improvement across the first, second and fourth domains (see above) of the Public Health Outcomes Framework.
• Knowledge and intelligence – concerned with delivering “a new national evidence and intelligence service” to support assessment of public health need and track performance against key outcomes. PHE will seek to raise the national standard of disease registration, and will work in partnership with NICE to assess the effectiveness of treatments in improving public health. Notably, cancer registration will migrate from the NHS to PHE by April 2013, when PHE will launch a new Cancer Registration Service to “collect consistent high quality, near real-time data” on all cancers diagnosed in England.

Making communities safe
The health protection functions of PHE bear a complex relationship to the NHS. The agency will investigate risks to public health including infectious disease outbreaks, and assess the availability and effectiveness of drug treatments for these threats. PHE will take over the functions of the Health Protection Agency, which will impact on the health protection activities of CCGs, the NHS CB and local authorities.

For example, PHE will have a strategic role in immunisation. The NHS CB will commission vaccination services, but PHE will set their quality standards, assess their performance, fund and manage the development of new programmes and the extension of existing ones, and even purchase, store and distribute the vaccines; while CCGs will commission treatment of infectious disease and work with PHE and local authorities on outbreak control.

It is not surprising, therefore, that the Faculty of Public Health has expressed concern about the “complex new arrangements” for disease control and warned that the system will require “excellent communication and very close collaboration between GPs and their teams, public health staff and hospital services”. This, rather than changes in people’s lifestyles, is most likely to be the area on which the effectiveness of the new public health system is judged.

Pharma and public health
Public Health England may only have 5% of the NHS budget, but its impact on prescribing and other NHS services should not be disregarded. The agency will act as a communication network and body of expertise to guide the new public health system within local government – which in turn will influence and work collaboratively with CCGs and primary and secondary care providers.

PHE’s impact on immunisation and disease control is likely to be particularly important. However, in keeping with the Government’s ‘nudge’ approach to unhealthy lifestyles, it is unlikely to intervene decisively in ‘lifestyle’ and ‘wellness’ issues.

Where the pharmaceutical industry can contribute in concrete terms to PHE’s agenda – for example, by providing better immunisation solutions or affordable drugs that help to prevent serious illness – it may find the agency a willing ally that can impact on GP and hospital prescribing.

At other times, it may find PHE inclined to promote non-drug solutions to public health issues, especially in terms of behaviour change; the industry needs to engage constructively with these issues.

As well as public health outcomes, PHE will be concerned at all times with helping the NHS and local government to save money. Pharma will thus have opportunities to align itself with PHE’s agenda by offering solutions that reduce the cost of public health improvements.

The Department of Health has asked NICE to develop several additional integrated health and social care quality standards.

NICE will begin work on quality standards on the care and wellbeing of both adults and children with autism and on the mental wellbeing of older people in residential care.

The DH has also requested that the Institute develop similar standards of care where no existing guidance on a topic exists.

Earl Howe, Parliamentary Under-Secretary of State for Quality said NICE’s quality standards “help define what good care looks like”.

The topics where no guidance exist and requires development are:

• Autism in adults
• Autism in children
• Child maltreatment
• Domiciliary care
• The transition between child and adult services
• The transition between health and social care, including discharge planning, admission avoidance, reducing readmissions and reducing unnecessary bed occupancy
• Mental wellbeing of older people in residential care
• Management of physical and mental co-morbidities of older people in community and residential care settings
• Medicines management in care homes

Work on two pilot health and social care quality standards is already being undertaken by NICE. Guidelines for the standard of care of people with dementia and the health and wellbeing of children in care will be published in April next year.

Dr Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, said the Institute welcomed the request by the DH to develop the quality standards as part of its new role.

“It’s important for health and social care services to work in tandem and the standards we develop will play a vital role in ensuring services are closely aligned to ensure effective, high quality patient care is consistently achieved.”

GPs must be involved in the reconfiguration of the NHS in Scotland if the new system is to be a success, BMA Scotland has warned.

The Scottish Government has proposed to replace community health partnerships (CHPs) with new health and social care partnerships in order to deliver care through shared budgets and targets.

BMA Scotland welcomes the switch but has said that clinicians should be at the “very heart of implementing changes” to ensure they are not “doomed to failure”.

The Association has called for GPs to take on a central role on the new partnership boards and wants reassurances the reforms will not result in the shift of work from secondary care to GPs in primary care.

“We have always advised a review of CHPs,” said a BMA spokesperson. “We are very concerned about the failure of these locally and a lot of GPs have walked away from them. If this gives us an opportunity for improvement, then we welcome it.

“But we want ensure GPs are involved in the new boards and that clinicians are also at the very heart of implementing changes. We need to ensure it will not lead to any further shift of work to primary care. That shift is not resourced either in terms of staff, premises or funding.”

Nicola Sturgeon, Cabinet Secretary for Health, said the changes are part of the Scottish Government’s commitment to creating a system of health and social care that is “robust, effective and efficient”.

A Devonshire NHS trust that pioneered the delivery of integrated health and social care has abandoned plans to seek independent foundation trust (FT) status.

Torbay and Southern Devon Health and Care Trust (TSDHCT) is now seeking to merge with an existing or emerging FT.

The decision followed a report that the Trust was unlikely to meet Monitor’s economic criteria for FT status because many of its services are not profitable.

The trust stated that reducing the scope of its services in order to meet the criteria was not compatible with “maintaining and developing good integrated care”.

South Devon Healthcare FT is thought to be Torbay’s most likely partner.

A former PCT provider arm, TSDHCT has provided integrated health and social care for a population of 300,000 people since 2006.

TSDHCT Chief Executive Anthony Farnsworth said shortly before the decision that while the unprofitable aspects of the trust’s work could be managed within a PCT, they meant Torbay would not “pass the test of viability” to gain FT status.

He noted: “Although the pressing immediate question is one of financial viability, the more profound consideration is whether the best option is to make the organisation viable (but possibly smaller) in pursuit of the FT application at the possible expense of our local system of health and care services.”

Following the board’s decision to seek a partner, he added: “The approach agreed will provide us with the financial security enjoyed by a larger organisation, and a solid footing from which to deliver and develop integrated care for the future.”

Labour leader Ed Miliband has attacked the Government’s handling of the NHS reforms insisting they ignored the views of key healthcare professionals.

Speaking at the Royal College of Nursing conference, Mr Miliband accused the Government of pushing ahead with its controversial structural changes despite serious concerns from the RCN.

He said the Government had dismissed the RCN as “just a ‘vested interest’” but insisted they are actually the “defenders of the health service”.

“The government have been acting like they are the masters, not the servants, of the NHS,” said the Labour leader. “They are not the masters. Not this government. Not any government.

“Our health service is owned by patients, professionals and the people. And their voice – your voice – deserves to be heard.”

Mr Miliband added that he couldn’t promise to agree with the College on all matters but would not ignore them as the Government had done during the ‘listening exercise’ as part of the Health and Social Care Act.

Nurses were told that Mr Miliband wants to create a partnership with the College to address long-term challenges facing the health service. “I want to start working with you now to protect the values of the NHS and to hold the government to account for what’s going on,” he said.

“You are not just on the frontline in our NHS. You are the first line in the defence of our NHS.”

The Labour leader also revealed a new party initiative during his speech. NHS Check will allow staff and patients to report problems encountered by hospitals, clinics and GPs as a result of the NHS reforms.

The Government has accepted all of the Future Forum’s recommendations in its second report into the proposed changes to the NHS.

The report focused on integration, public health, education and training and information. It proposes that commissioners and local authorities should share budgets to accelerate service integration.

It says shared budgets would allow freedom and flexibility whilst new funding models are still being developed and criticised “structural change prescribed centrally” for obstructing current service integration.

The report, written by GP Robert Varnham and former local authority chief executive Geoff Alltimes, followed the first set of NHS Future Forum recommendations in June after the Government’s ‘listening exercise’ on the Health Bill.

It found there was “almost universal welcome” for a focus on the integration in health and social care by health professionals. But currently it was “too hard to make progress” and that a “number of changes in the system are necessary”.

“The greatest current challenge facing the NHS is the need to balance financial ‘grip’ with local ‘freedom’”, the report said. “Frontline professionals and managers expressed a desire for greater freedom to design locally responsive services.

“However, they also described how innovation, clinical engagement and the development of locally sensitive services were stifled by a tendency towards centrally imposed change and micro-management.

“We will watch with interest to see how the NHS Commissioning Board establishes a new way of working, which balances the imperative for local freedom and flexibility with the need to maintain financial control and sustainability.”