The NHS has launched a plan to support its overloaded A&E services, with the formation of ‘urgent care boards’ able to invest in emergency care.

NHS England will work with the NHS Trust Development Authority and Monitor to address the problem of increasing A&E waiting times.

One priority is for hospitals to bring forward their planning for next winter to ensure that seasonal urgent care needs are under control.

The growing pressure on A&E services is due to increasing demand – four million more people in England are using these services than in 2004 – combined with the budget cuts of the ‘Nicholson challenge’.

Health Secretary Jeremy Hunt angered the BMA by blaming the increased A&E attendance figures on lack of GP access, but it is beyond doubt that many people use A&E to bypass primary care and referral barriers.

The NHS support plan therefore aims not only to help maintain A&E capacity, but to relieve the pressure on emergency care through GP and outpatient care.

At the same time, the increasing number of people attending A&E who require urgent hospital care points to a need to improve not just access to care, but the quality of care outside hospital.

While 90% of patients in A&E are seen within four hours, the average waiting time is increasing. The support plan notes: “Long waiting times in A&E not only deliver poor quality in terms of patient experience, they also compromise patient safety and reduce clinical effectiveness.”

The urgent care boards will bring together healthcare leaders from across the local NHS. By the end of May, these boards will ensure that local recovery and improvement plans are in place for each A&E department.

NHS England will ensure that extra money is made available: the urgent care boards will oversee the use of the fees paid for emergency admissions, and ensure that expenditure achieves specific improvements.

Professor Keith Willett, NHS England’s National Director for Acute Episodes of Care, commented: “When pressure builds across the health and social care system, the symptoms are usually found in the A&E department.”

The Mid Staffordshire NHS Foundation Trust has been placed under administration by Monitor, the NHS economic regulator.

A report for Monitor said the Trust was “unsustainable” and recommended closing down its maternity, A&E and intensive care units.

The first Foundation Trust to go into administration, Mid Staffs will be run for the next 145 days by two analysts from Ernst & Young before it is reconfigured.

The report stated that the services it recommended for closure could be provided at hospitals in North Staffordshire, Wolverhampton and Walsall.

While Monitor said the Francis report was not the reason for its decision, it warned that Mid Staffs was “neither clinically nor financially sustainable”.

Mid Staffs received a £20m bailout in 2012, pending the Francis report’s publication. The report, which listed the Trust’s failures during four years in which over 400 patients died through neglect, did not inspire confidence in its future.

The administrators will seek to work with local commissioners and other healthcare organisations to produce a long-term plan for service delivery. Current services will continue during the 145-day administration period.

A local campaign group, Support Stafford, has called the plans for shutting down acute services in Stafford “unacceptable”.

Jeremy Lefroy, Conservative MP for Stafford, commented: “There is a vital need to retain acute services in Stafford and Cannock because the capacity elsewhere is simply not there.

“They also need to consider the huge disadvantage to local people who would have to travel much longer distances for their treatment, but also for hospital visitors who would have to do the same.”

The Government has revised its proposed regulations governing competition between NHS providers, following widespread protest from doctors.

The regulations, published a month ago, were criticised as removing the right of clinical commissioners to make decisions based on patient interests rather than the business rights of competing providers.

The amended version broadens the freedom of commissioners, stating that “integration” and “quality” are both valid reasons for not putting a service out to competitive tender.

However, the Royal College of General Practitioners (RCGP) has expressed concern that the new regulations, by virtue of their statutory nature, are imposing too many conditions on commissioners.

The aim of the new regulations was stated by the Government to be a replacement for the Secretary of State control abolished by the NHS reforms. In other words, having emphasised the “autonomy” of the new CCGs, the Government is imposing strict controls to defend the interests of the private sector.

The original secondary legislation, published in February, appeared to create a legal basis for the forced tendering of nearly all NHS services, enforced by Monitor.

A letter to the Daily Telegraph signed by more than 1,000 doctors urged MPs to force a debate on the new regulations, while the Academy of Medical Royal Colleges expressed concern that services would be disrupted by legal disputes.

Health Minister Lord Howe said: “It has never been and is absolutely not the Government’s intention to make all NHS services subject to competitive tendering or to force competition for services.”

New amendments to the regulations include:

• Commissioners are required to record how their decisions support the integration of services.

• Exceptions to competitive tendering include cases where avoiding competition leads to better quality or integration of services.

• Monitor no longer has the power to enforce competitive tendering.

The underlying purpose remains the same: to protect “patient choice” by ensuring that NHS commissioners have to put services out to tender unless they can justify not doing so in terms of better clinical outcomes.

The publication of the new secondary legislation coincides with that of a BMJ study stating that 40% of CCG board members have financial ties to private healthcare providers.

Clare Gerada, Chair of the RCGP, commented: “The revised regulations do not go far enough in ensuring that commissioners are genuinely free to decide whether or not to expose services to competition. Despite the revisions, they will still be required to show that there is only one capable provider in order to avoid having to put a service out to tender.”

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.”

Monitor has placed Mid Staffordshire Foundation Trust under administration, saying it cannot be sustained in its current form.

The combination of the trust’s current financial difficulties and the impact of the Francis report has proved impossible to surmount.

Monitor will appoint special administrators to run Mid Staffs and plan its reorganisation – with options including the dissolution of the trust.

Mid Staffs is the second Foundation Trust to be placed under administration this year: the first, South London, was judged to have failed financially but not clinically, with PFI debts being a major factor.

Mid Staffs is also facing financial problems, having been bailed out with £20m from the DH in 2012, and having to cut its costs by 7% this year. Its small size – only two acute hospitals – counts against it economically.

However, it is also under pressure not to let its clinical standards slip, following the Francis report into over 400 preventable deaths at Stafford Hospital from 2004 to 2008.

The growing panic in the trust was exposed when a Stafford Hospital paramedic abused health campaigner Julie Bailey on Twitter, saying that he hoped she became seriously ill and found the nearest hospital shut down.

Julie Bailey’s ‘Cure the NHS’ campaign is credited with having led to the Mid Staffs enquiry. Her mother was among the people who died due to serious medical neglect at Stafford Hospital.

Monitor sent a ‘contingency planning team’ into Mid Staffs five months ago. Its report into “sustainable options for alternative clinical models in the area” will shortly be published, the regulator said.

The special administrators will have 150 days to develop a plan for service reconfiguration, working with local commissioners.

Professor John Caldwell, Chairman of Mid Staffordshire FT, said: “We have accepted for some time that MSFT working alone cannot produce a long lasting solution to the issues we face to ensure financial and clinical sustainability.”

Given that the financial constraints of FT status previously led the trust to experience a disastrous breakdown of care, finding a solution there is a key challenge for the NHS reform programme.

The new rules for tendering of NHS services have been defended by Health Minister Earl Howe and condemned by the Royal College of Midwives (RCM).

According to Earl Howe, the regulations do not enforce competitive tendering: they simply enforce patient choice.

However, the RCM is concerned that Monitor is being given the power to enforce competitive tendering in virtually all circumstances, while the promised ‘discretion’ of CCGs is abolished.

The difference in views relates to the question of which is more important to patients: the right to exercise choice, or the continuity and integration of services.

The NHS (Procurement, Patient Choice and Competition) Regulations 2013 are secondary legislation following the Health and Social Care Act, and will become law on April 1 unless actively challenged.

Following widespread criticism, Earl Howe said: “These regulations are about ensuring that when services are tendered for, whether from NHS, voluntary sector or independent providers, the rules that are applied to the process are fair.

“We have always said that competition in the NHS should never be pursued as an end in itself, but only where this is in the interests of patients. “This principle underpins the right of patients to exercise choice when accessing treatments.”

The concern of critics – including Labour peer Lord Hunt, the RCM and NHS campaign groups – is that decisions about tendering will be driven not by patient choice, but by lawyers acting for private healthcare providers.

The RCM, which represents maternity service professionals across the UK, argued that the new regulations abolish the control of local NHS commissioners over what services will be open to competitive tendering.

Expressing concern that a business-driven carve-up of the NHS franchise will damage the continuity and integration of maternity services, the RCM called for the new regulations to be debated in both Houses.

Jon Skewes, the RCM’s Director for Policy, Employment Relations and Communications, commented: “We were repeatedly assured by ministers that compulsory competitive tendering would not be imposed on organisations commissioning maternity services. The regulations as they stand will mean that this is exactly what will happen.

“Continuity of care is vital in maternity services if we are to have safe and high quality care. I fear that the fragmented service that these regulations could lead to will mean poorer care for women, babies and their families.”

New regulations for NHS procurement laid before Parliament will force CCGs to put virtually all services out to competitive tender.

The new rules, which will become law by default unless actively opposed, undo changes to the primary legislation agreed during the ‘listening exercise’.

Monitor will have powers to impose competitive tendering on any NHS contract where commissioners have maintained an existing contract or made a decision based on clinical rather than business criteria.

In February 2012, Health Secretary Andrew Lansley told the developing CCGs: “It is a fundamental principle of the Bill that you as commissioners, not the Secretary of State and not regulators, should decide when and how competition should be used to serve your patients’ interests. The healthcare regulator, Monitor, would not have the power to force you to put services out to competition.”

The new regulations make it clear that CCGs are legally obliged to put all services out to tender, and Monitor has the power to enforce that.

Similarly, Health Minister Earl Howe reassured the Lords in 2012: “Clinicians will be free to commission services in the way they consider best. We intend to make it clear that commissioners will have a full range of options and that they will be under no legal obligation to create new markets, particularly where competition would not be effective in driving high standards and value for patients.” This also appears to have been untrue.

Labour Lord Philip Hunt commented on the new legislation: “Whatever was said in Parliament, it seems that the Department of Health and Monitor have just carried on as if nothing has changed. By hook or by crook, a market is being introduced.

“There is very little international evidence that a market in healthcare leads to better or more cost-effective service, in fact most suggests the opposite,” he added. “Post-Francis report, the key consideration should be quality of care.”

The public enquiry report on preventable deaths at Stafford General Hospital has placed emphasis on improving the ‘transparency’ and regulation of the NHS.

The long-delayed report by Robert Francis QC recommends bringing together economic and care quality regulation.

However, it does not – as had been predicted – recommend that the NHS have the power to take back Foundation Trusts into public ownership.

In addition, it blames the breakdown of care at Stafford Hospital, which caused 400 to 1,200 preventable deaths, on a “systemic” failure rather than calling for leaders to be held responsible.

The Staffordshire-based organisation Cure the NHS said it would continue to campaign for the dismissal of those who “covered up” the scandal, including NHS Chief Executive Sir David Nicholson.

The scandal of poor care at Stafford General Hospital between early 2005 and early 2009 has been called the most serious failure of care standards in NHS history.

The local PCT, the Healthcare Commission and the Royal College of Nursing all denied that anything was seriously wrong. Only local campaigners kept the number of deaths and the suffering of patients in the public eye.

During an extended phase of patient neglect that Francis calls “appalling”, Mid Staffordshire NHS Trust gained Foundation Trust (FT) status.

The first enquiry in 2010, which was internal to the NHS, concluded that a “chronic shortage” of nursing staff caused by the hospital’s drive to meet the financial conditions to become an FT was the main cause of the problems.

It also noted the severe negligence implied by persistent failures to provide “the most basic elements of care” to patients in terms of hygiene, pain relief, feeding and hydration.

The Labour Government twice refused to open a public enquiry into the Mid Staffs scandal, but the Coalition Government did so in 2010.

In May 2011, Nicholson warned that the Francis report would conflict with the direction of NHS reform: it would recommend the unification of Monitor with the Care Quality Commission (CQC), when their roles were being moved further apart; and it would recommend that the NHS take back FTs that failed to maintain care standards, when FT status was being made obligatory.

The 12-month delay in the publication of the Francis report may be linked to these issues – certainly, the recommendation concerning FTs has been dropped. While the joining of Monitor with the CQC is still recommended, it appears unlikely given that Monitor is now concerned only with enforcing competition.

Other recommendations in the Francis report include:

• A “duty of candour” towards patients and the public for all healthcare organisations, including a ban on gagging clauses and a requirement to publish all upheld complaints on the organisation’s website.

• Only registered people may care directly for patients.

• The CQC should develop a team of specialist hospital inspectors.

• GPs should be responsible for monitoring secondary care services received by their patients.

Health Secretary Jeremy Hunt has said that “the crisis in standards of care” is the single greatest problem facing the NHS. However, how the recommendations of the Francis report can be integrated with the market agenda of the NHS reforms – for example, how the “duty of candour” compares with the commercial confidentiality insisted on by independent health providers – remains to be seen.

QIPP is trumping NICE as the driver of local prescribing decisions, with price ranked above value, the parliamentary Health Select Committee has been told.

Witnesses representing healthcare providers, patients and the pharmaceutical industry told the MPs that local commissioners are still restricting patient access to NICE-recommended treatments.

The ‘grey area’ between two conflicting agendas, cost-cutting and innovation, was highlighted as a cause of confusion among decision-makers.

Laura Weir, chairwoman of the patient coalition group Patients Involved in NICE, noted that despite patients’ legal right to receive drugs approved by NICE, the implementation of guidance was often blocked or delayed at local level.

“Currently there is no scrutiny or monitoring of NICE approved medicines, and there’s no one body that is responsible,” she said, arguing that the Care Quality Commission (perhaps together with Monitor) could help the NHS Commissioning Board to monitor that aspect of CCG work.

Stephen Whitehead (pictured), ABPI Chief Executive, pointed to the conflict of priorities: “Although often there will be medicines that go on the formulary, there is often not the freedom of the healthcare professional to prescribe the most appropriate medicine for that patient.

“This has been explicitly recognised by government through the publication of Innovation, Health and Wealth, which says the uptake of NICE medicines is a problem in the UK.”

Linda Patterson, Clinical Vice President of the Royal College of Physicians, highlighted the key issue: “There is an issue about implementation, which is partly about practice and the clinical decision maker implementing the guidance or not.

“On wider implementation, that is a debate about how we encourage good practice to be implemented across the country without variation. At the moment, there is a rather grey area as to who is responsible.”

The payment by results (PbR) system for healthcare reimbursement is unfit for meeting the changing needs of society, according to the King’s Fund.

The think tank identified the current tariff as a barrier to the shift of healthcare from hospitals to the community.

A range of payment systems would be needed, the report argued, to encourage local innovation and to balance the priorities of quality, cost and supply.

The report explored the payment systems used in the NHS and other health economies, and examines whether PbR is able to support such long-term objectives as disease prevention and the care of long-term conditions.

Payment by results incentivises hospitals to continue treatment, thereby blocking a shift to preventative and community-based care, the report said.

It concluded that different services require different payment systems: PbR is most appropriate to elective care, but less suited to other services.

In addition, the King’s Fund said, payment systems need to be flexible to assist adaptation at a local level and trade-offs between priorities.

The NHS needs a new reimbursement framework that allows different payment systems for different types of service, the report argued.

Monitor, the foundation trust regulator, commented that it could “recognise many of the areas for improvement identified in the report” and would give it “careful consideration” when developing its pricing strategy.

Health Minister Lord Howe said: “We are working to make sure a payment system supports care being delivered closer to patients’ homes.”

He added: “We are working to expand our best practice tariff programme which supports patient-focused care, encourages innovation and makes better use of resources.”