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Proposals for shaking up the NHS are woolly and impractical, says Robert Hill. It is just as well government White Papers do not fall within the Trade Descriptions Act. Equity and excellence, the White Paper on the future of the NHS published at the beginning of July, would also most certainly face prosecution. The biggest item on the charge sheet would be that the document is so vague and incoherent that it does not justify the term ‘White Paper'. "So, although strategic health authorities are, in the name of efficiency, to be abolished as statutory bodies, they are almost certain to remain in practice." Take the policy idea that is at the heart of Equity and excellence – giving consortia of GPs the responsibility for commissioning health services. There is nothing wrong with that, in principle. But we then read that there will be a long list of important exceptions. For example, the day-to-day health services GP practices themselves provide to patients have been excluded in order to avoid the conflict of interest that would arise from GPs commissioning services from themselves. Who will then commission these vital services? It's not clear. Also exempted from the scope of the GP consortia are pharmacy, dentistry, ophthalmology and maternity services. A new quango – the NHS Commissioning Board – will take on responsibility for these functions. But it is stretching credulity to believe that a national body can sufficiently understand local circumstances and context across the country to manage these services well. Almost certainly, the new board will have to create regional or sub-regional operations. So, although strategic health authorities are, in the name of efficiency, to be abolished as statutory bodies, they are almost certain to remain in practice. There are other aspects of the commissioning landscape which are also unclear. The Department of Health knows that GP consortia covering a population of between 100,000 and 150,000 will not be strong enough to hold big hospital trusts to account – that's why primary care trusts (PCTs) were amalgamated some years ago. The White Paper says that, in order to address this problem, one GP consortium will act as the lead commissioner for several others. Making that work effectively is hard, and if it is effective, how much say will local GPs end up having in shaping local health services? How does GP commissioning fit with the other big idea in the White Paper – extending patient choice? What do patients do if their GP consortia will not commission the services or prescribe the drug they want – to whom do they appeal? How will a system that abolishes targets ensure that waiting times do not rise? There are no answers to these points. Local government also needs to be wary about being too effusive in welcoming the White Paper. On the face of it, local authorities appear to do well. They take over responsibility for health improvement functions, have a say in the appointment of local directors of public health, assume the formal leadership of joint strategic needs assessments, and oversee the operation of the new patient advocacy body, HealthWatch. In addition, statutory health and wellbeing boards will promote integration across health, adult social care and children' services. But, scratch beneath the surface, and things are not quite as rosy as they seem. The statutory role of elected members in health overview and scrutiny committees is to be abolished. The secretary of state will set local authorities targets – referred to as ‘objectives' – for improving health outcomes. Health improvement funding will be ring-fenced. NHS commissioning will remain the ‘sole preserve' of GP consortia and the NHS Commissioning Board. Even disputes on the organisation of local health services – the perennial point of contention between the health service and local authorities – will seemingly now go to the NHS Commissioning Board rather than to an independent panel, as was the case previously. This is the least coherent document that the coalition government has produced to date. In some ways, that is not surprising. The ideas did not form part of the coalition agreement in May and have been cobbled together in a matter of weeks. We should, therefore, see the White Paper as just stage one of an ongoing policy development process. Let's hope there is a lot more coherence by the time the Bill that will give legal effect to the new NHS regime is published. Robert Hill is an independent analyst on public policy and service issues and former adviser at Number 10

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WHITEHALL

Why the White Paper lacks coherence

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