White paper puts GPs in the driving seat of the new NHS

BMJ 1997; 315 doi: (Published 13 December 1997) Cite this as: BMJ 1997;315:1559
  1. John Warden

    The British government views its new 10 year plan, outlined this week, as a turning point for the NHS. The white paper The New NHS gives control of most of the NHS budget to GPs and community nurses, writes John Warden

    The new NHS, foreshadowed in the white paper, will build on what has worked and discard what has failed. It is the basis of a 10 year programme of “evolutionary change rather than organisational upheaval.” There will be no return to Labour's old command and control system. But there will be an end to the competitive internal market, introduced by the Conservatives; in its place will be a system of “integrated care” based on partnership driven by performance. The government believes that “what counts is what works.”

    Many features of the internal market will survive. For example, the separation between the purchase and provision of hospital care will be retained; cooperation, however, will replace competition. Local doctors, nurses, and health authorities will have new powers to commission services and ensure that the local NHS is built around the needs of patients. Health authorities will have a powerful supervisory role with greater input from local councils. NHS trusts are to remain in their present form as providers. The approach is described as interdependence rather than independence.

    More attention will focus on the quality of care and less on the finance. Trusts will have to publish the costs of treatments to expose inefficiency. National standards of care will be guaranteed. Savings on bureaucracy will redeploy £1bn ($1.6bn) into frontline care. Computer technology, including telemedicine, will be diverted from administration to patient care. A nurse led telephone helpline, NHS Direct, will advise patients on self treatment round the clock.

    A key feature will be the jointly agreed local “health improvement programme.” This will govern the actions of all parts of the local health service and set out the strategy for improving health care. Health authorities will monitor the implementation of the health improvement programme, with reserve powers to ensure that major new buildings and medical staffing appointments are consistent with it.

    Key components of the 10 year plan for NHS

    • A Commission for Health Improvement will oversee the quality of clinical services

    • A National Institute of Clinical Excellence will promote clinical cost effectiveness

    • A national schedule of reference costs will measure efficiency of the NHS trusts

    • A national service framework will examine the best ways of providing particular services

    • Health improvement programmes will improve health care locally

    • Primary care groups will bring together GPs and community nurses to commission health care

    • An Advisory Committee on Resource Allocation will distribute NHS cash more fairly

    • An annual survey of patients' and users' experience will compare performance

    • A task force will involve NHS staff in shaping new patterns of health care

    Health authorities will devolve responsibility for direct commissioning of services to new “primary care groups” comprising all GPs in an area together with community nurses. They will replace fundholding in 1999. In the meantime there will be no new admissions to the fundholding scheme. In time, health authorities will withdraw from commissioning, and primary care groups will have the opportunity to become freestanding primary care trusts.

    For alignment of clinical and financial responsibility, primary groups will take devolved responsibility for a single unified budget. Each group will have available their population's share of resources for hospital and community health services within a “single cash-limited envelope.” In future one stream of cash limited funds will flow through health authorities to primary care groups. Although there will be concern about cash limiting general medical services, the white paper says that the new arrangement will give GPs the maximum choice of treatment options.

    The paper says: “For the first time in the history of the NHS, all the primary care professionals, who do the majority of prescribing, treating and referring, will have control over how resources are best used to benefit patients …. The argument between fundholding and non-fundholding is yesterday's debate. The time has come to move on, taking the best of both approaches.”

    Groups rather than individual practices will reach service agreements with NHS trusts about the quality and level of hospital care. Over time, the groups will extend indicative budgets to individual practices for the full range of services. Initially every practice will have a prescribing budget, as most do now. Extracontractual referrals will be abolished, but GPs who need to make personalised arrangements to meet a patient's special clinical needs will be able to do so.

    Health authorities, however, will clearly retain a powerful role. Primary care groups will be accountable to them and will work within the health improvement programme. The authority will have power to withdraw freedoms from groups that get into serious difficulty.


    Tony Blair said: “I want the NHS once more to be the envy of the world”


    Trusts will be accountable to NHS regional offices. Besides rigorous scrutiny of their costs and performance, trusts will be assessed against the wider goals of improving healthcare outcomes.

    A stated aim is to renew the NHS as a one nation health service. Closer integration of health and social care, with pooled budgets, is envisaged. Statutory duties of partnership placed on NHS bodies to work together will extend to local authorities, whose chief executives will participate in meetings of the health authority.

    And although market forces are eschewed, primary care groups will be expected to bear down on trusts' costs to achieve value and to change providers.

    The white paper calls it a tough and challenging programme, parts of which may be a long haul and take time to show visible improvement. But the end result, it says, will be an NHS that gets better every year and is modern and dependable.


    • The New NHS is available from the Stationery Office, price £12.50.

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