DESIGNED TO CARE

Renewing the National Health Service in Scotland

44. In developing proposals for the replacement of the internal market, the Government have sought the views of those working in the NHS in Scotland, and have listened carefully to the criticisms of the existing arrangements. A consistent theme to emerge is the need for new arrangements which can deliver significantly better services for patients, by improving clinical links between parts of the National Health Service, and wholeheartedly pursuing the development of first rate primary care and hospital services. There will be no 'big bang'; we want to build on what we have. At the same time, solutions need to be flexible enough to respond sensitively to local needs rather than imposing an inflexible blueprint on them. The Government believe that the arrangements set out in this White Paper will achieve these goals.

45. The model which the Government will introduce to replace the internal market has a number of distinct aims. First and foremost, it is intended to improve clinical relationships within the NHS in Scotland, and to clarify the accountabilities of its different parts. In turn, this should help to promote the partnership and co-operation which are so fundamental to the effective delivery of health care services and which are an integral part of the Health Improvement Programmes already being developed in the NHS in Scotland.

46. The Government made clear in our manifesto that we had no intention of turning the clock back to a time when the NHS was run by a crude command and control system. It is widely accepted that such an approach undermines devolved decision-making, and so would run counter to the Government's whole approach. That approach is geared to ensuring a focus on patient care so that those who deliver services locally can respond to changing circumstances and changing patient needs quickly. Such responsiveness cannot be achieved if matters continually have to be referred upwards. The Government have therefore retained distinctive roles for those who are to be responsible for the development and implementation of strategy and for those who deliver services directly to patients: the strategic role and the service role.

47. One of the adverse features of the internal market was the scale of the bureaucracy and the associated costs to which it gave rise. The Government have already taken steps to reduce bureaucracy and achieve savings through the elimination of unnecessary duplication of support and other services. The Government's intentions emphasise the role of clinicians and patients in the design of services, and encourage the integration of service delivery in a seamless pattern across the interface between primary, secondary and tertiary care.

48. The Government have decided that the existing system must be reformed as soon as possible, in order to tackle these issues. We will do so by retaining some features of the existing system while replacing those which have been shown to work against the best interests of patients. It is an approach which is evolutionary and incremental, and an approach based on the belief that people achieve more by working together in partnership.

49. A start has already been made. The Priorities and Planning Guidance issued in August 1997 set out the framework for planning which the Government wish the National Health Service in Scotland to adopt. A number of further changes are in train on the management of human resources and financial services, designed to achieve greater consistency in service organisation across the country. These proposals, which have come forward from the NHS, are intended to achieve greater efficiency in the organisation of these important support services, as well as to eliminate waste and duplication. Later in the White Paper we set out further proposals intended to ensure that wherever people work within the NHS in Scotland they are treated fairly and equitably in accordance with principles established at national level.

50. Soon after taking office, the Government announced their intention of taking forward a review of acute health services in Scotland. The Acute Services Review is being led by the Chief Medical Officer and is expected to report in Spring 1998. More than 250 people across the NHS in Scotland and beyond are directly involved in the work of the Review, which is necessary if the NHS in Scotland is to be able to respond to the challenges of the next century. The Review is being conducted in accordance with the Government's commitment to openness. Everyone with an interest in the future of these services has been encouraged to become involved. Those conducting the review have been asked to frame their proposals in the context of a development plan for the next 5-10 years.

51. In September the Government also launched their Framework for Mental Health Services in Scotland which is intended to promote the development of local, comprehensive mental health services and pave the way for the replacement of services currently provided in outmoded institutions. By fostering a framework of collaborative organisations seeking to improve the pattern of service in the best interests of patients, the changes which are now set out will make it easier for these policy initiatives to be implemented speedily.

Key Features of the New Arrangements

52. The internal market led to a focus on the short term, with too much emphasis on an annual contracting round. Service developments need to take place over a longer time frame. Our Health Improvement Programmes are designed to promote a longer-term perspective on health and the elimination of the bureaucracy associated with contracting. Annex A sets out the current arrangements for Health Improvement Programmes.

53. Our modernised Health Service should lead to management savings of around £100 million over the lifetime of the Parliament. In summary, the roles of each part of the NHS in developing and implementing the Health Improvement Programme are:

• Health Boards have the lead role in its development and will retain their existing responsibilities in relation to public health protection, health improvement, needs assessment, service strategy and performance management, and will be given a small number of new powers to ensure that local strategies can be implemented. To discharge these responsibilities, Health Boards will also need to liaise closely with local authorities.
• NHS Trusts will be retained, re-focused on improving the quality of service to patients by giving clinicians who work in the hospitals, along with those who use their services, a bigger say in their management. The number of Trusts operating within the NHS in Scotland will be reduced, though detailed proposals for their configuration will be the subject of public consultation in the light of the principles set out in this paper. There will be two main types of Trust: Acute Hospital Trusts and Primary Care Trusts.
• Primary care will be given strong organisational form through the creation of Primary Care Trusts. They will be responsible for all primary health care and will typically comprise community hospitals and mental health services as well as networks of general practices in Local Health Care Co-operatives. These Co-operatives will replace the standard GP fundholding system, which will be brought to an end. Joint Investment Funds (JIF) will be established to encourage co-ordination of services at the interface between primary and secondary care. Primary Care Trusts will also need to work closely with those responsible for social work services and housing.
• At the national level, the Government intend the Management Executive to tackle nation-wide NHS policy and planning matters and ensure greater consistency in the implementation of policy. Within The Scottish Office Department of Health the Management Executive, working in collaboration with the Public Health Policy Unit (PHPU), will make sure that the NHS contributes to broader Government policies in health and social affairs.

Accountability

54. The arrangements which have been described will establish a new set of accountability relationships within the NHS in Scotland. Health Boards will continue to be accountable to the Management Executive as now, but the cross-membership achieved by the inclusion of Chairmen of NHS Trusts as non-executive Directors of Boards (paragraph 67) will help ensure that Boards establish a strategic agenda which can be achieved with the resources available locally.

55. Trusts will be accountable to Health Boards for the implementation of Health Improvement Programmes by means of their individual Trust Implementation Plans (TIPs) (Annex A). The Management Executive's performance management of Health Boards throughout the year will monitor performance and ensure that Trusts are being properly held to account. Additionally, the Chairman of each Trust will attend the annual Accountability Review with representatives of the Health Board, where he or she will be expected to account directly for matters relating to his or her Trust's activity. As at present, Trusts will be expected to produce an annual report, but the annual public meeting at which they present it will in future be held in conjunction with the Health Board. Trusts will also be required to publish a range of specified clinical performance indicators which will be aggregated on an annual basis as part of the Annual Report on the NHS in Scotland. The Government see the development of these indicators as an important aspect of Trusts' accountability to the general public.

56. The particular circumstances faced by the three Island Health Boards have led the Government to conclude that they should continue to have responsibility for strategy and operational management through their directly-managed units. The Island Boards are expected to adopt the general principles and approach set out in this Paper, and should therefore review their existing internal management arrangements to ensure they can support the Government's proposals.

Figure 1
The New Structure