| 12. 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. 13.
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.
14. 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.
15. 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.
16. 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.
17. 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. To
assist information flows, the whole of the NHS in
Scotland will be linked to secure health service
telecommunications over the coming year. The
White Paper also sets 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.
18. 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 White Paper.
There will be two main types of Trust:
Acute Hospital Trusts and Primary Care
Trusts, although this will have to be
varied in some areas to best serve local
populations.
- 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, which
will play a key role in Primary Care
Trusts, will replace the standard GP
fundholding system, which will be brought
to an end. Primary Care Trusts will lead
discussions on the Joint Investment Funds
(JIF), which will be established to
support agreements between primary and
secondary clinicians on changes in the
clinical settings in which care is
delivered and on priorities for quality
improvement. 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.
The new structure is shown
in schematic form in Figure 1.
Figure 1
THE NEW STRUCTURE
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