Step-by-step guide to NHS changes

Image caption The government's plans for the NHS have been under review

When the overhaul of the NHS in England was announced last summer it was dubbed the most radical re-organisation of the health service since its inception more than 60 years ago.

Over the following months the criticisms mounted to such an extent that the government was forced to call a halt to the progression of its legislation to allow an independent review to be carried.

The consultation by the NHS Future Forum has now been completed and the panel has published it recommendations.

On Tuesday the government set out how it was going to alter its plans. So what has changed?


Now: Charities and private sector firms are already involved, particularly in areas like mental health service and end-of-life care. In the hospital sector, they have a much smaller role. However, under the Labour government firms did start to win some contracts and now handle 3.5% of all non-emergency operations, such as hip and knee replacements.

Original proposal: Ministers wanted to see the NHS opened up to more competition. The talk was of allowing "any willing provider" to enter the market. That alone would probably not have made a dramatic difference, but the plans also called for a regulator to be created which would have a duty to promote competition.

Review recommendation: Competition still has a role to play, the panel said. But it must also be balanced against the need for collaboration and integration to ensure the best for patients and therefore the primary duty to promote competition has to be dropped in favour of using it to promote choice and integration. In a nutshell, more managed competition.

Government position: Agrees there needs to be a better balance between co-operation and competition and so regulator's competition duty to be dropped. There will also be a more phased appproach to competition with community services being targeted first.

Control of the budget

Now: Managers working for primary care trusts (PCTs) currently hold the purse strings. This allows them to make decisions about what services should be available and where they should be located.

Original proposal: Much of this budget and responsibility was to be transferred to GPs working together in consortia although it was envisaged funding of specialist services such as neurosurgery would probably need to be done on a national level.

Review recommendation: GPs should still be the key players, but need to work closely with other health professionals, such as nurses and hospital doctors. Clinical senates, multi-disciplinary groups of health workers, will be set up to oversee consortia.

Government position: May go further than review recommended as there are suggestions it will become mandatory for nurses and hospital doctors to become part of the decision-making board of consortia. The forum rejected this on the grounds it would be tokenism, preferring instead to have a duty for them to be consulted. The phrase consortia to be dropped for clinical commissioning groups.

Pace of change

Now: N/A

Original proposal: Ministers wanted a quick roll-out. Pilots started within months with the idea that GPs working in consortia would take responsibility from 2013.

Review recommendation: The big bang approach should be dropped for a system whereby the national board takes charge in areas where consortia are not ready to take responsibility. But there should be no opt out as some critics have suggested, the panel said.

Government position: Largely in line with the review's proposals, although there are suggestions in Lib Dem circles that there could be some kind of opt out completely if individual areas are not ready. Many believe that is unlikely however.


Now: There are essentially three tiers of management. More than 150 PCTs make decisions locally and are monitored by 10 strategic health authorities (SHAs). Ultimately, they are answerable to the health secretary.

Original proposal: PCTs and SHAs to be scrapped and replaced by GP consortia and a national board. Controversially one clause proposed the health secretary relinquishing responsibility for the health service - something ministers at the time said was to free the NHS from political interference.

Review recommendation: PCT and SHA days are still numbered, but role of the national board will need expanding if there are large numbers of consortia not ready by 2013. The forum also wants the clause requiring the health secretary to ensure there is a comprehensive health service to be retained.

Government position: Once again the government has agreed with the forum. Health secretary to retain responsibility for NHS. However, one aspect to note is the prospect of the remnants of primary care trusts - the so-called primary care clusters - to remain as regional outposts of the national board to allow extra support for those groups not ready to assume their responsibilities by 2013.