5 Healthcare |
The Spending Review settlement
45. The Department of Health was one of only two
departments (the other being the Department for International
Development) for which the Government had pledged to protect funding.
In the Spending Review the Department was allocated an increase
in its Resource budget, with cumulative growth reaching 1.3% in
real terms by 2014-15 on the assumptions used in the Spending
Review. The Administration budget (i.e. the Department's 'back
office' costs) within the Resource budget falls in real terms
by 33% by 2014-15. This is in line with the average decrease across
departments of 34%. At the same time, the Department of Health
Capital budget will fall by 17% in real terms by 2014-15 (compared
with an average decrease across departments of 29%) on the assumptions
used in the Spending Review.
46. As we have seen, the Spending Review also committed
the NHS to set aside funding within the Resource budget, growing
to £1 billion by 2014-15, to fund social care (including
a specific allocation for reablement services).
47. The Department
of Health takes up a significant portion of the Government's total
funding across departments: by 2014-15 the Department of Health
will account for 33% of the total Resource budget and 11% of the
total capital budget. The ability of the NHS to operate within
its settlement is therefore vital to the achievement of the Government's
- There has been some political debate regarding
the Government's description of the Spending Review settlement
as a real-terms increase. The fact of the matter is that the question
of whether or not the settlement fulfilled this description depends
on which particular parts of the settlement are included in the
calculation. The 1.3% real terms increase in the Resource budget
(on the assumptions used in the Spending Review) is consistent
with the Coalition Government's commitment on health spending.
However, this cumulative real terms growth for the NHS is significantly
reduced if the additional £1 billion NHS funding for social
care (which will be formally transferred to local authorities
on the basis of an agreement with the NHS, rather than spent directly
by the NHS itself) is separated out, as demonstrated by the following
49. The discussion of whether or not the settlement
could be considered a 'real terms' increase is also affected by
whether one considers the Resource budget in isolation (as above)
or the total budget (resource plus capital). The total budget
(resource plus capital) increased only marginally in real terms
if the additional social care funding is included, and actually
was expected to fall by 0.54% in real terms by the end of the
Spending Review period if this funding is excluded. The Government
has confirmed that the additional social care funding is essentially
a transfer from the NHS capital budget.
50. This debate has now been overtaken by events.
Since the Spending Review, the Office for Budget Responsibility
(OBR) has revised its earlier forecasts for the GDP deflator.
This is the general measure of inflation used by the Treasury
to calculate inflation-adjusted or real figures, and in particular,
is the measure used in the Spending Review to calculate NHS funding
in real terms. For three of the four years of the spending review
the OBR has now revised its GDP deflator forecasts upwards. The
cumulative GDP deflator from 2011-12 to 2014-15 is now forecast
to be around 0.65% higher (10.49% instead of 9.84%) than the estimate
used in the Spending Review. As the cash rise in the total NHS
settlement announced by the spending review was 10.21% by 2014-15,
the real terms increase of 0.34% over four years is now forecast
to be a real cut of around 0.25% - equivalent to an average annual
real cut of 0.062%. Compared with this year, this translates into
a real cut of around £0.25 billion by 2014-15.
51. The marginal nature of the real terms increase
in spending on health meant that the Government's commitment would
be vulnerable to small shifts in inflation. When questioned on
this issue in the House on 7 December, the Secretary of State
"At the Spending Review we set out what met
our commitment. I am very clear that...revenue funding for the
NHS will increase in real terms...The gross domestic product deflator
will move from time to time, but the commitment that we set out
was clear and will continue".
As it stands, however, the
Government's commitment to a real terms increase in health funding
throughout the Spending Review period will not be met. This emphasises
the fact that the settlement, although generous when compared
to other departments, represents a substantial challenge to the
The 'Nicholson Challenge'
BACKGROUND TO THE NICHOLSON CHALLENGE
52. Over the past 39 years the NHS has received combined
capital and revenue funding of an average of 3.9% per annum above
has allowed it to keep pace with long-term pressures from demography,
medical advances and rising patient expectations. The NHS is now
in a position where it will need to make substantial efficiency
gains to allow it to continue to meet the demands made of it.
Indeed, several witnesses have noted that various aspects of NHS
inflation more or less cancel out any increase in funding received
under the Spending Review.
53. This state of affairs has not come as a surprise
to the NHS, and it was anticipated by Sir David Nicholson, the
Chief Executive, through the establishment of the QIPP (Quality,
Innovation, Productivity and Prevention) programme, designed to
deliver efficiency savings of £15-20 billion between 2011
and 2014. This 'Nicholson Challenge' was first set out in the
NHS Annual Report for 2008-09,
well before the change of government and the Spending Review.
The challenge reflects independent analysis, such as the 2009
report by the King's Fund and the Institute for Fiscal Studies
that also suggested the NHS would need to sustain large annual
productivity increases in order to maintain the quality of its
services against a background in which it was recognised that
health spending was bound to rise more slowly in the immediate
future than it had done over the previous decade.
54. The public sector pay freeze for the first two
years of the period will contribute to the required efficiency
gains. The Committee is mindful that the achievement of the Nicholson
Challenge will depend on the efforts of NHS staff whose pay is
55. The scale of the challenge is immense. Sir David
told us "It is huge. You don't need me to tell you that it
has never been done before in the NHS context and we don't think,
when you look at health systems across the world, that anyone
has quite done it on this scale before".
56. In considering the financial constraints facing
the health service it is important to remember that this efficiency
challenge predates both the White Paper reorganisation and the
specific Spending Review settlement: but these subsequent developments
provide a new context within which the challenge must be delivered.
MAKING THE SAVINGS HAPPEN
57. Although the NHS has received a significant increase
in resources over the last decade or so, this has been put to
use in expanding services ('using more to do more') rather than
focusing on making efficiency gains ('doing more with the same').
We recognise that the current efficiency challenge is not about
cutting £15-20 billion from the NHS budget, nor should
it lead to a reduction of £15-20 billion of services. Instead
the NHS must derive £15-20 billion more value from its budget,
in order to meet rising demand and improve the quality of services
without a corresponding increase in funding.
58. The importance of viewing the challenge in this
way was stressed by the King's Fund in its July 2010 paper 'Improving
As the NHS grapples with significantly smaller increases
in funding from 2011, there is a danger that the necessary focus
on improving productivity becomes, at best, an end in itself and,
at worst, a misunderstanding that the NHS needs to dramatically
cut budgets, reduce services for patients, and sack staff. The
NHS will need to carefully select the strategies which, together,
produce more value from the same or similar resource -
not the same for less.
59. On a general level, witnesses have told us that
efforts to meet the spending challenge in a coherent way are being
complicated by the lack of a clear 'narrative' from central government.
Dr Hamish Meldrum of the BMA told us:
I think we really need to see a much better narrative
than we have up till now: not only what is the rationale for actually
making it that amount but actually where are these moneys going
to be reinvested, what jobs are going to be needed in order to
do that and, therefore, both locally and nationally, having much
greater detail about the whole flow of funds and resources over
the next four years.
This was supported by Dr Peter Carter of the RCN,
who told the Committee:
the current worry is that the service redesign at
the moment is done on the back of needing to save money rather
than the back of a good, properly thought through strategic plan
which is taking a local health service forward.
efficiency challenge for the NHS is not about cuts. It is about
doing more with the same amount of money. The Government needs
to ensure this fact is more clearly communicated both by the NHS
itself and to the wider community.
61. The scale of the challenge is enormous. The NHS
does not have a good recent record on improving productivity.
While it is widely accepted that measuring productivity is problematic
and that an entirely satisfactory method has yet to be devised,
ONS figures show that between 1997 and 2007, measured NHS productivity
was flat or declining over the whole period,
whereas private sector productivity improvement averaged 2% per
year. The Secretary of State told us that this low productivity,
coupled with the 'relatively high platform of resources' that
the NHS had been given over previous years, actually indicated
that there was plenty of scope for productivity improvements.
This is true, provided that the correct mechanism can be found
to turn this potential into results.
62. There is
an urgent need for a credible plan to deliver the efficiency gain
which is the central requirement of the Spending Review settlement
for the NHS. Many witnesses have drawn attention to the need for
this plan and have expressed concern that it is not yet available.
We share this concern.
63. In his 2002 review of future funding of the NHS,
Sir Derek Wanless set out three funding scenarios depending on
progress made in relation to future demand, supply and costs of
healthcare. A study by the King's Fund in 2007 concluded that
the NHS was progressing in line with the middle scenario ('solid
progress') but that in the period up to 2013-14, there was likely
to be a shortfall in funding of just under £21 billion. £9
billion of the shortfall was made up from factors such as real
pay and prices, and capital investment, while £12 billion
of the gap in funding related to the need to effect actual improvements
in the quality of care, resulting from changes in the way care
was delivered. 
64. This message of quality is one that we are also
hearing from the Department of Health. The Secretary of State
told us that the QIPP programme was "deliberately designed
around the proposition that we are going to increase quality and
deliver greater efficiency by the use of innovation and prevention
to deliver an overall rise in quality and productivity. Productivity
only captures a sense of doing the same thing with fewer inputs.
We're looking not only to carry on doing the same thing, but to
increase the quality of what we do by changing the design of what
we do". Sir
David Nicholson assured us that it was 'perfectly possible to
improve quality and increase productivity simultaneously'.
The White Paper stated that the QIPP programme would 'continue
with even greater urgency, but with a stronger focus on general
practice leadership. The QIPP initiative is identifying how efficiencies
can be driven and services redesigned to achieve the twin aims
of improved quality and efficiency'.
Edward Macalister-Smith, Chief Executive of Buckinghamshire Primary
Care Trust, told us that 'it is possible to close that gap, and
it is possible to do it while maintaining quality and improving
patient experience. But it needs to be very, very determined and
it is going to involve really quite radical changes to the behaviour
and the operations of all parts of the system'.
65. The demand pressures will mount steadily over
time. It is for this reason that it is vital for the Government
to ensure that the savings programme also gets results on a consistent
basis across the Spending Review period, rather than focusing
solely on the end point of making £20 billion worth of savings
by 2014. The Department assured us that they were planning on
66. Efficiency gains of this kind are difficult to
measure. Sir David Nicholson told us that savings deriving from
the tariff changes would be subject to a matrix and milestones
to be published in December, with monitoring against these standards
published in The Quarter for each quarter of the savings
programme. We were told that each individual NHS organisation
would also have, by March, an efficiency plan based on the expectations
67. The QIPP
programme is the tool available to healthcare to make efficiencies,
and represents a good starting point. However, the scale of the
challenge is so immense that QIPP will need to demonstrate clear
savings early in order to provide the savings programme with the
momentum to proceed at a steady pace towards the £15-20 billion
goal. Close monitoring and consistent reporting of performance
against publicly available norms will be essential if these gains
are to be seen as real improvements rather than accounting changes.
68. Sir David Nicholson gave us the following assessment
of how the savings would be made:
If you look at those savings, about 40% of them will
come from essentially a mixture of things which are much more
under our central control. So, for example, the pay savings, the
management costs savings, the administrative cost savings, the
savings on central budgets of the Departmentall of those
thingscome to about 40% of the total savings. That is reported
out and we can look at that. The second group of savingsabout
20%come from service change. So that is the thing I talked
about; the movement from secondary to primary care and that sort
of thing. The third lot is about 40%, which is the savings you
get through the tariff in the acute sector, so driving efficiency
69. The Secretary of State stressed the particular
importance being placed on the reduction in management and administration
costs: 'by 2014-15, the one third real-terms reduction in administration
costs across the NHS will yield a reduction in total administration
costs of £1.9 billion. That is effectively one tenth of the
maximum efficiency savings we are looking for'.
Nigel Edwards of the NHS Confederation cautioned that only a small
proportion of savings could actually be made from administrative,
management and 'back office' savings: "most of the money
is spent on clinical care. If you want to reduce your spending,
make your spending more efficient, that is, I am afraid, where
you have to concentrate".
70. The Secretary of State is also placing significant
weight on the tariff.
The tariff is already being used to generate 3.5% efficiency gains
in the NHS in 2010-11.
If the tariff is to drive 40% of the £15-20 billion efficiency
gains required by the Nicholson Challenge then this equates to
£2 billion of savings in the acute hospital sector per year.
This is roughly equivalent to 5.5% of the PCT allocation spent
on general and acute secondary care, and potentially even more
for some services, since not all acute sector services are covered
by the tariff. Edward
Macalister-Smith told us that in his area he expected the majority
of savings to be made from provider efficiency resulting from
a squeeze of the tariff: "it has got to make that productivity
gain in the acute hospital and that is going to be tough".
The NHS Confederation also raised concerns about the pressures
on acute trusts.
The Secretary of State insisted that achieving 40% of savings
through the tariff would not be simply about squeezing costs rather
than improving quality and efficiency: "the tariff is driving
best practice and efficiency. We are going to develop the tariff
to do these things and it will be a powerful instrument to make
But reducing the tariff does not, in itself, produce efficiency
gains, although it does put hospitals under more pressure to reduce
costs. It may be that hospitals meet the squeeze on tariffs by
ceasing to provide services, or by subsidising unprofitable lines
with profitable ones, without actually improving efficiency.
71. We are concerned
that 40% of the necessary efficiency improvements are to be derived
from tightening the tariff. There is no guarantee that reductions
in the tariff will always result in genuine efficiency gains,
and there is a risk that the quality of services could suffer
if changes are driven by reductions in the cost of the tariff
alone. There should not just be across the board cuts in the tariff.
It needs to be revised to remove perverse incentives and encourage
72. The efficiency challenge is inescapably tied
up with the restructuring of the NHS, as set out in the Government's
White Paper, Equity and Excellence: Liberating the NHS
(July 2010). Described in the foreword as a 'bold vision', the
major reforms set out in the paper include the devolution of commissioning
from PCTs to GP consortia, the establishment of an independent
NHS Commissioning Board, the conversion of all NHS Trusts to foundation
trust status, a significant reduction in the number of NHS bodies,
and a radical streamlining of the Department's own NHS functions.
We are conducting a separate inquiry into the most significant
of these changes, the transition to commissioning by GP consortia,
and this Report is not an analysis of the White Paper proposals.
The transition to the new structure coincides more or less exactly
with the Spending Review period and will frame the spending plans
for the NHS.
73. Presenting the White Paper to the House, the
Secretary of State said 'I recognise that the scale of today's
reforms is challenging, but they are designed to build on the
best of what the NHS is already doing'.
In evidence to us on 20 July 2010 Mr Lansley stressed that, for
the majority of clinicians in the NHS the restructuring was 'not
an upheaval, it is an empowerment'.
He continued this theme when appearing before us for the current
inquiry on 23 November: 'what I am proposing is an evolution.
I have never called it a revolution'.
74. Witnesses to the inquiry have described the reforms
in more drastic terms. Sir David Nicholson, Chief Executive of
the National Health Service, told us that 'the scale of the change
is enormousbeyond anything that anybody from the public
or private sector has witnessed, really'.
John Appleby, Chief Economist at the King's Fund, told the Treasury
Committee on 1 November 'This is not about tinkering around the
edges [...] It is about some radical alterations in the structure
and fabric of health careclosing hospitals and centralising
some services, which are some of the big things that the NHS has
found difficult to do over its history'.
75. The Secretary of State told the Committee that
the White Paper reforms feed into the efficiency challenge by
ensuring 'that those who are responsible for making clinical decisions
do so alongside the resource consequences' and by promoting the
better integration of services between community and hospitals.
We have also heard from Sir David Nicholson that the dual challenges
of efficiency savings and service reorganisation needed to be
'not parallel but mutually reinforcing'.
We agree that this is necessary, but we have heard numerous warnings
of the risks involved in combining the tight spending envelope
and the need for unprecedented efficiency savings with the large-scale
reorganisation of NHS structures. The Department of Health's own
analytical strategy document for the White Paper acknowledges
There are clear risks associated with the transition
period. For example, SHAs and PCTs will cease to exist, but there
will be a reliance on them in the short-term around both managing
the transition period and delivering ongoing efficiency savings,
such as those associated with the QIPP programme.
76. The Nuffield Trust, in their recent briefing
on the White Paper and Spending Review, set out the risks of trying
to combine the reorganisation with the need for efficiency savings:
Even if well managed, widespread organisation reform
can mean services stand still for a period rather than progress.
If managed poorly, services and finances may suffer. There is
clear evidence that organisations distracted by reform can experience
major financial and service failure. Failure can take several
forms; these include a lack of control of expenditure, rushed
service changes, or more fundamentally, a decline in the quality
of care. This is the more worrying because quality is less readily
measurable than finance, and in the current financial climate
there will be much attention to the bottom line.
77. Dr Peter Carter of the RCN highlighted that these
concerns are also shared by staff on the ground:
This is a heck of a challenge. The £15 billion
to £20 billion on its own [...] is absolutely massive, has
never been done before, and that on its own would be a major challenge.
The White Paper on its own would be a major challenge. Put the
two things together and this is as big and as complex as you could
78. In particular, the reorganisation is going hand
in hand with the White Paper commitment to reduce NHS management
costs by more than 45% over the next four years, with the aim
of freeing up further resources for front-line care. The White
Paper stated that:
[...] as a result of the record debt, the NHS will
employ fewer staff at the end of this Parliament; although rebalanced
towards clinical staffing and front-line support rather than excessive
administration. This is a hard truth which any government would
have to recognise.
79. The reduction in management pre-empts the reorganisation,
but it raises questions about the delivery of both the reorganisation
and the Nicholson Challenge. We know the direct costs of the management
reductions (we were told that it would cost up to £900 million
in redundancy costs, but that it could 'save £880 million,
there will be wider implications for the control of the restructuring
and, in particular, the ability of the system to sustain a focus
on the delivery of healthcare during a time of such upheaval.
Professor Chris Ham told us:
[...] there are always risks associated with a big
reorganisation change of this kind because for a couple of years
at least the people involved in that reorganisation are distracted
from the core business. While they are reorganising the structures,
the focus on improving care for patients and getting better efficiency
will often take, sadly, second place.
80. The King's Fund has stressed the important role
that managers had to play in delivering both efficiency savings
and a successful reorganisation:
Leadership time and capability need to be dedicated
to furthering the QIPP agenda and ensuring effective implementation,
while also taking forward the radical changes to the organisation
of the NHS that are in the pipeline. This will not be easy at
a time when substantial cuts are being made to management costs.
It is vital that the contribution of managers and leaders of local
systems is recognised alongside the drive to empower frontline
81. Nigel Edwards of the NHS Confederation told us
'some of the managerial control systems and other more standard
techniques that we have relied on in the past to get financial
balance may work less effectively, because of the changes that
82. Sir David Nicholson assured us in Committee that
he was aware of these risks and would be taking appropriate action,
recognising that although the reorganisation was unusually 'bottom-up'
and 'fluid', there was a need for 'more stakes in the ground'.
Specifically, he told us that:
there is no doubt in my mind that in some ways we
are going to have to centralise more power in the very short term
to deliver the benefits in the medium and long-term [...] we will
have to take a very tight rein in relation to the management of
This tight control would be supported by the new
Operating Framework in December and the preparation over the next
few months of detailed plans for individual organisations.
We welcome Sir David's recognition
of the need for close financial oversight during this transition
period. We believe there must be more detail in the Operating
Framework and over the coming months on the exact nature of these
controls and, in particular, how they will address the transitional
arrangements from PCTs to commissioning consortia.
83. It is important to recognise that these changes
are already happening and that the absence of a clear plan risks
undermining both a logical approach to the savings programme and
the opportunity to use this process to develop higher quality
services for patients. The new Operating Framework needs to provide
84. We have already discussed the importance of selling
the challenge as making efficiency gains rather than simply 'cuts'.
Unfortunately we are increasingly hearing examples that fall into
the latter category. At the time of writing, increasing numbers
of news stories were appearing in the media about PCTs struggling
to meet costs and services being rationed. Pulse reported on 23
November that many PCTs were 'warning their plans rely on huge
cuts and 'spending all contingency funds'';
the Yorkshire Post has reported that North Yorkshire PCT will
be ceasing to offer IVF treatment to new patients, stopping minor
surgery at GP clinics, and delaying non-urgent hospital treatment;
while the local press in Kent is reporting that the Eastern and
Coastal Kent PCT has ordered GPs to delay referring to hospitals
'low-priority' treatments (such as hip and knee replacements and
some cases of cataract surgery) in an effort to ease pressure
on beds and cut overspending.
In terms of job losses, the RCN has already identified almost
18,000 NHS posts at risk in England,
while UNISON noted "already there are reports coming through
of hundreds of jobs being threatened across the country".
85. The BMA told the Committee: 'We are already seeing
that, in some places, the challenge is not being addressed in
a terribly evidence-based or logical way, in that you are relying
on happenstance of people retiring or leaving the service to try
and make savings. What you will need, if you are going to try
to achieve the sort of savings that are talking about, is a fairly
massive reconfiguration of the way services are delivered'.
86. Dr Carter argued that the process was being handled
in a way that could serve to complicate the problem: 'Our fear
is that what we are going to see is a squeeze on the acute hospitals
without the reinvestment in the community infrastructure, which
is going to make a difficult situation even worse'.
87. Although the Secretary of State rejected the
suggestion that PCTs were in meltdown,
it is evident that the impending reorganisation is already affecting
the functioning of certain PCTs. Sir David Nicholson acknowledged
that it was 'a big challenge' to deliver the efficiency programme
in such a context, especially away from the pathfinder consortium
If you were to ask me whether I think we can sustain
152 independent PCTs between now and 1 April 2013, I would say
that we cannot. Increasingly, in parts of the country, we see
that we cannot do that now. That is not to say that we want to
abolish them, or that we would abolish them statutorily, but we
need to make arrangements so that we can pool the capacity that
we've got. Hence, in London, they're looking at clustering organisations
together and having one management team to run a series of PCTs.
I have absolutely no doubt that that will be the model across
the country as a whole. So, you will see PCTs being clustered
together with single management teams in order to sustain the
management capacity, both to enable them to devolve the responsibilities
to the local government and consortia and, on the other hand,
to enable them to hold on to the accountability chain, which is
going to be so critical for us over this period.
David Nicholson has acknowledged the risks of delivering the efficiencies
programme over the transition period to the new NHS structures,
and we are encouraged by his determination to maintain tight financial
controls during this time. However, we are concerned that there
has been a lack of co-ordination in the period since the White
Paper was published, and the Government has not communicated a
clear narrative to support PCTs and other NHS organisations in
implementing the reforms.
89. To compound the problem of these indirect costs
and risks, the direct cost of the reorganisation remains unclear.
The National Audit Office's recent report on machinery of government
changes examined the costs and risks of such changes, and concluded
that reorganisation costs tend to be significant; that the ability
of central government bodies to identify reorganisation costs
was very poor; and that central government bodies were weak at
identifying and systematically securing the benefits they hoped
to gain from reorganisation.
It is important that the NHS reorganisation does not follow this
90. The analytical strategy for the White Paper discusses
the factors that will contribute to the cost of the reorganisation,
but at the time of writing, the Government had not produced an
estimate of the cost of the reorganisation, beyond the statements
of redundancy costs mentioned above. The Government has made reference
to the figure of £1.7 billion that derives from the requirement
originally set out in the NHS Operating Framework for 2010-11
(under the previous Government) for PCTs to set aside 2% of funds
for the purposes of non-recurring 'service transformation' costs.
In a Westminster Hall debate on the implications of the Spending
Review for the NHS, Simon Burns MP, Minister of State at the Department
of Health, stated that the Government recognised 'that amount
of money as money that can or could be used for reorganisational
this sum may be earmarked for 'service transformation' purposes,
it pre-dates the current Government and cannot be regarded as
an accurate estimate of the costs of implementing the specific
proposals of the White Paper.
91. The estimate of reorganisation costs of £2-3
billion, as proposed by Professor Kieran Walshe of the Manchester
has been widely cited, and may provide a more accurate indication
of the reorganisation costs. Ultimately it is for the Government
to demonstrate that it has made its own assessment of the reorganisation
costs, to publish these figures, and then monitor the actual costs
against their budget.
92. The cost
of the White Paper reorganisation emphasises the need to achieve
the higher end of the £15-20 billion of efficiency savings
identified in the Nicholson Challenge. These costs must be clearly
identified and planned for, if the spending challenge is to be
achieved. It is unfortunate that the Government has not yet provided
even a broad estimate of the likely reorganisation costs; and
it is unhelpful for the Government to continue to cite the £1.7
billion figure, as it does not relate to their specific proposals.
The next round of White Paper documents must present a clear assessment
of the likely costs, both direct and indirect, and demonstrate
how they are to be accommodated into wider spending plans.
53 HC Deb, 11 November 2010, col184WH Back
Office of Budget Responsibility: Economic and Fiscal Outlook,
Cm 7979, 29 November 2010 Back
HC Deb, 7 December 2010, col 163. Back
Ev 82 Back
King's Fund response to the Spending Review, 20 October 2010,
Ev 119 (NHS Confederation); Ev 112-113 (British Medical Association);
Nuffield Trust briefing, NHS resources and reform: Response
to the White Paper Equity and Excellence: Liberating the NHS,
and the 2010 Spending Review. October 2010, p9. Back
NHS, NHS Chief Executive's Annual Report for 2008-09, May
2009, p47. Back
The King's Fund and Institute for Fiscal Studies, How cold
will it be? Prospects for NHS Funding: 2011-17, July 2009.
Q 22 [Sir David Nicholson] Back
The King's Fund. Improving NHS Productivity - more with the
same, not more of the same, July 2010, p2. Back
Q 237 Back
Q 250 Back
Office for National Statistics (2010). Public Service Output,
Inputs and Productivity: Healthcare, p1. www.statistics.gov.uk/articles/nojournal/healthcare-productivity-2010.pdf Back
Q 389 Back
The King's Fund, July 2010, Improving NHS Productivity - More
with the same not more of the same, p9. Back
Q 392 Back
Q 15 Back
Department of Health, Equity and excellence: Liberating the
NHS, Cm 7881, July 2010, p47. Back
Q 137 [Mr Macalister-Smith] Back
Q 398 [Mr Douglas, Sir David Nicholson] Back
Q 399 Back
Q 356 Back
Q 146 [Mr Edwards] Back
The calculated price for a unit of healthcare activity, under
the Payment by Results scheme, as paid by PCT Commissioners to
treatment providers (i.e. acute hospitals). Services such as mental
health and community care are currently excluded from the tariff. Back
Q 79. Unlike in previous years, in 2010-11 there was no uplift
in tariff prices and a 3.5% efficiency requirement was imposed
to cover pay and price inflation. Back
In 2010-11 the PCT announced opening allocation was set at £80bn
[National Audit Office, Briefing for the House of Commons Health
Select Committee - Health Resource Allocation, December 2010,
p8]. 44.8% of primary care trust expenditure was spent on general
and acute secondary care [Ibid, p17], which would be equivalent
to £35.8bn of that £80bn. Back
Q 138 Back
Ev 120 Back
Q 389 Back
HC Deb, 12 July 2010, col 663. Back
Oral evidence taken before the Health Committee on 20 July 2010,
HC (2009-10) 380, Q 1 Back
Q 359 Back
Q 34 Back
Oral evidence taken before the Treasury Committee on 1 November
2010, HC (2010-11) 544-II , Q232 Back
Q 349. Back
Uncorrected transcript of oral evidence taken before the Health
Committee on 19 October 2010, HC (2010-11) 513-i, Q 92 Back
Department of Health, Equity and Excellence - Liberating the
NHS: Analytical Strategy for the White Paper and associated documents,
p14. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117351.pdf
The Nuffield Trust briefing, NHS resources and reform: Response
to the White Paper Equity and Excellence: Liberating the NHS,
and the 2010 Spending Review. October 2010, p3 Back
Q 243 [Dr Carter] Back
Department of Health, Equity and excellence: Liberating the
NHS, Cm 7881, July 2010, p11. Back
Q 44 [Sir David Nicholson] Back
Uncorrected transcript of oral evidence taken before the Health
Committee on 16 November 2010, HC (2010-11) 513-ii, Q 246. Back
The King's Fund, Improving NHS Productivity - more with the
same not more of the same, July 2010, p27. Back
Q 144 [Mr Edwards] Back
Q 373 [Sir David Nicholson] Back
Q 371 [Sir David Nicholson] Back
Pulse website, 10 November 2010, GPs face debt crisis as PCTs
fall £300m into the red, http://www.pulsetoday.co.uk/story.asp?storycode=4127669 Back
Yorkshire Post, 22 October 2010, Services axed as care trust
battles huge debt. http://www.yorkshirepost.co.uk/news/Exclusive-Services-axed-as-care.6594054.jp Back
This is Kent, 12 November 2010, Health chiefs block non-urgent
operations in bid to save money and keep beds free.
Royal College of Nursing, Frontline First Interim Report,
November 2010, p5. Back
Q 239 [Mr Collis] Back
Q 233 Back
Q 277 [Dr Carter] Back
Q 377 Back
Sites in the pathfinder programme, whereby groups of GP practices
(consortia) are supported in taking forward GP commissioning of
services ahead of the formal transfer from PCTs under the White
Paper timetable. Back
Q 372 Back
National Audit Office, Reorganising Central Government, HC
452, Session 2009-10, March 2010. Back
Department of Health, Equity and Excellence - Liberating the
NHS: Analytical Strategy for the White Paper and associated documents,
p5. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_117351.pdf Back
HC Deb, 11 November 2010, col 179WH. Back
Professor Kieran Walshe, Reorganisation of the NHS in England,
BMJ 2010; 341:c3843 (16 July 2010): Back