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| NHS changes: The key questions | |
| (about 1 hour later) | |
| By Nick Triggle Health correspondent, BBC News | By Nick Triggle Health correspondent, BBC News |
| The government has given the clearest indication yet about the changes it is prepared to make to its overhaul of the NHS in England. | The government has given the clearest indication yet about the changes it is prepared to make to its overhaul of the NHS in England. |
| In April, amid mounting criticisms, ministers announced there would be a pause in the roll-out of the plans. | In April, amid mounting criticisms, ministers announced there would be a pause in the roll-out of the plans. |
| Now David Cameron has announced several concessions he is prepared to make. | Now David Cameron has announced several concessions he is prepared to make. |
| These include relaxing the deadline for the new system to be up-and-running, and getting hospital doctors and nurses involved in managing the budget alongside GPs. | These include relaxing the deadline for the new system to be up-and-running, and getting hospital doctors and nurses involved in managing the budget alongside GPs. |
| But his intervention has raised as many questions as it has answered. | But his intervention has raised as many questions as it has answered. |
Too many cooks? | Too many cooks? |
| In recent months, much of the criticism about the plans has focused on the risk of privatisation. But when the changes were first unveiled last summer it was the decision to put family doctors in charge of the budget through GP consortia that attracted most of the attention. | In recent months, much of the criticism about the plans has focused on the risk of privatisation. But when the changes were first unveiled last summer it was the decision to put family doctors in charge of the budget through GP consortia that attracted most of the attention. |
| The prime minister now says GPs will be joined by hospital doctors and nurses to create clinical commissioning. This was something the House of Commons' health committee had called for. | The prime minister now says GPs will be joined by hospital doctors and nurses to create clinical commissioning. This was something the House of Commons' health committee had called for. |
| But there is now concern among those who originally supported the plans. The NHS Alliance, which represents staff working in the community - including many of the GPs who were piloting the changes - says involving other NHS staff too heavily could be damaging. | But there is now concern among those who originally supported the plans. The NHS Alliance, which represents staff working in the community - including many of the GPs who were piloting the changes - says involving other NHS staff too heavily could be damaging. |
| It says hospital doctors may have an interest in promoting the profitability of their hospital - even though it may not be in the best interests of patients. It also warns that decision-making and accountability could be diluted. | It says hospital doctors may have an interest in promoting the profitability of their hospital - even though it may not be in the best interests of patients. It also warns that decision-making and accountability could be diluted. |
A two-tier system? | A two-tier system? |
| The NHS has been working on a deadline of 2013 for the creation of the consortia, but it now seems those areas that are not ready will not be compelled into adopting the new structures. | The NHS has been working on a deadline of 2013 for the creation of the consortia, but it now seems those areas that are not ready will not be compelled into adopting the new structures. |
| Health Secretary Andrew Lansley has warned that if some parts of the country are allowed to opt out - even for a short-time - there is a risk that a two-tier system will be created. | Health Secretary Andrew Lansley has warned that if some parts of the country are allowed to opt out - even for a short-time - there is a risk that a two-tier system will be created. |
| This happened in the 1990s, when half of GPs were given more responsibility under a system known as GP fundholding. It led to different standards of care in different areas. | This happened in the 1990s, when half of GPs were given more responsibility under a system known as GP fundholding. It led to different standards of care in different areas. |
More bureaucracy? | More bureaucracy? |
| The plans were originally hailed as a way of getting rid of NHS bureaucrats. Facing the chop were two tiers of management - 151 primary care trusts and the 10 strategic authorities that keep an eye on them. | The plans were originally hailed as a way of getting rid of NHS bureaucrats. Facing the chop were two tiers of management - 151 primary care trusts and the 10 strategic authorities that keep an eye on them. |
| But if anything, the prime minister's speech has opened the door to more layers of bureaucracy. At the top of the tree will be the national board to which consortia will be answerable. | But if anything, the prime minister's speech has opened the door to more layers of bureaucracy. At the top of the tree will be the national board to which consortia will be answerable. |
| However, with no fixed deadline for consortia to take responsibility for the budget, it is possible that primary care trusts in some slimmed-down form will remain in certain areas. | However, with no fixed deadline for consortia to take responsibility for the budget, it is possible that primary care trusts in some slimmed-down form will remain in certain areas. |
| On top of that, there is now talk of "clinical senates". As yet it is uncertain exactly what they will do and how they will work. The best bet is that they may take charge of complex care that can not be done locally by individual consortia, such as cancer or heart surgery. | On top of that, there is now talk of "clinical senates". As yet it is uncertain exactly what they will do and how they will work. The best bet is that they may take charge of complex care that can not be done locally by individual consortia, such as cancer or heart surgery. |
| So in theory all this could mean there will be as many as four levels of NHS management. | So in theory all this could mean there will be as many as four levels of NHS management. |
The end of competition? | The end of competition? |
| Hardly. The independent regulator of NHS foundation trusts, Monitor, could now have the twin role of promoting competition as well as the integration of care to ensure the best interests of patients are served. | Hardly. The independent regulator of NHS foundation trusts, Monitor, could now have the twin role of promoting competition as well as the integration of care to ensure the best interests of patients are served. |
| However, the British Medical Association has been quick to point out that the two things can sometimes be contradictory. BMA leader Dr Hamish Meldrum described the prime minister's speech as "not a game-changer", and added the situation was "muddy". | However, the British Medical Association has been quick to point out that the two things can sometimes be contradictory. BMA leader Dr Hamish Meldrum described the prime minister's speech as "not a game-changer", and added the situation was "muddy". |
| Others were more positive. The NHS Confederation, which represents managers, said it was pleased with the clarification, pointing out that while competition should not trump all else, it was important in tackling poor practices. | Others were more positive. The NHS Confederation, which represents managers, said it was pleased with the clarification, pointing out that while competition should not trump all else, it was important in tackling poor practices. |
| How the regulator manages to balance the two - and what direction it is given - will undoubtedly be one of the key issues. | How the regulator manages to balance the two - and what direction it is given - will undoubtedly be one of the key issues. |
What about listening? | What about listening? |
| When Mr Cameron, Nick Clegg and Mr Lansley stood side-by-side at a hospital in April to announce the pause they all said they wanted to listen and reflect on their proposals. | When Mr Cameron, Nick Clegg and Mr Lansley stood side-by-side at a hospital in April to announce the pause they all said they wanted to listen and reflect on their proposals. |
| To do this, they set up a panel of experts - known as the NHS Future Forum - to take a lead. More than 200 events were organised as the views of doctors, nurses and patients were sought. | To do this, they set up a panel of experts - known as the NHS Future Forum - to take a lead. More than 200 events were organised as the views of doctors, nurses and patients were sought. |
| The events have now finished, but the forum has yet to hand in its report, due to be given to the Cabinet next week. For many, the report's conclusions will be the true test of whether they can support the plans. | The events have now finished, but the forum has yet to hand in its report, due to be given to the Cabinet next week. For many, the report's conclusions will be the true test of whether they can support the plans. |
| Peter Carter, general secretary of the Royal College of Nursing -one of the most vocal critics of the NHS changes - simply said: "We have to reserve judgement until we see more detail." | Peter Carter, general secretary of the Royal College of Nursing -one of the most vocal critics of the NHS changes - simply said: "We have to reserve judgement until we see more detail." |