Equity And Excellence In Liberating The NHS

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In Britain, the health policy established today is a set of decisions made by private and public agencies over hundreds of years1. These decisions have helped in shaping the organizations and financing of the health care. The National Health Service came into existence on 5 July, 1948 and its aim was to provide a range of health services to everyone in need. It was established on three core principles. It was to provide equal standard of service throughout the UK that is to be universal. The second principle was to be free at the point of contact to all in need not making their ability to pay a factor and also it was to be comprehensive, covering all health needs 2. In order to make the NHS system better to patients and professionals, the NHS white paper was introduced.

In this write up, I will be summarizing my views about the NHS white paper "Equity and Excellence: Liberating the NHS" and how the current NHS framework is different to what is mentioned in the whitepaper. It provides blue print for a wide range of changes whose impact on the population and their health will be evident only in the long run.


This white paper aims at changing the way patients are treated and to provide them with access to the information they want about their care and to follow the policy of 'no decision about me without me' and assumes greater control and choice over care and thus leading to the formation of an NHS which is more responsive to patients' problems. The main emphasis is on 'freedom, fairness and responsibility'. The white paper sets out the long term vision about the future of NHS which is build on the core values and principles of the NHS. It would involve shared decision making, improving the efficiency in monetary terms and thus reduce the deficit, moving to GP commissioning, closing down of strategic health authorities and PCT's, establishing a new NHS commissioning board, tackling health inequalities and giving more chance to public and patient's voice to be heard. Giving the professionals more autonomy would make them more accountable for the results they provide3.

In order to fund and to foresee the GP consortia, a new NHS commission board will be set up and tit will be responsible to Department of Health. Also , in secondary care the foundation trust model will be used as a model for all NHS hospitals. This would in turn mean regulation by Monitor and Care Quality Commission (CQC)4. Monitor will become the regulator of all health and social care sectors and CQC Liberating the NHS also sets out a number of specific choice commitments around extending the choice of treatment and provider planed hospital care, especially in case of mental care, end of life care, maternity and long term conditions5.


The NHS system today is not patient -centred. In the current system, patients have no say in the kind or treatment they are being provided or who is providing the service. The services provided now are designed in such a way that patients themselves are expected to fit around the services rather than the other way round. It has a strong emphasis on the quality of the system provided. But, in comparison with some other countries, the NHS does not thrive well in certain areas like the mortality rates in case of some respiratory measures, stroke, and some cancers. The current NHS also has a strong focus on the evidence-based medicine which are funded and supported by National Institute of Health Research and National Institute of Health. 6

The current NHS system includes Primary care trusts (PCTs) and Strategic Health Authorities. PCTs are local health organizations with the responsibility of improving the quality of care by developing primary and community health services, by commissioning secondary care services and also by delivering effective and appropriate care by addressing health needs and inequalities.


Community pharmacies, being one of the places where millions of people visit, is the best place to provide a wide range of health services. The above mentioned NHS white paper presents with an opportunity to work more closely with patients, doctors, public and other health care professionals to achieve better health outcomes. This would help the pharmacies to expand the range of clinical and public services they provide and thus help patients manage their conditions better by getting the most from their medicines and to by keeping patients well informed and more involved in their own care.

The greater transparency in NHS pricing will benefit the pharmacies in such a way that the one who provide high quality services patient care will be rewarded. Eventually, the policies set will also help reduce the health inequalities. 7 This would mean that the future NHS would focus on prevention and cure and also the incentives for the healthcare professionals would be given on the basis of the quality and the outcomes of the services provided rather than the quantity. It is important for these proposals to be put into practice as the finances are constrained in the NHS and it cannot afford to be satisfied just by the use of medicines.8According to the changes mentioned in the mentioned white paper, the NHS would fulfill one of the main aims of government which is to reduce the management costs by 45%.

Handing over the funding to the GPs would mean that they would be more involved and responsible in the patient care. The clinical expertise of the GPs when combined with the funding responsibility could prove to bring more benefits to patients.


This system plans on exercising the concept of 'any willing provider 'for providing a wide range of choice from among which the patients can choose their service or care provider. But, this would mean that there would be new entrants into the market and all of them will need to have access to the same data and also an equal level of support in order to provide these services in an efficient manner. As the service providers can be of completely different fields, it might prove to be difficult to compare their outcomes and the service provided.

One of the worrying factor is the use of health premium to reward those areas which the health inequalities. The principle used behind this thought is right but there is risk in the most deprived areas as there is more chance of them losing out. In the rural areas, there is very limited access to services and hence the patients do not have a great deal of choices. In such cases, the choice will be dependent on the area you live. The patients need to fully understand the implications of the choice they are making and therefore the information has to be not just available to patients but also interpreted8. According to the white paper, the patients will have their own say in the kind of treatment they are provided. While a huge proportion of people have the ability to do so, there may be a small proportion who are unable to make their own decisions regarding their health. For such patients, it must

Almost 80% of the budget of NHS is currently held by the Primary Care Trusts (PCTs).There are around 151 PCTs across the country and these along with regional bodies are known to be the Strategic Health Authorities. According to the reforms in this white paper, the budget is to be taken from the PCTs and handed over to the General Practitioner (GP) consortiums and also phasing the Strategic Health Authorities completely over the next two years. These consortiums are formed by a number of GP practices working together and it is planned to take the full financial responsibility by 2013. The problem occurs when not all GPs want to sign up for it. Something similar to this has been introduced in the 1990s, but not on such a large scale. The GPs were given responsibility of fund holding which allowed them to take charge of local budgets. This idea was not a complete success as only half the GPs ended up signing for it and the budget was so limited that it could be used only for the most basic parts of hospital care9. As a result, though we know that the system is being currently piloted, it is still unclear on how it is going to work.

The above facts demonstrate that there is an equal array of advantages and disadvantages on the policies that would come into practice according to the white paper, 'Liberating the NHS'. The concept of 'any willing provider' can lead to loss of the services which a community pharmacy currently performs. I fear that services like Medicine Use Reviews (MURs), Minor Ailments etc which at present provides a huge income for the community pharmacy and also builds the relationship with the patients could be scrapped. With the GPs being responsible for 80% of the funding, they might be in the opinion that as the patients are already being reviewed by the clinicians, why is there a need to invest extra money on pharmacies in providing similar services. It also appears that community pharmacies may have different paymasters- NHSCB for the national contract, GP consortia for local services and Local Authorities for public health services. The proposed structure does not clearly indicate how the services are to be commissioned by different organizations. This can result in division of services to patients. Pharmacists are experts in providing the health services with all the skills and experience to prevent people from becoming unwell. It is also unclear in the white paper, how the 'any willing provider' model would exercise a uniform set of rules to all the providers and their assessment .10

It proves hard to support the policies of the white paper with the information provided in this current situation. A great deal needs to be done to increase the contribution of community pharmacies. Pharmacists should be characterized as central in all the aspects of patient care in relation to medicines and pharmacy services to be set in to care pathways. It would have been extremely effective if the GP consortia involved a mixture of health care professionals including a seat for Pharmacy. Though the government rightly wants to implement the accurate policies, there is still confusion on how these are going to be exercised and the role that pharmacy would actually play in the new NHS structure. There should be a clear explanation of what effect the change would have on pharmacies and its services.