Details

26.Oct.2010

The President of the Family Division has taken the rare step of issuing an ex parte “non-molestation” injunction against the son of an elderly couple over his alleged aggressive behaviour towards them.

In A Local Authority v DL & Ors [2010] EWHC 2675 (Fam), Mr and Mrs L are an elderly married couple aged 85 and 90 respectively. They live in a house with their son, DL, who is in his fifties. Mrs L is disabled and receives support by way of direct payments and twice daily visits from a care provider.

The local authority accepted that neither Mr nor Mrs L were incapable of managing their affairs, and both appear capable of deciding what their relationship with their son should be and whether he should continue living under the same roof.

The case arose because of the son’s alleged behaviour towards his parents. It was claimed that he has been aggressive and on occasions been physically violent.

The council had documented incidents going back to 2005. These include “physical assaults, verbal threats, controlling where and when his parents may move in the house, preventing them from leaving the house, and controlling who may visit them, including Mrs L’s carers”.

The judge said there had also been reports that the son was trying to coerce his father into transferring ownership of the house into his name, and had been applying pressure on the parents to have Mrs L moved to a care home against her wishes.

The council wanted to take steps to protect the parents from DL. It had considered and rejected (and this was met with Sir Nicholas' approval):

• Using the criminal law
• An application under the Mental Capacity Act 2005
• An application for an ASBO under the Crime and Disorder Act 1998
• An application under s.153A of the Housing Act 1996.

The local authority also acknowledged that neither of the parents lacked capacity to take proceedings on their own or each other’s behalf, and recognised that the mother in particular wanted to preserve her relationship with her son. Mrs L feared that if steps were taken to remove him, there was a risk that at worst he might commit suicide or at best she might not see him again. The council also recognised that the father would be unlikely to take steps against the mother’s wishes.

The council nevertheless considered that it owed the parents a duty to protect them from the son’s behaviour. It applied for an order restraining DL from acting unlawfully; it did not apply for an order excluding the son from the house.

It also decided to apply without notice to DL as it feared that an application on notice might provoke the violence it wanted to prevent, and because it would allow service in the “safest and most sensitive way possible”.

The local authority advanced two bases on which the judge could make the order: the inherent jurisdiction of the High Court to protect vulnerable adults; and s.222 of the Local Government Act 1972.

Sir Nicholas Wall stressed that he had heard no oral evidence and made no findings of fact. The judge said he was of the view that while the case before him involved an extension of the inherent jurisdiction and it could be possible to distinguish it from Re SA (Vulnerable Adult with capacity: Marriage) [2005] EWHC 2942 (Fam), [2006] 1 FLR 867, the Re SA case did provide a jurisdictional basis for the exercise of the inherent jurisdiction on the facts of the case.

The judge also said that s.222 of the 1972 Act “does arguably…..found jurisdiction for the type of injunctive relief claimed”. But Sir Nicholas added: “At the same time, it does not seem to me that s.222 adds greatly to the arguments advanced under the inherent jurisdiction.” He said both “stand or fall together”.

Sir Nicholas made an order including not only a Harbin v Masterman investigation by the Official Solicitor but also service on the defendants, liberty to apply and determination by a High Court judge of any subsequent on notice hearing.

“Whether, on detailed investigation the facts prove to be as the application plainly believes them; whether the jurisdiction on which I have found to exist (a) does indeed exist; (b) falls to be exercised; and (c)  if so on what terms – these are all matters which are open for debate on an inter partes hearing before a High Court judge on circuit.”

Details

25.Oct.2010

The government has set out the terms for its review of the controversial Vetting and Barring Scheme (VBS) as well as for an overhaul of the criminal records regime.

Under terms of reference laid down in Parliament last week, the review will look at the fundamental principles and objectives behind the VBS regime.

It will:

• Evaluate the scope of the scheme's coverage
• Examine the appropriate function, role and structures of relevant safeguarding bodies and appropriate governance arrangements, and
• Recommend what, if any, scheme is needed now, “taking into account how to raise awareness and understanding of risk and responsibility for safeguarding in society more generally”.

Sunita Mason, the government’s independent advisor for criminality information management, will meanwhile lead the review on criminal records.

She is to consider whether the disclosure of minor offences and police intelligence to prospective employers within the criminal records check should still form part of the process.

Home Office Minister Lynne Featherstone said the original vetting and barring scheme was not a proportionate response.

She said: “There should be a presumption that people wishing to work or volunteer with children and vulnerable adults are safe to do so unless it can be shown otherwise.

Featherstone added that the criminal records regime had developed piecemeal for years, and needed a revamp to strike a balance between protecting civil liberties and protecting the public.

Children and Families Minister Tim Loughton argued that the original VBS plans threatened to drive a wedge between children and well-meaning adults.

“Such individuals should be welcomed and encouraged as much as possible, unless it can be shown that children would not be safe in their care.”

The final recommendations in relation to the VBS are due to be published early in 2011.

Home Secretary Theresa May suspended the vetting and barring scheme in June, claiming that the original plans were draconian. She said she wanted to reduce the scope of the scheme to “common sense” levels.

Details

22.Oct.2010

Three London boroughs are considering a cost-cutting merger of every major service they offer, a move which could see the creation of a so-called “super-council”.

The Conservative-led councils of Hammersmith & Fulham, Westminster and Kensington & Chelsea are setting up working groups to look at combining children’s services, environmental services, adult social care and corporate services.

The groups are expected to make their recommendations in February 2011. Councillors at the authorities will then consult with staff and partners.

In a statement released today, the leaders of the three councils said: “Ensuring we can provide a high standard of local services in today’s tough economic climate means thinking differently about how we operate…we need to seriously examine new ways of working including sharing service provision with other local authorities to deliver more for less.”

The three authorities will retain their political identities, with elected councillors and leaders. Some service areas, such as core democratic services, are unlikely to be merged.

However, the leaders – Cllr Stephen Greenhalgh of Hammersmith & Fulham, Cllr Colin Barrow of Westminster and Cllr Merrick Cockell of Kensington & Chelsea – said they “won’t rule anything out at this stage”.

They added: “Our plans may be the first of their kind, but sharing of services in this way can no longer be viewed as a radical concept. It will soon become the norm for local authorities looking for innovative ways to keep costs down while delivering high quality front line services.”

With promises to “squeeze every penny and every pound,” there are fears that cuts to front-line job cuts are inevitable. Critics have claimed that the plans could lead to significant damage to local provision and the quality of services.

Cllr Greenhalgh said the leaders would “do everything humanly possible to maintain the services we have”. But he warned that “nobody should be under any illusions about the difficulty of the challenge ahead”.

Following this week’s Comprehensive Spending Review, Hammersmith & Fulham has estimated that it will need to save a further £65m, on top of £55m saved over the last four years. This is expected to be partially funded by around 700 job cuts.

Ed Archer

Details

20.Oct.2010

The Chancellor of the Exchequer, George Osborne, unveiled the Comprehensive Spending Review today.  Philip Hoult, Editor of Local Government Lawyer, selects some of the key outcomes for local authorities and related public sector organisations – and the lawyers who advise them.

Overall

• The government says the review involves “a settlement for local government that increases local authorities’ freedom to manage their budgets, but will require tough choices on how services are delivered within reduced allocations”
• Local government grant funding will be cut by 26%. Councils are to see a 7.1% annual fall in budgets
• There was confirmation that there will be an estimated 490,000 job losses in the public sector
• The Spending Review is said to be underpinned by “a radical programme of public service reform, changing the way services are delivered by redistributing power away from central government and enabling sustainable, long term improvements in services”
• Localisation of power and funding will be achieved by, amongst other things, removing the vast majority of ring-fencing around resources to local authorities and extending the use of personal budgets for service users
• There will also be increasing diversity of provision in public services “through further use of payment by results, removing barriers to greater independent provision, and supporting communities, citizens and volunteers to play a bigger role in shaping and providing services”

Adult social services

• The Spending Review “makes available sufficient resources for local authorities so that they do not need to reduce access to services, and can fund new approaches that improve outcomes for those receiving social care”
• The current Department of Health grant to local authorities for social care, the Personal Social Services Grant, will increase by £1bn in real terms by 2014/15. “To reduce administrative burdens and increase flexibility for local authorities, this grant will be merged into local government formula grant”
• The NHS is to set aside funding growing to £1bn by 2014/15 to fund new ways of providing services, including reablement services provided by the NHS. “This will help to break down the long-standing barriers between health and social care”
• The government is to look at setting proportions of appropriate services across the public sector that should be delivered by independent providers, such as the voluntary and community sectors and social and private enterprises. “This approach will be explored in adult social care, early years, community health services, pathology services, youth services, court and tribunal services and early intervention for the neediest families”
• The government is to take forward proposals to invest in mental health liaison services at police stations and courts to intervene at an early stage, diverting mentally ill offenders away from the justice system and into treatment
• There will be fundamental reforms to simplify the welfare system, “promoting work and personal responsibility through the new Universal Credit as well as providing enhanced support for those with the greatest barriers to employment through the Work Programme”

Children’s services

• There will be real terms increases of 0.1% in each year of the Spending Review for the 5 to 16s school budget
• A new fairness premium worth £7.2bn in total over the Spending Review period will be introduced to support the poorest. This includes an extension from 2012/13 to 15 hours per week of free early education and care to all disadvantaged two-year-old children, and a new premium worth £2.5bn targeted on the educational development of disadvantaged pupils
• The Department for Education will have £15.8bn of capital funding over the Spending Review period. The government will rebuild or refurbish more than 600 schools through the Building Schools for the Future and Academies programme. “The decision to end BSF will allow new capital to be focused on meeting demographic pressures and addressing maintenance needs”
• The government is to look at setting proportions of appropriate services across the public sector that should be delivered by independent providers, such as the voluntary and community sectors and social and private enterprises. “This approach will be explored in adult social care, early years, community health services, pathology services, youth services, court and tribunal services and early intervention for the neediest families”

Community Safety

• Police resource funding will be reduced by 14% in real terms by 2014/15
• The effectiveness of frontline policing is to be protected “by reviewing terms and conditions of service, and making efficiencies in IT, procurement and the back office to deliver savings”
• The introduction of directly elected police and crime commissioners will “ensure that police forces focus their resource on tackling the crime and anti-social behaviour which matters most to local communities”
• There will be a 13% real terms reduction to fire resource expenditure. “This will require the Fire and Rescue Service to modernise, increase efficiency and deliver workforce reform”
• Councils and their partners will have greater flexibility to work across boundaries in health, policing, worklessness and child poverty
• The government plans to reform the sentencing framework “so that it both punishes the guilty and rehabilitates offenders more effectively”. Proposals will include the use of tough community penalties where they are more effective than short prison sentences; using restorative justice; and paying private and voluntary providers by results for delivering reductions in reoffending.

Employment

• The estimated number of public sector job losses was confirmed at 490,000
• The state pension age will increase from 65 to 66 in 2020
• The findings of the interim Hutton report on public service pensions have been accepted. “The government will commit to continue with a form of defined benefit pension, and seek progressive changes to the level of employee contributions that will deliver an additional £1.8 billion of savings a year by 2014-15. The nature of the benefit and the precise level of progressive contributions will be determined once Lord Hutton’s final recommendations have been received”
• Public service workers will have new rights to form cooperatives

Governance and risk

• Local authorities are to be given a “universal power of competence” (note: there appears to be no detail in the Spending Review on whether this differs from a “general power of competence”)
• The government has promised significant devolution of financial control to councils, “by removing ring-fencing around all revenue grants except simplified schools grants and a new public health grant, the number of separate core grants simplified from over 90 to fewer than 10, and more than £4bn of grants rolled into formula grant”
• There will be funding in all four years of the Spending Review to enable local authorities to freeze their council tax in 2011/12
• The “important” flexibility of prudential borrowing is retained, “with a forecast that total capital expenditure by local authorities will fall by 30% by 2014/15”
• The government has selected the first community budgets in 16 local areas, to pool departmental budgets for families with complex needs, from 2011/12. “These will pool departmental budgets for local public service partnerships to work together more effectively, help improve outcomes, and reduce duplication and waste”. All places may be able to operate these approaches from 2013/14
• Councils and their partners will have greater flexibility to work across boundaries in health, policing, worklessness and child poverty
• The government will reduce spending on council tax benefit by 10% and localise it from 2013/14 while protecting the most vulnerable. “In addition, the government will consider providing greater flexibilities to local authorities to manage pressures on council tax from the same date”
• £200m is to be made available to councils in 2011/12 to accelerate reforms of local services
• There will be, as already announced, an end to the previous top-down performance framework for councils. Local authorities and partners will be able to cease reporting any of the 4,700 local area agreement targets
• Funding will be made available to support the Big Society including pilots for National Citizen Service
• A £100m transition fund will be set up to support those voluntary and community sector organisations most affected in the short-term by public spending reductions

Healthcare

• There will be real terms increases in overall NHS funding in each year to meet the government’s commitment on health spending, with total spending growing by 0.4% over the Spending Review period
• There will be an additional £1bn a year for social care through the NHS, as part of an overall £2bn a year of additional funding to support social care by 2014/15
• The government has promised continuing funding for priority hospital schemes
• Reforms to NHS already announced include: GPs being given power to commission patient care; abolition of PCTs and SHAs by 2013; ring-fencing of public health funding with a premium for tackling pockets of ill health and reducing health inequalities; encouragement of greater diversity and efficiency of providers, with patients able to use independent providers paid for by the NHS
• Councils and their partners will have greater flexibility to work across boundaries in health and child poverty

Housing

• Social housing is to be made “more responsive, flexible and fair”. Social landlords will be able to offer a growing proportion of new social tenants new intermediate rental contracts that are more flexible, at rent levels between current market and social rents. The terms of existing social tenancies and their rent levels are to remain unchanged
• The council housing financing system will be reformed “so local authorities have greater control over their own finances, and can reinvest to meet local housing need”
• Investment via the Decent Homes programme “will continue to improve the existing social housing stock”
• There will be continuing, “but more modest”, capital investment in social housing. Building of new social housing is to be cut by 74%
• The government insisted that its changes would allow the government to deliver up to 150,000 new affordable homes over the Spending Review period
• A New Homes Bonus is to be introduced to directly reward and incentivise local authorities and local communities to be supportive of housing growth, “equivalent to matching the additional council tax from every new home for each of the following six years”. The total regulatory burden on the house building industry is to be reduced
• There will be provision for the disabled facilities grant to rise with inflation. Reform of council housing finance system will “build in the resources needed to carry out future disabled housing adaptations required in the council housing stock”

Litigation and enforcement

• The sentencing framework will be reformed “so that it both punishes the guilty and rehabilitates offenders more effectively”. Proposals will include the use of tough community penalties where they are more effective than short prison sentences; using restorative justice; and paying private and voluntary providers by results for delivering reductions in reoffending
• The government is to take forward proposals to invest in mental health liaison services at police stations and courts to intervene at an early stage, diverting mentally ill offenders away from the justice system and into treatment
• The government is already consulting on the closure of 157 “under-utilised” courts, and “will reform the court system to provide a more efficient service, using mediation and alternatives to court where possible”. Court is to be seen as the last resort rather than the default option
• The Ministry of Justice budget will be reduced to £7bn by 2014/15. The department will reduce its back office and administration costs by 33%. Capital investment is to be focused on essential maintenance and on projects that produce sustainable savings. New IT and court projects are to be limited to essential capacity
• The government to consult on major reforms to the legal aid system to deliver access to justice at lower cost to the taxpayer. “This will involve taking tough choices about the types of cases that should receive public funding, and focusing on support on those who need it most”. Reforms will increase competition in the market and reform remuneration for providers
• The government will look at setting proportions of appropriate services across the public sector that should be delivered by independent providers, such as the voluntary and community sectors and social and private enterprises. “This approach will be explored in adult social care, early years, community health services, pathology services, youth services, court and tribunal services and early intervention for the neediest families”

Planning

• The government will increase housing supply by reforming the planning system so that it is more efficient, effective and supportive of economic development
• A New Homes Bonus is to be introduced to directly reward and incentivise local authorities and local communities to be supportive of housing growth, “equivalent to matching the additional council tax from every new home for each of the following six years”. The total regulatory burden on the house building industry to be reduced
• Further detail on tax increment financing and the future incentives and planning powers open to local authorities to support growth will be provided in a White Paper on local growth later this year
• The Localism Bill will ensure that the planning system both works for sustainable growth and is responsive to the needs of local communities. “As part of these wider reforms, there will be a new presumption in favour of sustainable development”
• The CRC Energy Efficiency scheme will be simplified. The first allowance sales for 2011/12 emissions will take place in 2012 rather than 2011. Revenues from sales totalling £1bn a year by 2014/15 will be used to support the public finances, including spending on the environment, rather than recycled to participants
• There will be £1bn of funding to capitalise a UK-wide Green Investment Bank
• The government has promised continued investment in flood and coastal erosion risk management, with £2bn spent during the Spending Review period.

Procurement

• The Cabinet Office will continue to work with the Treasury to drive improvement, cost savings and innovation across government through the Efficiency and Reform Group
• The government will pay and tender for more services by results rather than be the default provider, look to set proportions of specific services that should be delivered by non-state providers including voluntary groups; and introduce new rights for communities to run services, own assets and for public service workers to form cooperatives
• The approach of setting proportions of appropriate services to be delivered by independent providers “will be explored in adult social care, early years, community health services, pathology services, youth services, court and tribunal services and early intervention for the neediest families”
• Communities will be given due notice and the right to buy or run public assets and services that might otherwise close or face significant reductions
• The Office for Civil Society has been funded to provide support for the Big Society, which will include “encouraging volunteering, building the capacity of the voluntary and community sector, establishing community organisers and setting up a Community First Fund to support local and community organisations”. The Cabinet Office has been funded to pilot the National Citizen Service
• The effectiveness of frontline policing is to be protected “by reviewing terms and conditions of service, and making efficiencies in IT, procurement and the back office to deliver savings”
• Central government is to use its scale as effectively as possible in common areas of spending such as procurement, property and major contracts – addressing the findings of Sir Philip Green’s Review
• In some areas, the government’s approach to efficiency will be to mandate a single central process. In others departments will have to follow a specific set of steps or go through a tighter approval process.
• Key measures include: central mandation of commodity procurement, with centrally negotiated deals “available to local government as well”; stronger scrutiny processes for major projects to assure they will deliver on time and to budget; making better use of experts across Whitehall; and a more coordinated approach to supplier management to ensure government acts as a single client with key suppliers

Projects

• Further detail on tax increment financing and the future incentives and planning powers open to local authorities to support growth to be provided in a White Paper on local growth later this year.
• The £1.4bn Regional Growth Fund will support projects with significant potential for private sector economic growth and employment, supporting those areas and communities that are currently too dependent on the public sector. The White Paper on local enterprise partnerships will be published shortly
• The government will rebuild or refurbish more than 600 schools through the BSF and Academies programme. “The decision to end BSF will allow new capital to be focused on meeting demographic pressures and addressing maintenance needs”
• There is to be protection for high-value transport maintenance and investment, including over £10bn over the Spending Review period on road, regional and local transport schemes, including construction of the Mersey Gateway bridge; £14bn for Network Rail, including major improvements to the East and West Coast Main Lines; £6bn for upgrades and capital maintenance on the London Underground network; and funding to enable Crossrail to go ahead
• The government’s intention is to proceed with PFI projects “that will deliver sustained improvements in highways maintenance in Sheffield, Hounslow and the Isle of Wight and extend the Nottingham tram network with two new lines”. The government will be urgently working with the four local authorities to establish how these projects can be delivered affordably

Property and assets

• Communities will be given due notice and the right to buy or run public assets and services that might otherwise close or face significant reductions
• Further detail on tax increment financing and the future incentives and planning powers open to local authorities to support growth to be provided in a White Paper on local growth later this year
• There will be a new system of national property controls across the central civil and operational estate. “The government believes there could be substantial gains to be made from a more coordinated approach to property asset management in the public sector.” The Government Property Unit has been established and will as a first step set up property vehicles for the Central London and Bristol office estate from 2011/12
• The government will continue to look into the potential sale of public sector assets, including property holdings, “which could operate more sensibly and efficiently in, and with the private sector”

Transport

• There will be protection for “high-value transport maintenance and investment”, including over £10bn over the Spending Review period on road, regional and local transport schemes, including work on the A11, M4/M5, M1, Midland Metro, Tyne and Wear Metro and construction of the Mersey Gateway
• Other funding in the Department for Transport’s settlement: £14bn for Network Rail, including major improvements to the East and West Coast Main Lines; £6bn for upgrades and capital maintenance on the London Underground network; and funding to enable Crossrail to go ahead
• The government’s intention is to proceed with PFI projects “that will deliver sustained improvements in highways maintenance in Sheffield, Hounslow and the Isle of Wight and extend the Nottingham tram network with two new lines”. The government will be urgently working with the four local authorities to establish how these projects can be delivered affordably
• There will be protection of the statutory entitlement for concessionary bus travel
• Bus subsidies paid directly to operators are to be reduced by 20% to save £300m by 2014/15. “The government will also work with bus operators and local government to examine smarter ways of administering this subsidy”
• Local government resource grants are to be cut by 28%. The government will simplify the number of grants “to give local authorities more control and greater flexibility in how they spend this money”

Details

20.Oct.2010

A local authority is not entitled, when considering whether to provide accommodation for young asylum seekers leaving care at the age of 18, to take into account the possibility of support from the National Asylum Support Service, the Court of Appeal has ruled.

The case of SO, R (on the application of) v London Borough of Barking and Dagenham [2010] EWCA Civ 1011 involved the accommodation needs of an asylum seeker from Eritrea who was leaving care.

The local authority had formally terminated its support for SO in October 2009 on two grounds: first that further representations to the Home Secretary in pursuance of asylum were manifestly unfounded; and second that he was eligible for support from NASS under s.4 of the Immigration and Asylum Act 1999. The council did not raise the question of its power under s.23C of the Children Act 1989.

The appellant then challenged Barking and Dagenham’s decision. In the High Court, Calvert Smith J dismissed the claim for judicial review. He also agreed with the council that s.23C(4)(c) of the 1989 Act did not give it a power to provide accommodation.

Giving the lead judgement in the Court of Appeal, Lord Justice Tomlinson bemoaned the “impenetrable nature of the legislation” which was “far from clear”. However, he said that local authorities do indeed have a power under s.23C(4)(c).

The judge added that since the powers given to the Secretary of State under s.95 (and s.4) of the Immigration and Asylum Act are residual and cannot be exercised if the asylum seeker (or failed asylum seeker) is entitled to accommodation under some other provision, a local authority cannot take into account the possibility of support from NASS.

Lord Justice Tomlinson praised Barking and Dagenham for continuing to provide accommodation and a subsistence allowance to the applicant throughout the litigation.

The Court of Appeal ruling was welcomed by The Children's Society, which intervened in the case and argued that the provision of accommodation was intended as a crucial safety net to protect the welfare of young people leaving care.

The Society said children's rights campaigners had become increasingly worried about the plight of some care leavers, particularly in the light of many local authorities' planned spending cuts.

Bob Reitemeier, Chief Executive of The Children’s Society, said: "The Court of Appeal ruling has clarified the law and this will be especially important not just to the young people it directly affects but to all those working in children’s rights. It will help ensure that consistent decisions can be made concerning those young care leavers who are unable to secure suitable accommodation through the normal housing routes."

Details

19.Oct.2010

The acting chief executive of the NHS Confederation has said he is “deeply worried” about the impact cuts to local government budgets could have on the provision of social care, warning that this could cause serious problems for the NHS.

Nigel Edwards voiced concern at a growing trend for councils to only provide care for those in critical or substantial need.

“It seems inevitable that we will see a significant withdrawal of support from some of the most vulnerable people in our society - before long we could see a majority of councils only supplying services to those with the most critical of needs," he said.

“At a superficial level, this may ease pressure on the social care budget. But the needs of these vulnerable people and their families will not simply disappear - if needs are not met by social care, people will turn to the NHS.

“Some will present as emergencies in A&E departments and GP surgeries, others will find themselves trapped in hospital unable to get home, blocking the bed from someone else who badly needs it.  Everybody loses: the users of services, those who care for them, the taxpayer and the NHS. It’s a classic false economy.”

Edwards said decisions on the long-term funding of social care were desperately needed, but feared that nothing would happen “until we are well into this parliament”.

Arguing that there is a strong case for an interim solution, he added: “Local and central government need to urgently work together to consider how they can mitigate the impact of this spending squeeze on some of the most vulnerable people in society.”

Speaking more generally about the challenges faced by the NHS, Edwards said: “The country faces very serious financial issues and everybody has to play a part in finding the solution ­– for that to happen there must be a frank and honest debate about implication of the decisions being taken.

“The public need to go into this with their eyes wide open. The NHS may have some limited protection to its budget but it still faces a potent cocktail of financial pressures.”

Edwards said the NHS faced funding increases that – while protected – would not deal with growing demand, one of the biggest reorganisation’s in the service’s history, and a pre-existing need to find between £15-20bn of savings.

The NHS Confederation acting chief executive warned that cutting management costs was only a small part of the answer.

He said: “We are already on course to cut management costs by a hefty 45% – quite a task during a major transition. Even this drastic action will save less just £0.85bn of the £20bn we need to find. So I am afraid that there are no pain-free choices if we are going to make this happen.”