The government stands accused of privatisation even by the very clinicians the reforms are supposed to empower, yet Humana, a potential supplier of commissioning support to consortia, has withdrawn from the UK, presumably because they think the prospects of making money out of the NHS in the near future are bleak. Some have said the reforms are being implemented too quickly, not allowing enough time for all GP consortia to develop sufficiently to take over commissioning responsibilities. The Prime Minister, however, taking a lesson out of Tony Blair's book, was clear that the government wanted to act quickly.
There are other paradoxes and contradictions. While the talk, particularly by Liberal Democrats, is of devolution and localism, the Bill creates, in Monitor and the NHS Commissioning Board, two very powerful national bodies with wide-ranging powers to direct and instruct commissioners and providers. In contrast, the health and wellbeing boards within local authorities appear to have very few powers. And although local scrutiny powers are to be strengthened, their effectiveness will depend on whether local councillors have the information and expertise to ask the right questions.
Andrew Lansley has been clear about his intention to hand responsibility for the day-to-day running of the NHS to an independent body – hoping to distance politicians from local scandals and quieten the sound of bedpans in Whitehall. Yet the Bill gives the Secretary of State many reserve powers. As long as the NHS is funded from general taxation, there will have to be public accountability via the Secretary of State to parliament and the public accounts committee will continue to scrutinise whether public money is being spent wisely. And the Secretary of State will presumably be the person to whom local MPs and the public take their concerns when local services are closed.
Much of the Bill is dedicated to establishing a new economic regulator (Monitor) with powers to set prices, enforce competition and (with commissioners) ensure the continuity of 'designated' services. It will also be keeping a watchful eye on GPs to make sure their commissioning is fair and transparent. Ministers have given reassurance that the new system will still allow for integration of services. While there are provisions to allow consortia to pool budgets and a duty on the Board to 'encourage' consortia to work closely with local authorities, the main responsibility for promoting integration lies with the health and wellbeing boards. They are unlikely to prove a match for the might of Monitor.
The Bill, and the White Paper before it, was heralded by politicians as putting patients at the centre of the NHS. But it is unclear how their voice will be heard. There are no public representatives in the governance of consortia – instead they have a duty to promote patient involvement. And while Monitor will have to promote and protect the interests of patients neither its governance nor functions make it clear how it will do this.
So where does the truth lie in all this? The Bill is vast in scope and sets out a flexible framework of rules and structures. It is therefore difficult to predict where this will lead; the government itself has not been clear about its vision. The sweeping powers being given to Monitor suggest the government believes the NHS can be regulated like utilities or telecoms. Yet unlike these industries it is the commissioner and not the customer who pays for services. There is therefore likely to be conflict, and the mechanisms for resolving this are weak. There is little evidence to suggest that a system of independent regulation is any better at resolving the difficult trade-offs between access, quality, efficiency and cost that have to made in a publicly funded health system. I fear that there are difficult times ahead for the NHS and for the politicians pushing through these radical and untested reforms.
- Listen to Anna's initial comments on the Health and Social Care Bill
- This blog also appeared on the Guardian health care network