Paradoxes in the debate about the Health and Social Care Bill

The Health and Social Care Bill has divided opinion. While it has been heralded as revolutionary by some commentators, others claim it is an evolution of the last government's reforms.

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the reforms are supposed to empower, yet Humana, a potential supplier of commissioning support to consortia, has withdrawn from the UK, presumably because they think the prospects of making money out of the NHS in the near future are bleak.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.

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#317 tony plumridge

My experience as chair of a PCT was that the doctors who are likely to lead this process are those that will most seek to exploit the system - the majority who work tirelessly for their patients will not wish, have the time, or be trained to manage the new systems.

#318 David Booth

The big risk is that these reforms will consume considerable organisational energy in trying to make sense of and adapt to what is yet another major change to the UK healthcare system - increasing uncertainty for those who work in the NHS and distracting focus from the clear and simple objectives of improving patient care, outcomes and cost-effectiveness.

#319 Ronald Fernee

This Bill is just another scheme to pettyfog the fact that the Government ultimately wants to cut services and funding, and to split the NHS up into little privitised chunks. Remember what happened to the railways? These people seem to never learn!

#329 Bryan Yates
Patient Safety
Mid Surrey Link

Control systems are essential to the efficient running of the proposed Comsortia proposals. Control was immediately recognised as a weak point in bringing together the various elements outlined in the July 2010 White Paper for Consortia commissioning.
Financial control will only contain excessive spending and profit taking if very tight Financial contracts are issued by the Department of Health and signed by the various recipents of Government money witin the new NHS System.

#330 George Farrelly
The Tredegar Practice

I am a GP in Tower Hamlets. The are many concerns for me with these so-called reforms. One is the proposal for people to be able to register with a GP anywhere in England. This may sound like an attractive idea, but to those who understand the ecology of primary care, it is filled with problems.

#331 Naomi Elton
Consultant in child & adolscent psychiatry

I am a child & adolescent psychiatrist. I am very concerned about the likely effects on patient care for patients in my specialty.

Firstly, and more generally, it seems clear that the re-organization itself will be very costly. There is little evidence that a re-organization along the lines proposed will render a system that would be more cost-effective than the status quo. The numbers of GP consortia will be far greater than the numbers of existing PCTs so it's hard to see how management costs within the envisaged system will be reduced. Most GPs will not have the skills or time to engage in commissioning, so will be forced to delegate commissioning to other organizations. In a competitive market, multinational companies may be the most successful contenders. If such organizations take on the commissioning, I believe that commercial interests will inevitably be a big influence over the process and its outcomes. There is little good evidence to allow us to believe that patient choice or more accurate assessments of the local health needs will be outcomes of the envisaged changes as the bill intends, and the opposite is in fact more likely.

A concern I have for children is that as the recent Kennedy Report makes clear, children’s services are in desperate need of integration. In their day to day work, practitioners must work together, and when they fail to do so, this is to the very great detriment of the patient. Proper co-operation between practitioners is unlikely to be accomplished by putting the provider organizations into a position in which commercial interests foster high levels of competition. It goes without saying that it will be the most economically disadvantaged children, young people and their families who will be worst provided for within the new system. Their cases are usually the most complex and will for competitive providers and commissioners be the least commercially attractive.

#402 Anne Palmer

From the Health and Social Care Bill

853. Under this Part of the Bill, the Secretary of State would have the power to make schemes to transfer staff or property, rights and liabilities from one body to another as a result of bodies being abolished or created by this Bill. Schemes might make transfers of staff or property to a range of bodies, including for example local authorities, commissioning consortia, the NHS Commissioning Board, any public authority providing health services or a qualifying company11 . (I’m sorry, but this just will not “do” at all. Far too ambiguous. “the Secretary of State would have the power to make schemes (what schemes?-some-thing that hasn’t been thought of yet?) to transfer staff or property? Which Staff? And supposed they do not want to go? Never have I come across such as this before and I thought some written points in the Labour Government was BAD!)

11 A qualifying company is a company wholly or partly owned by the Secretary of State and formed under section 223 of the National Health Service Act 2006, for the purpose of providing facilities or services to the NHS. Such a company could be used, for example, as an intermediate solution to hold Primary Care Trust property before it is transferred to either local authorities, providers or consortia. Section 223 is an existing provision and has been used by Secretary of State in the past to set up a number of companies to offer services to the NHS, such as NHS Professionals Limited, Bio Products Laboratory Limited and Community Health Partnerships Limited (the LIFT delivery company). (Read this through carefully)

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