Ten questions to ask about the Health and Social Care Bill

In July of last year, The King's Fund set out ten key questions to ask about the health White Paper. Now, as the Health and Social Care Bill is about to be published to enact the proposed reforms, we look ahead to see what key issues need to be resolved.


1. Will the authorisation process for consortia be flexible enough to ensure that they take on commissioning responsibilities only when they are able to do so?

We welcome the establishment of pathfinder consortia to take forward general practice commissioning. But if general practices are to be more successful than primary care trusts (PCTs) in undertaking commissioning, it will be important to balance the speed of implementation with the readiness of practices to take on their major new responsibilities. While some consortia will be able to assume their functions quickly, others may not be ready by April 2013, the date set for the full transfer of commissioning to consortia.

2. Will steps be taken to ensure that the NHS Commissioning Board really is the 'lean and expert' body described in the White Paper?

The establishment of the NHS Commissioning Board – at arm's length from the Department of Health – has the potential to reduce political micro-management of the NHS. This represents a major shift in NHS governance and could help to devolve power to frontline clinical teams and give greater autonomy to providers and commissioners. As the Board is established, its relationship with ministers needs to be clarified, as does its accountability for performance within the NHS. It will also be important that the Board does not expand its staff to the point where it becomes the Department of Health by another name.

3. Will the NHS Commissioning Board be required to work with consortia in the commissioning of primary medical care and to report annually on how consortia have discharged their responsibilities?

The NHS Commissioning Board will be responsible for the commissioning of primary medical care services, although it may delegate part of this responsibility to consortia. Experience shows that quality improvement in primary care is best undertaken at a local level based on a thorough understanding of the work of practices and the use of performance data to bring about improvements. The NHS Commissioning Board will not be able to take this task on alone because it will lack the expertise and be too remote from the provision of care on the ground.

4. Who will be responsible for local system leadership and where can consortia get support in commissioning specialist services that do not fall within the ambit of the NHS Commissioning Board?

There are some aspects of commissioning that individual consortia are unlikely to be able to undertake without support – for example, the reconfiguration of acute services across a county or a city, or the concentration of specialist services such as stroke, trauma and vascular surgery in fewer centres in order to deliver better outcomes. There is a need for 'local system leadership' to address these issues and to complement the expertise that consortia can bring to bear in commissioning other services. This is particularly the case in London, where there are major challenges in reducing duplication between hospitals.

Provider reform

5. Will the government support the Provider Development Agency in working with the most challenged NHS trusts to change service provision even at the risk of political unpopularity?

The proposals for provider reform are in many ways even more challenging than the ambitious plans for commissioning. Here at the Fund, we have always thought it highly unlikely that all NHS trusts can become foundation trusts by 2014 or that all existing foundation trusts will remain financially viable as NHS finances tighten. Establishing a Provider Development Agency to oversee provider reform is a step in the right direction, but it will need to act decisively to change service provision ahead of the new economic regulator taking on its full responsibilities.

6. Will the 'any willing provider' policy be implemented in a way that avoids fragmentation and supports efforts to improve the co-ordination of care?

The government wishes to support choice and competition by allowing any willing provider to deliver care to NHS patients. This could help to stimulate innovation and to develop new models of care, which in turn may help with the requirement to find up to £20 billion in efficiency savings by 2015. The benefits are likely to be felt in areas of planned care, where patients can use information about providers' performance to decide where to seek treatment. In the case of unplanned care, especially for people with complex needs, there is a risk that services could become more fragmented if more providers enter the market.

7. Will practical advice and support be made available to NHS organisations that wish to become employee-owned mutuals to make a reality of the stated aim of creating 'the largest and most vibrant social enterprise sector in the world'?

Provider reform includes support for new organisational forms including social enterprises and employee-owned mutuals as part of a government-wide programme to increase diversity in service provision. The previous government was equally enthusiastic about social enterprises and mutuals, but progress has been slow, not least because of concerns among NHS staff about pensions and job security. We welcome the emphasis on provider diversity and the exploration of these new organisational forms, and hope that more support will be given to NHS organisations wishing to become employee owned.


8. How will regulation work in the case of provider failure and what exit strategy will be used?

Previous attempts to apply market principles in the NHS have foundered on the weakness of regulation. While much is made of the argument that the innovation offered by new market entrants will help to drive improvements in performance, this will only happen if unsuccessful providers are allowed to fail and ultimately exit the market. Politicians need to have the courage of their convictions and accept failure is inevitable when providers compete for a limited budget.

9. Will the regulator adopt a nuanced approach and ensure that collaboration and integration are not harder to achieve?

Market regulation must help to promote collaboration, as well as competition, where appropriate. Ministers have put much more emphasis on the importance of expanding choice and competition than on the need for collaboration and integrated care. If the economic regulator acts as a competition commission for health care and fails to recognise the importance of providers working together to improve outcomes, this may work against the stated aims of the White Paper.

10. Will the government create a framework for the economic regulator and the NHS Commissioning Board that prevents price competition having adverse consequences for quality?

The market-based reforms developed by the previous government were founded on a national tariff that removed price as an issue in negotiation between providers and commissioners. Ministers have suggested recently that the prices in the national tariff may in future be seen as a maximum, with providers being allowedto deliver services at lower cost. International evidence has shown the risk that quality of care may suffer if providers compete on price.

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#293 jonathon tomlinson

The most vulnerable patients behave the least efficiently; missing appointments, greater treatment resistance and non-concordance, greater social determinants of health etc. Market forces with further disadvantage them by directing resources to more efficient providers. The inverse care law more crucial then ever after 40y.

#294 Bruce Gray
Heart of England FT

Ref. point 6: "The benefits are likely to be felt in areas of planned care, where patients can use information about providers’ performance to decide where to seek treatment."

Data, data, data. Will it be available, accurate, meaningful? And will pts be able to make sense and do comparisons with it. That's a lot of unknowns. Quality accounts are variable/sketchy now; will they improve?

#297 Rob Osborne

Although these are all great and relevant questions to ask about the Bill, they do all seem to have an NHS (and therefore Health) slant, surely there are questions you should be looking to ask about the impact on Social Care too.

#298 James Coleman

Who is answering these questions? and where are they based?

#300 Steve Turner

My question would be - how will staff be engaged in this process and genuinely encouraged to feel valued and to have their say?
The people who work for it are the NHS's greatest resource.

#301 Shirley Williams
Social work professional
Self employed in safeguarding arena

Who in these new consortia arrangements will have the interest/take responsibility for partnership working, particularly in relation to safeguarding children and adults?

#305 Guy Patterson
Regional Adviser

I would reiterate Rob Osborne's concern that the focus is too narrow, and i would go further and suggest that the questions are evidence of the fact that social care will be left to pick up the crumbs, and many of those who provide social care services on a voluntary basis lose what little funding they currently have.

#306 Mark Johnson
Director - TPP Law

After all the talk about creating a vibrant social enterprise sector in health, there is surprising little in the Bill to encourage this. There provisions about ensuring fair competition for services and powers for consortia to provide financial assistance, but nowhere is the "right to provide/ request" given statutory force in the way it has been in local government. A possible oversight or a deliberate policy?

#309 Tess Harris
Polycystic Kidney Disease Charity

I have yet to see any reference to helping patients cope with these reforms.

So far, the emphasis has been on the GPs and the rest of the NHS, especially regarding their future education and training needs.

But who will 'educate' the patients? /Who will help them understand the changes? We've only just worked out the old hierarchy.

Is the government planning a communication campaign to explain what all these reforms mean to patients? How much will that cost? After seeing the cash wasted on the inaccurate and repulsive NHS Choices website (written by journalists and amateurs), I worry that more money will be spent on vacuous posters etc telling us this is health nirvana and we renal patients will get kidney transplants sooner.

As someone who answers a charity helpline, what do I say to patients to explain GP's decisions regarding commissioning? 'Patient choice' is an oxymoron for renal patients, as dialysis choice is increasingly to do with convenience and not based on free market competition.

Some GPs decisions are already baffling and upsetting to PKD patients.

Moreover, to some of us patients, these reforms are just allowing GPs more ways to say 'No' to patients - possibly without the necessity to give explanations. Even more reason to distrust them if you have a chronic, incurable life-threatening condition.

And I remain unconvinced of the need for such massive reforms. I read the July White Paper and found only 33 references (some outdated) to support the reforms affecting a £100bn budget.

Where is the evidence-base, so beloved of the DH and politicians? Andrew Lansley apparently spent 6 years preparing his case - if so, I'd like to see details of the public and professional consultations that took place to support this upheaval.

If a PKD researcher presented such a flimsy paper for peer review, let alone democratic scrutiny, s/he would be treated with scorn.

#310 A. Barkshire
retired Director of PCT

Extremely limited questions and perspective- I am surprised that the Kings Fund is providing such limited analysis and insight. For example, there will be massive conflict of interest if commissioning of primary health care services ie management of the contracts with each GP practice is delegated to Consortia (that are supposed to be run by / led GPs) Clearly a National Board is too remote - so it would seem this is something that Andrew Lansley had not thought through. Who will look out for poorly performing doctors and take relevant action? It appears that Consortia decisions can be made entirely privately without input from patients, and with no requirement for information to be shared with the public. No public Board meetings or questions. So no public accountability. The role of Monitor to force competition seems very poorly understood / articulated in these questions. I could go on and on. Get your act together Kings Fund - you are certainly no longer the organisation you used to be.

#313 Mark Rickenbach
GP Trainer, Associate Dean, Professor Healthcare

What is the likely format of the skills network outlined in the recent white paper. It is to provide education and advice, oversee appraisals and support doctors in difficulty? Can it provide support for GP consortia? I am concerned about ensuring that systems to organise medical education remain firmly in place so that we can focus on improving the clinical pathways of care

#320 JJS Winn

Patient choice of provider will be limited by a patient's ability or willingness to travel. For the vast majority I strongly suspect that local provision will remain the reality outside of major conurbations.

And I am intrigued to know what evidence there is that GP consortia will manage public money better and for enhanced outcomes; I have to remain hopeful that if Pathfinder consortia prove less effective in this the whole reform concept will be stopped.

#322 Bill Power
Ex Manager

As a former NHS PCT Manager let me tell you that by handing PCT’s responsibility to Doctors will save huge management costs-how do I know this.

I was formerly a Manager in a PCT in Birmingham so I know all about the wastage and paper chase with the bureaucracy at first hand.The improvements to the NHS will be striking and the savings will be immense.

The chattering classes who are opposing this change and champagne socialists -Well they don't know what they are taking about.

It was the Last government) which created PCT’s and all the other Organisations in the Health Service(of which there are many)-so any savings will go towards continuing our first class health service.

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