The case for evolution
Some major strands of the proposed reforms take forward policies that were already in progress under the previous government. For example, giving GP practices a leading role in deciding which health services to secure for their local population has already been implemented in some areas through the voluntary 'practice-based commissioning' scheme (although GPs get to work with only 'virtual' rather than real budgets). Giving all NHS trusts greater freedoms by requiring that they achieve foundation trust status was also underway – the last government's original target was for 2008, although this was eventually put back to 2014, the date the coalition has now adopted.
The Labour government had also introduced choice and competition into NHS-funded hospital care: all patients referred to hospital for non-urgent treatment can currently choose between any NHS or private sector provider that is registered with the Care Quality Commission, willing to provide care at NHS prices and holds a contract with the NHS. In other words, an 'any willing/qualified provider' model.
There is also already an independent authority to oversee competition in the health service: the Co-operation and Competition Panel (CPP). The Panel investigates potential breaches of co-operation and competition rules laid out by the Department of Health, including the requirement to support patient choice and to commission services in a transparent way from 'providers who are best placed to deliver the needs of their patients and population'.
So do the coalition government's reforms represent more of the same? Not quite.
The case for revolution
The proposed reforms involve a radical shift in budgetary responsibility with the majority of NHS funds shifting from primary care trusts (PCTs), who are closely supervised by strategic health authorities (SHAs) and the Department of Health, to GP commissioning consortia. A new NHS Commissioning Board will oversee the consortia, as well as taking on responsibility for commissioning specialised services. The Board's role is intended to be 'quasi regulatory' rather than managerial. The local and regional management of the service is being completely removed through the abolition of PCTs and SHAs. The leadership of public health is to be transferred from the NHS to local authorities. And perhaps most controversially, competition between health service providers is being pushed with increased vigour.
Under the reforms, Monitor would take on a new role as an economic regulator, and would be charged with 'promoting competition' in the service. Up to now, the Department of Health has in practice played this role, setting NHS prices and making decisions on the basis of CCP recommendations. In future, Monitor will be responsible (together with the NHS Commissioning Board) for setting prices and, in cases where an organisation is in breach of its licence, will have the power to issue fines and to direct the organisation to take particular actions. This is a completely different type of body to the CCP, which has no enforcement powers of its own.
These major changes to the service are being driven forward simultaneously, and with speed. The Secretary of State published the blueprint for the reforms within two months of taking his post.
Is it a myth or a fact?
Myth. If the reforms are implemented, within the next two years SHAs and PCTs would be abolished, GP consortia would be made statutorily responsible for the majority of the NHS budget, local authorities would be responsible for public health and two major new national bodies – the new Monitor and the NHS Commissioning Body – would take responsibility from the Department of Health to lead the system.
So while key aspects of the reforms may not be completely new, some are, and their scale and the speed with which they are planned to be introduced makes them more revolutionary than evolutionary.