Opposition to the Health and Social Care Bill: an Arab Spring for the NHS?

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The Royal College of Nursing's belated decision to express outright opposition to the Health and Social Care Bill has reignited the smouldering debate on NHS reform in England.

Positions in this debate have become increasingly polarised, notwithstanding concessions made by the government in response to the report of the Future Forum and concerns expressed in the House of Lords. The irony is of course, that many of the changes included in the Bill could proceed without legislation in the unlikely event that the Bill is dropped.

The government may be guilty of a major tactical error in deciding to enact its reforms through a lengthy and complex piece of legislation rather than through the evolutionary change we and others advocated, but many of the Bill's critics have undermined their case by making exaggerated claims that it heralds the end of the NHS as we know it. Their credibility is also weakened by the fact that some of them have made similar claims since the introduction of the internal market in the 1990s and yet the fundamental principles of the NHS remain intact. Patient choice and provider competition will become more important, but this does not amount to the wholesale privatisation of provision that some fear.

At The King's Fund we continue to argue that the reforms need to be assessed on their merits. In our view, competition could bring benefits in areas such as planned and elective hospital care, where many patients would welcome the opportunity to choose which hospital to use. We are also clear that in many services there are strong arguments for health care providers to work together: the care of older people and of people with long-term conditions are good examples. This is why we have argued for integrated care to be given a higher priority.

We see no inherent contradiction between competition and integration. The complexity of health care and the wide variety of patient needs mean that one approach to organising care and ensuring resources are used efficiently is unlikely to be sufficient. As so often in health reform, the challenge is to put the right mix of incentives and levers in place, and to ensure that bold plans for reform are supported by plans for implementation.

We have therefore moved on from high-level analyses of the government's plans – in which we clearly set out the risks inherent in them – into more detailed studies of the proposed regulatory regime and into how payment systems need to be reformed to support integrated care. We have also drawn on research evidence and international experience to analyse the challenges involved in using both competition and integration to improve performance.

In undertaking this work, we are acutely aware of the need to plot a path to reform that avoids the destabilising effects of frequent restructuring. This is an issue on which the government is especially vulnerable and where senior NHS leaders have done much to limit the potential damage of the radical organisational changes that were set in motion after the publication of the White Paper. Despite their efforts, major questions remain about how the newly established organisations, including the NHS Commissioning Board and clinical commissioning groups, will deal with complex service changes when strategic health authorities and primary care trusts are abolished, as we discussed in our recent paper on health care in London. This is a serious concern in view of the need to accelerate the process of hospital reconfiguration that is underway in many areas.

Our view is that by the next election it will be the government's record in maintaining the improvements in performance seen in the last decade that will be under the most intense scrutiny. The Prime Minister's personal commitment to keep waiting times low throughout this parliament reflects this. The allocation of extra funding to support the 18-week referral-to-treatment target and the four-hour target in A&E is further evidence that government attention is shifting to issues that really matter to patients.

In 2012 we shall continue to analyse the impact of funding pressures on services and patients through our quarterly monitoring reports, which provide updates on NHS performance through the use of key indicators and by seeking the views of NHS finance directors. We will also be returning to our analysis of the impact of funding pressures on local authorities – in particular on social care – and the implications for the NHS. This work will be complemented by an audit of how performance has changed since the election, including shifts in public attitudes to the NHS.

Recent surveys, including one by the Commonwealth Fund, have shown the NHS in a positive light, but there is no room for complacency. The political and policy challenge is to adopt an approach to reform that leads to further improvements in performance while minimising the serious risks inherent in major organisational change and the loss of experienced managers. This approach must engage frontline staff, for it is their actions and decisions that ultimately will bring about real improvements in patient care.

From this perspective, the main worry for the government in the RCN's stance is not that it represents a fatal blow to its cherished legislation but that leaders of the biggest group of clinicians working in the NHS have come out publicly against the reforms. The question now is will the medical royal colleges follow suit, thereby adding to the pressure on the government? If so, how will health ministers respond to what could become an NHS version of the Arab Spring?

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Comment date
25 January 2012
Prevention is better than cure (though probably less lucrative). A major focus of healthcare strategy and funding should be towards education in schools, including such subjects as the food industry and what not to do in the event of catching a cold (ie clogging up GP surgeries). I also agree with an earlier comment that a fraction of the NHS drugs budget could be usefully diverted to researching 'herbal' treatments. With regards to the NHS funding and resource crisis, I would suggest nominal fines for patients who miss appointments or who otherwise do not abide by the recommended treatment. Finally, I would consider linking certain large companies' tax obligations to the health costs of their product, eg. getting the tobacco industry to contribute towards the costs of COPD and various associated cancers, the sugar and edible oil industries to subsidise obesity-related illnesses etc.

celia davies

Comment date
23 January 2012
I look to the KF to carry out meticulous detailed work across a range of health policy areas, a trusted critical friend of the NHS - keeping the confidence of the Service and of policymakers of whatever political hue. And I admire that. But today I recommend your readers look at Alex Scott Samuel's letter to the Guardian on 21.1.12. Yes views have polarised. Yes the NHS will need all the help it can get whether this Bill goes though or not, And double yes to the monitoring reports the Fund has planned. But what about this big picture take? Chris, are you sure you have both feet on that tightrope right now?

Jennine Morgan

GP retired,
Comment date
22 January 2012
Surely we have to do something to contain costs of Health-care. We know funds are limited. We have to live within our means. I am convinced that the last government poured tax-payers money willinilly into Healthcare and everything else, without proper audit. Outcomes were not good enough considering the money spent. This is not a retrospective view but a view I took at the time based on observation. We have a pretty good Heatlhcare system in UK. but there are big gaps in some areas. The NHS is a monster and it is imperative that it is properly controlled, audited and evidence based.

John Kapp

SECTCo (www,sectco.org
Comment date
20 January 2012
Health inequalities arise because the rich can and do access complemenary care, so suffer long term conditions 18 years later, and die 9 years later than the poor, who cannot afford it. CCGs could make NICE-recommended complementary care (such as the Mindfulness Based Cognitive Therapy (MBCT) course free at the point of use, but opening up the market to third sector providers, to reduce the waiting time from its present 2,000 years. This should be funded out of the anti-depressant budget.

Prof Paul Camic

Research director, Dept of Applied Psychology,
Canterbury Christ Church University
Comment date
20 January 2012
I am not at all convinved that it is possible to develop high quality and efficient health care in the UK, when a state financed health care system is expected to compete with for-profit private health care within a capitalistic economy. It seems to be asking for the impossible. Competition in health care, per se, will not bring about lower cost. It may improve quality but the evidence for that is limited. In the US, where I was trained as a clinical psychologist, and where I had been a user of routine healthcare resources (in Boston and Chicago) for nearly 50 years, in my experience, it was the better resourced hospitals and clinics that had the better quality of health care delievery. They were not the least expensive but they were the best (e.g. Massachusetts General Hospital, Tufts New England Medical Center, University of Chicago Hospitals, Northwestern Memorial Hospital, to name but a few). The best health care in the US is most often delivered by private, non-profit medical institutions (not public nor for-profit private). The ethos, values, funding and organisation of these instituions are generally oriented toward clincians being able to do their jobs well and a quality of care that is high. It is not about one Chicago hospital, for example, being of good quality because it is competing with another hospital...or one GP competing with another, it is because the level of quality is better among some clinicians and institutions and that is what draws patients to them. Quality health care delivery is expected if not demanded (this does not mean that all US health care is of high quality, because it certainly is not). The focus of the debate, in my opinion, is not often enough about quality. Another related but different area is funding. Keeping health care 'free' at point of service means we are limiting income to health care organisations and GP practices. It also means we give card blanche to people who do not show up for their appointments, which costs millions of pounds per year. As Sweden has successfully done, by instituting a modest fee at point of service, we would reduce no show appointments significantly and for those who do come, added income would be raised for further development of quality health care.


Comment date
20 January 2012
this is what we have been shouting and screaming for all this time

they should have trimmed the PCTs and made them work under the leadership of the CCGs.There would have been more integration within the CCGs and better negotiations as the clinicians would be the managers employers

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