Britain’s Greatest Institution: The NHS

The new Queen Elizabeth Hospital Birmingham is a shining example of what can be achieved with investment in the NHS

The NHS, surely, whatever your political persuasion, or Party, must be considered one of Britain’s finest achievements. Created in 1948 from the recommendations of the Beveridge Report, the NHS has stood as a pinnacle of what can be achieved by a Government that is willing to act. It must be the greatest single achievement of the Labour Party, and that it still exists today, almost 65 years after its creation is testament to the Service.

I have a very close personal link to the NHS. My Grandmother worked under Nye Bevan  in the Department of Health. Both of my parents work as Consultants in the NHS. Almost half of my extended family work as healthcare professionals in the NHS. When I was born7 months prematurely (and was so small that I was slightly bigger than the palm of your hand), in 1991, my life was saved by the NHS.

The NHS is therefore very important to me personally.

Politically, it is also very, very significant. The NHS survived 18 years of Conservative Government in the ’80s and ’90s. The Blair Government transformed the Service, leaving office with the shortest waiting times ever and the highest satisfaction rate ever, according to the British Social Attitudes Survey. The Conservative-Liberal Democrat Government has recognised that there needs to be in the NHS. Not only do budgets need to be cut significantly if the Government’s deficit reduction plan is to be met, but there also needs to be a change in the way in which services are commissioned; dealing with an ageing population that is in need of more personal care outside of hospitals will probably be the most significant challenge that the NHS faces.

The Health and Social Care Bill

Andrew Lansley set out the three aims of the Bill as being:

  • More power for GPs.
  • Open the NHS to private sector providers to increase innovation and choice in the NHS.
  • Increasing NHS productivity.

Sir David Nicholson, the current Chief Executive of the NHS has set out the “Nicholson Challenge”, to find £20bn in savings over the next three years. This will require a saving of around 20% of the NHS budget of £100bn. The Government will cut the cost of NHS management and administration by 33%, and capital spending in the NHS will fall by 15% over the next 4 years. The 2010 PBR promised a small increase in total NHS spending. This is going ahead, but is dependant on inflation. As inflation rises above what was predicted in 2010, the real terms increase becomes smaller. The effect of this is that NHS budgets will be flat over the next four years.

The bill allows this to be done by creating the National Commissioning Board to allocate resources within the NHS, allowing GPs to commission services through Clinical Commissioning Groups (“CCGs”), expanding the remit of Monitor to include responsibility for economic competition in the NHS, and to abolish Strategic Health Authorities and Primary Care Trusts to allow management costs to be cut by 33%.

The practical effect

The effect of the bill, organisationally speaking is huge. The pre 2010 structure of the NHS looks like this (Link here) :

We are now to replace the “bureaucracy” of this set up with new structures; the Department of Health (DH), the National Commissioning Board, four regional (Strategic) authorities, 50 Commissioning support units (don’t call them PCTs), nearly three hundred Clinical Commissioning Groups, and 15 Clinical Senates. That is 6 layers and five interfaces with half the staff. In practice: DH interfaces with the NCB who deals with 4 regional authorities who in turn interface 50 CSUs who interface 300 CCGs interfacing 15 Senates.

That looks something like this:

Pretty complicated? I thought so too. Rather than decentralising power, vast swathes of power held on a local level by members of Primary Care Trusts (who are unelected) will now be transferred to national and regional QUANGOs.

The Controversy

The H&SC Bill is the most controversial piece of legislation to be bought forward by the Coalition (so far!). The most contentious areas are:

  1. That the Secretary of State will no longer have a duty to promote a comprehensive health service. Under the NHS Act 2006, and the preceding 1977 and 1946 Acts, the Secretary of State had a duty to “promote a comprehensive health service”. Under the present Bill, that the SoS has a different role, that they “must for that purpose provide or secure the provision of services in accordance with this Act“. This means that NHS staff will no longer be fulfilling a duty owed to the Secretary of State.
  2. “Any willing provider“. Under the H&SC Bill any willing provider will be in a position to provide services to the NHS. Under the last Labour Government, the NHS was the “Preferred Provider”, i.e. that services would remain in the public sector unless the private sector could show additional benefit or value for money. The new phrase used in the Bill is “Any qualified provider”. Those providers will therefore be in a position to take up NHS contracts.
  3. The role of Monitor. Under Labour, the role of Monitor was to promote, support, and evaluate the role of Foundation Trusts. Under the new Bill, Monitor would become a economic regulator responsible for promoting competition in the NHS, and ensuring that the private sector is allowed to bid for NHS contracts and the the public sector does not operate restrictively.
  4. Choice and Competition. The NHS “internal market” under New Labour was successful in providing choice for patients by creating Personal Health Budgets that were aimed at people with long term illnesses. This allowed them to develop their own package of care in collaboration with their GP and other clinicians. There is little role for competition however, in acute services where there is usually only one ambulance service and one hospital in an area.
  5. Exposing the NHS to European Union competition law. Under the EU Procurment Directive 2004/18 incorporated into UK law in the Public Contracts Regulation 2006 services for the NHS are not subject to the full range of procedures set out in EU Law. It remains to be seen whether the Bill in fixing national tariffs for treatment could be considered to allow the NHS to act in an anti competitive manner.
  6. “49%” – NHS Hospitals will be able to take on up to 49% of their work as private work, in stark comparison to the 2% under Labour. This is one of the most concerning aspects of the Bill.

These are the aspects of the Bill that could be the most dangerous to the NHS. I find it highly unlikely that the Health and Social Care Bill we be dropped completely. The Prime Minister is politically tied to the Bill. If it were dropped, a huge amount of Parliamentary time would have been wasted. It is likely that there will be major concessions on the Bill, and that Andrew Lansley will be quietly sacked as soon as the political situation allows. He has failed to communicate the message behind the Bill, and will probably end up paying for it with his career.

Drop the Bill? I don’t think so.

I do not think that the Bill should be dropped. The NHS would be in a completely horrendous position – it should be amended. The  “Clusters”, the transitional structures between PCTs and SHAs and the new CCGs are already being formed; in some areas CCGs are already formed and in some areas they are in operation as pilot schemes. The National Commisioning Board, that will go on to commission dental services, services for the Armed Forces, prison health services, high security mental health services and GP services is already in existence. Strategic Health Authorities will be abolished in almost exactly one years time. From April 2012 the “any qualified provider” aspect to the Bill will begin, and from October this year the NCB will run the NHS and Monitor will begin its new economic role.

The significant difference between the new Government and the last is the opening up of provision of NHS services to new providers. A greater role for GPs will be carved out; However, GPs have always been private contractors rather than NHS employees. That has been the case since 1948. The “profit” motive has always existed in the NHS, and there has always been a rationing of care in the NHS. That will not change.

The single biggest change of the Health and Social Care Bill was to open the NHS up to new providers, and to create a much more open market. Ironically, this could have been achieved without a new Act of Parliament and instead through delegated legislation. The NHS will remain as a health service that is universal, and it will remain free at the point of use. Most people who work for and provide services to the NHS will be motivated by profit, but as I set out above this has been the case since 1948. Patients will probably receive the same treatment and standard of service that they receive now, and these changes will mostly unnoticed by the man on the street. The archetypal Mondeo Man and Worcester Woman will notice little change.

The real thing that concerns me with the Government’s approach to the NHS is that they will be spending £3.4bn on reforms that show little sign of being more efficient in the long term. In the short term, there will be disruption that will affect performance. Setting a flat budget for the NHS for the next four years is the most dangerous thing that the Government is doing. 3.5% of the NHS Budget could be saved by not implementing these reforms. We will find ourselves with an NHS that is in the same position as 1997 – starved of cash, and it will be up to the next Labour Government to restore the NHS to its 2010 position.

UPDATE: We now know that there will be a health summit held in Downing Street – Only groups that are in favour of the existing Bill are going to be present. The BMA, the RCGPs, the RCN and other groups have all be excluded. I had hoped that the Government would work with those groups that were willing to listen to make this bill a better bill, and to develop a new framework for the NHS with more GP involvement. It now appears that the Prime Minister is unwilling to make any further concessions because politically he is wedded to the Bill.

This Government has no serious political direction in my view, beyond deficit reduction. There is “no money” for them to spend on ambitious new projects. Reforms, like these reforms are therefore going to be  the big achievements of this Government. As Tim Montgomerie has pointed out, even Conservative Cabinet Ministers are opposed to the existing Bill. Senior Liberal Democrats are opposed to the Bill. Senior Labour politicians are opposed to the Bill. There is political support for the Bill, but a heavy price is being paid in goodwill by the Government for continuing with it. If they are unwilling to seriously negotiate with the relevant interested parties and insist on continuing with this piece of legislation then the Bill should be opposed – Having GPs be  more involved in the commissioning of services is important. Being politically reckless and uninterested in the views of the medical professions are possibly the worst thing that this Government could do.

Health and Social Care Bill: Opposition Grows

I thought that it might be useful to collate some of the strongly worded opposition to the NHS Health and Social Care Bill. The opposition is widespread and includes professional groups, bodies that represent GPs (The very people who will be “empowered” (?) by the BIll, patients groups, and political groups inside and outside of the Coalition.

Letter to The Guardian, 7th February 2012. Sent on behalf of the Royal College of Nursing, The British Medical Association, the Royal College of Midwives and the Chartered Society of Physiotherapy:

We are the representative and professional bodies representing the majority of doctors, nurses, midwives and physiotherapy staff in theNHS. For months our members have been telling us about the chaotic way the reforms are being implemented on the ground, before the legislation has even been passed (Report, 7 February). It has been an unnecessary distraction when the NHS should be focusing on a far more important issue: finding the £20bn in efficiency savings it needs to make at a time when demand is increasing. We are concerned that the bill will mean we end up with a service where it is harder for patients to receive joined-up care. Eleventh-hour tinkering in the form of amendments is not enough; we call on the government to do the sensible thing – withdraw the bill and work with clinicians to bring stability back to the NHS.

The ill-advised bill enters its Lords report stage today. We call upon peers to vote against it.


Signed by: Dr Peter Carter Chief executive and general secretary, Royal College of Nursing, Dr Hamish Meldrum Chairman, BMA Council, Professor Cathy Warwick General secretary, Royal College of MidwivesDr Helena Johnson Chair, Chartered Society of Physiotherapy

Professor Lindsey Davies, President of the Faculty of Public Health (93% of the Faculty’s Members are opposed to the Health and Social Care Bill)  said:

We are now calling on the government to withdraw the bill in its entirety, because it would be in the best interests of everyone’s health.

Our 3,300 members – experts in planning and providing for people’s health – have been closely involved in trying to make the government’s proposed reforms work since they were first introduced. Based on our members’ expert views, it has become increasingly clear that the bill will lead to a disorganised NHS with increased health inequalities, more bureaucracy and wasted public funds.

The bill will increase health inequalities because there is the real danger that vulnerable groups like homeless people will not be included when health services are being planned. Clinical commissioning groups and service providers will be able to pick and choose what procedures they perform and which services they put in place.”

Unless the bill is withdrawn, FPH’s concern is that the NHS will lack the strategic leadership needed to deliver an effective and integrated service. There are major concerns about how emergency planning, screening and immunisation services will work. The bill does not make it clear what costs the NHS will be expected to cover if private providers go bankrupt.

Professor Davies continued: “We also face increasing costs for health services as the private sector will need to make a profit out of commissioning and running NHS services. This will use more taxpayer’s money that could be used for patient care. At a time when the NHS needs to save £20 billion, this is an unaffordable and unnecessary burden on the NHS.

Like our members, we make decisions based on the best available evidence, and we have a clear mandate from them to take this position. We do not do this lightly. We will continue to do all we can to take make sure this bill is fit for purpose.

Over 1,000 GPs wrote to The Independent in October last year calling for the bill to be dropped:

Because it is universal and comprehensive, and publicly accountable, and because clinical decisions are made without regard for financial gain, the NHS is rightly regarded all over the world as the benchmark for fairness and equality in healthcare provision.

The transfer of services to private, profit-making companies will result in a loss of public accountability and a damaging focus instead on low-risk areas that are financially profitable. A confused patchwork of competing providers will deliver a fragmented and inequitable service, and any reliance on personal health budgets or insurance policies will increase inequality.

Because there will be a financial incentive for providing treatment, patients will be over-treated, the potential costs of which are limitless. The possibility of the commissioning role being outsourced to the private sector is also of deep concern.

In forcing through this ill-conceived Bill, without an electoral mandate and against the objections of healthcare professionals, the Government is also ignoring overwhelming evidence that healthcare markets are inefficient and expensive to administer.

The public has been misled by claims that no major reorganisation of the NHS would be undertaken, by repeated denials that what is happening represents privatisation, and by suggestions that the Bill enjoys the support of the medical profession. We do not accept that “things have already gone too far”. The enactment of some of the Bill’s proposals has been premature and possibly unlawful, but some of its most damaging aspects may still be mitigated. We believe that on moral, clinical and economic grounds, the Health and Social Care Bill must be rejected.

This gem, from the Tory Reform Group (Although they have since said this is not official TRG policy):

Mr Lansley seems like a man clinging to a time-bomb that only he cannot hear ticking. The Government urgently needs to look at what he is trying to do and accept that it needs drastic, perhaps total, reconsideration.

Is politics truly the art of the possible? What is certainly impossible is ploughing on without confidence. This is the situation in which Andrew Lansley now finds himself, where self-confidence is no match for the lack of confidence held other people.

That we need urgently to consider what this Health Bill is doing is obvious. In all likelihood that means starting all over again. Moreover, it is clear to me that the current Health Secretary is not the man to preside over this process.

For the good of the NHS, Andrew Lansley must admit defeat and head to the backbenches.

I am not opposed to the whole Health and Social Care Bill. The NHS needs reform, and some aspects of the Bill are encouraging. Much of the Bill remains dangerous, however, despite the 1,000s of amendments that the Government has tabled and the “Listening Exercise” that has been undertaken.

I hope to write over the weekend on the NHS reforms, and how the Bill can be made, to take the TRG’s metaphor, safe.

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