What are the reforms all about?
The Health and Social Care Bill 2011 gives GPs the responsibility to commission most secondary care health services, replacing the current commissioning structure of primary care trusts and strategic health authorities with GP consortia; gives Monitor (the regulatory body for foundation trusts) the role of encouraging more competition, allowing more services to be provided from outside the NHS; and transfers PCT’s responsibility for health improvement to local authorities. Although not explicit in the Bill, it also has implications for the way medical education and training is organised, and this is the subject of a separate Department of Health consultation, Developing the Healthcare Workforce.
Why is there so much opposition?
Doctors, nurses, NHS managers, health economists, patient groups and politicians have all expressed concern that introducing more competition will break up or destabilise NHS hospitals, as the easier-to-provide services will be cherry picked by private providers, leaving the NHS to deal with more complex and expensive care and threatening the viability of hospitals. This worry is compounded by the removal in the Bill of the duty of the Secretary of State to provide a comprehensive health service. The proposed new structures do not guarantee involvement of a breadth of clinicians beyond GPs; the structures for commissioning for rare conditions that require a critical mass of patients are unclear; there is no clear vision for how quality and service standards will be embedded into consortia’s commissioning practices; nor how patients will be involved in decision-making about their care, or how consortia will be transparent and accountable to the public. The future of medical education and training is uncertain, as the SHAs, the host bodies of the Deaneries, are abolished, but there is uncertainty about where their essential functions, like quality assurance of training and trainee management, will sit.
What are the alternatives?
The restructuring of medical education and training should be paused for two years to allow the NHS restructuring to bed in first. Competition should be only on quality of services, not price. The economic regulator, Monitor, should focus on promoting quality, integration and collaboration, not competition. Many, including the RCP, have called for GP consortia to include other relevant health professionals, in particular including hospital specialists to advise on commissioning at national and local level. The new bodies should be publicly accountable and transparent, with integrated patient involvement, and the NHS Commissioning Board should embed national clinical and service standards across the system, including integrated care pathways.
What happens now?
The government paused the Bill’s progress in Parliament to conduct a listening exercise on the Bill which ended on 31 May. A report from this exercise will be submitted to the prime minister in the next few weeks. The Royal College of Physicians submitted evidence, and like other health organisations, is locked into an intense round of lobbying meetings with Ministers, MPs, Lords, and civil servants, suggesting changes and improvements. We hope that they have not only listened, but are prepared to amend the Bill accordingly…
