MPs raise fears over government’s lack of plans for failures in NHS reformsBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2683 (Published 26 April 2011) Cite this as: BMJ 2011;342:d2683
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Parliamentary scrutiny of the Health and Social care Bill is
inadequate. The PAC report highlights some issues but does not seem to
appreciate the context in which the future NHS becomes a 'tooth' and
'claw' market with winners and losers, profits derived from the NHS
'health' budget, a bonus culture for private companies and the loss of the
sense that the NHS exists for us and our families when we are ill. It is
not meant to be a source of tax payers money for private greed.
Our government through the Secretary of State for Health will no
longer have a duty to provide comprehensive health care for the
population. Small groups of GPs are to determine what health services
their (often relatively small) populations 'need'. If there is no central
definition of what the NHS should provide only local determination then a
postcode lottery of health care will be inevitable and the level of
services the NHS provides will shrink.
We all understand that this Bill follows in the direction of travel
set by Margaret Thatcher's 'Working for Patients' document in the 1990's
and Labour's invitation to the private sector to 'cherry pick' elective
care at the beginning of the last decade. But it is not too late for us
to demand a change in direction and scrap this Bill. This should become
the 'Poll Tax' moment for this government.
Wales and Scotland manage their health servies without the intrusion
of the market. So should England.
Competing interests: No competing interests
Yesterday's 'National Health Service Landscape Review' report from
the Commons Public Accounts Committee (PAC)(1) makes some damning
criticisms of Andrew Lansley's deeply flawed Health and Social Care Bill
But the fact that even the PAC report fails to address a large number
of important issues in the Bill also exposes the shallowness of
parliamentary scrutiny of this large, complex and many-layered piece of
legislation - and the inadequacy of the Committee stage of the Bill in
addressing many of the Bill's proposals.
Strikingly absent from the report is any reference to the role or
accountability of the Secretary of State for the continued provision of
health services, indicating that even while apparently addressing issues
of accountability, the PAC has also remained oblivious to the significant
changes in Clause 1 Part 1 of the Bill, as Allyson Pollock and David Price
have pointed out in detail(3).
The report appears to accept without question the concept that
Foundation Trusts are "directly accountable to Parliament," even though
MPs raising questions in the Commons on their local Foundation Trusts are
not answered by Ministers, but referred instead to the Trust Chair(4).
The absence of any serious accountability to Parliament has been
tragically underlined by the disastrous case of the Mid Staffordshire
Hospitals Foundation Trust: given the scale of this collapse of care, it
is patently obvious that Parliament is in no position to scrutinise the
activities of hundreds of Foundation Trusts across England, as the
financial constraints upon them become more and more onerous.
The PAC, preoccupied as it is with accountability upwards to
Parliament, draws no attention to the massively reduced level of local
accountability of GP consortia, the NHS Commissioning Board and Health and
Wellbeing Boards, which, unlike NHS Trusts, PCTs and SHAs are not required
to meet in public, or publish board papers and minutes.
The PAC also ignores the clear wording of the Bill, which
deliberately avoids requiring these bodies to "consult" locally on changes
at local level: instead they are simply required to "engage" - "whether by
being consulted or provided with information or in other ways"(5).
The PAC report quotes one pathfinder consortium GP clearly stating
that while his consortium was required to "engage" with the local Health
and Wellbeing Board, it was "not accountable to it."(6)
On financial pressures, the PAC raises concerns for the continuity of
local services where Foundation Trusts fail: but it does not address two
other areas of major concern for local access to services.
The first is that gaps in services can arise even where Trusts take
steps to ensure they do not collapse. Monitor has on more than one
occasion stressed its view that Foundation Trusts should ensure their
financial viability by focusing on services which can deliver a surplus,
and therefore by implication pulling out of services which do not(7).
The Bill offers no mechanism to ensure that a full range of services
is accessible to each local population, and this duty on the Secretary of
State would be repealed by Clause 1 Part 1 of the Bill.
On the contrary, the new system, correctly described by the PAC as a
"highly devolved, market-based model" would allow "any qualified provider"
approved by Monitor to compete to provide services in area they choose,
regardless of the economic impact this could have on struggling Foundation
Trusts. GP Commissioners would have no say over which private companies
or social enterprises would be added to the list by Monitor, whose primary
brief would be to maximise competition(8).
The second concern is that GP consortia would be taking over from
Primary Care Trusts, many of which in the pursuit of "efficiency savings"
have drawn up lengthening lists of "low priority" treatments which will no
longer be routinely covered by the NHS - including hip and knee
replacements, painkilling injections, IVF and many more(9). There is
nothing in the Bill that requires consortia to address gaps opened up by
such cutbacks in NHS provision, which will leave patients in many areas
confronting a brutal choice of paying for private treatment or going
In this context it is also significant that the PAC has not
investigated the impact of Mr Lansley's proposal in the Bill to remove the
strict limit on the proportion of Foundation Trust income that can be
raised through private medicine(10).
At a time of unprecedented contraction of real terms NHS resources,
to open up the option of generating unlimited additional income from
private patients seems almost certain to lead Foundation Trusts to
prioritise the expansion of private services above NHS patients.
This means that some Foundations will be using assets and resources
funded by the taxpayer to deliver commercial services to a national and
international market, while NHS patients, for whom the Trusts will receive
a steadily declining tariff payments, take a back seat.
Almost four months after the publication of the Bill, and nine months
after the 'Liberating the NHS' White Paper, few of these issues have been
discussed in the media, or, quite obviously, in Parliament, where the
relevant clauses have been nodded through by MPs who appear oblivious to
the wording of the Bill and its implications.
Yet all of them are very serious issues for patients, the taxpaying
public and the entire population who depend for their health care on the
If the PAC and Parliamentary committees are not asking these
questions, who will? And if the current "pause is not opening up some more
focused debate on what's wrong with the Bill, what is it for?
Or will the Bill simply be pushed through in a haze of public
ignorance and misinformation?
3 Pollock AM, Price D How the secretary of state for health proposes to
abolish the NHS in England, April 9 2011, BMJ 2011;342:d1695
4 As set out in a written statement by Health Secretary John Reid on March
30 2004, HC Deb, 11 October 2004, c4WS,
5. Health and Social Care Bill 2011, 14P(2), page 30
6. PAC report Section 1 page 2.
7. Timmins N 'Hospitals told to focus on profit centres', Financial Times,
12 March 2007.
8. Health and Social Care Bill 2011, 52, page 62
9. Smith R, Malone J 'Patients denied treatment as NHS makes cutbacks,
Telegraph can disclose', Daily Telegraph December 17 2010
10. Health and Social Care Bill 2011, 150, page 128
Competing interests: No competing interests