Editorials

What will the Health and Social Care Bill mean for the NHS in England?

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e2159 (Published 20 March 2012) Cite this as: BMJ 2012;344:e2159
  1. Chris Ham, chief executive
  1. 1King’s Fund, London W1G 0AN, UK
  1. c.ham{at}kingsfund.org.uk

Implementation will be as important as legislation in determining its impact

To summarise the contents of the Health and Social Care Bill in a BMJ editorial is akin to paraphrasing War and Peace on Twitter (box). The provisions of the original bill, already long and comprehensive, have been made even more complex after about 50 days of parliamentary debate. Some 2000 amendments have been made to the bill in response to the work of the Future Forum and the concerns of peers.1 2

The Health and Social Care Bill explained

Main legislative changes
  • Primary care trusts and strategic health authorities will be abolished as part of a radical structural reorganisation, with new health and wellbeing boards being established to improve integration between NHS and local authority services

  • Clinical commissioning groups will take over commissioning from primary care trusts and will work with the new NHS Commissioning Board in doing so

  • A new regulator, Monitor, will be established to regulate providers of NHS services in the interests of patients and prevent anticompetitive behaviour

  • The voice of patients will be strengthened through the setting up of a new national body, HealthWatch, and local HealthWatch organisations

  • A new body, Public Health England, will lead on public health at the national level, and local authorities will do so at a local level

Key amendments
  • New duties to promote integrated care have been placed on key bodies including the NHS Commissioning Board, Monitor, and clinical commissioning groups

  • GP consortiums have been renamed clinical commissioning groups and the original deadline for establishing them by April 2013 has been relaxed—they will now take on their new responsibilities only when they are authorised to do so

  • Several changes have been made to widen clinical involvement in commissioning, with clinical commissioning group governance arrangements also strengthened and a requirement added for them to publish a members’ register of interests to meet concerns about conflicts of interest

  • The original duty on Monitor to “promote competition” has been deleted, amendments have been made to rule out competition on price, and other safeguards have been added to reduce the emphasis on competition

  • Changes have been made to make it clear that the secretary of state retains ministerial accountability to parliament for the provision of the health service

  • New duties were added to emphasise the need to promote research within the NHS and strengthen requirements to promote education and training

Critics’ concerns
  • Despite the amendments made, the emphasis on competition will lead to greater privatisation of services and fragmentation of the NHS

  • Radical restructuring of the NHS will be a major distraction for clinicians and managers at a time when it faces the biggest financial challenge in its history

The eventual legislation, expected to reach the statute book imminently, resembles a house that has been modified and extended by successive owners. The government has been forced into making alterations in response to widespread concerns about the bill’s impact, notwithstanding reassurances that the basic principles of the NHS will remain intact. A large number of regulations will be laid before parliament shortly to amplify the bill’s provisions, and these will add to the complexity of the changes and increase uncertainty about their impact.

As with any rebuilding project, there is debate about whether the bill will help to strengthen the NHS or undermine its very foundations. Critics have argued that the legislation heralds the beginning of the end of the commitment to provide universal comprehensive health services that are largely free at the point of use.3 Ministers have emphasised that this is not their intention, and that their plans simply build on the reforms of previous administrations, with the aim of enabling the NHS to meet the challenges that lie ahead.

The principal purpose of the reforms, as Andrew Lansley has recently restated, is to extend choice and competition.4 This commitment derives from views that were first articulated when he was secretary of state in opposition, in which he drew on the Thatcher government’s experience of privatising the former public utilities to set out seven principles to guide public service reform.5 6 The provenance of the reforms in the privatisations that occurred in the 1980s may have encouraged critics who claim that the bill heralds the end of the NHS.

The bill creates a new economic regulator, Monitor, which is charged with ensuring that the health sector acts in the interests of patients and prevents anticompetitive behaviour. Monitor will license providers of care and identify at an early stage if a provider is at risk—for example, because of financial problems. Under the government’s plans, all NHS providers are expected to become foundation trusts by 2014, and the policy of any qualified provider is intended to make it easier for private and third sector organisations to enter the market.

In conjunction with the new NHS Commissioning Board, Monitor will be responsible for regulating prices through a national tariff, and it will work with commissioners to ensure continuity of services in the event of provider failure. A new rules based regime to deal with providers in difficulty will be introduced to enable exit from the market where necessary. Monitor will exercise its powers as the regulator alongside the Competition Commission and the Office of Fair Trading within the framework of European competition law.

The commissioning of services is undergoing radical change with the abolition of strategic health authorities and primary care trusts in 2013. They will be replaced by the NHS Commissioning Board and around 200 clinical commissioning groups. These groups will take control of 60% of the NHS budget and will enable general practitioners, with the support of other clinicians and managers, to decide how best to meet the needs of the populations they serve.

Public health is also experiencing seismic changes. At a national level, Public Health England will be established to work across government on health improvement, while local authorities will take charge of public health responsibilities at a local level. Funding for public health will be transferred from the NHS to local authorities in line with these changes, with the expectation that local authorities will work closely with NHS organisations in discharging their new duties.

During its passage through parliament, the bill was amended to include commitments to promote integration alongside competition. Health and wellbeing boards will have a potentially important part to play here, especially in promoting integration between local authorities and NHS organisations. GPs could also help to make a reality of integrated care, both as commissioners and as providers, thereby allaying concerns about too much emphasis being put on competition.

As the dust settles in parliament and attention turns towards implementation, it is important to keep in mind the gap between policy intent and what happens in practice. Experience of NHS reform over many years underlines the challenges that face politicians of all parties in converting bold aspirations into action. The inertia built into existing ways of working acts as a powerful brake on the ambitions of even the most radical reformers and should not be underestimated.

The role of private sector providers is a case in point. These providers continue to make only a small contribution to the treatment of NHS patients because of the reluctance of many commissioners to open up the market, notwithstanding the efforts of successive governments to promote choice and competition. Critics who predict the privatisation of NHS provision exaggerate the importance of legislation almost as much as they neglect the impact of implementation.

Ministers could have avoided many of the difficulties that they have experienced by adapting the arrangements they inherited rather than promoting the longest and most complex piece of legislation in the history of the NHS. An evolutionary approach to reform that focused on those areas of care in need of further improvement would have been more appropriate and proportionate, and it would not have provoked the same degree of opposition from the very groups whose enthusiastic support is needed to ensure effective implementation.7

Such an approach would also have enabled NHS leaders to concentrate on finding efficiency savings and improving quality and outcomes without the distraction of a major top down restructuring. GPs will be expected to play a prominent role in dealing with these challenges through clinical commissioning groups, but it remains to be seen whether most groups will be ready to take on their responsibilities from 2013.

With rebuilding well advanced even before the bill is on the statute book, the task now is to ensure the work is completed on time and to plan, rather than harking back to what might have been. The occupants of the remodelled NHS will wait anxiously to see whether those who constructed it were visionary architects capable of creating a lasting legacy or cowboy builders whose workmanship failed to match the promises made in their glossy brochures. Patients will share their anxieties.

Notes

Cite this as: BMJ 2012;344:e2159

Footnotes

  • Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References