- Kieran Walshe, professor of health policy and management
The Health and Social Care Bill has now spent more than a year in parliament undergoing prolonged legislative scrutiny and some modification. During this time, opposition to it has hardened, and the coalition government’s NHS reforms now command little support from the health professions, healthcare organisations, think tanks, patient groups, the media, or the public.1 With many voices now calling for the bill to be withdrawn, it is worth giving serious consideration to what would happen if the government were to abandon it, and what the consequences would be for the NHS and for patients.
In anticipation of the reform legislation, the existing organisational structure of the NHS has already undergone substantial change. The 152 existing primary care trusts (PCTs) have been effectively wound up and replaced by about 50 PCT “clusters”—effectively, much larger PCTs. The 10 strategic health authorities have similarly been merged into four new larger ones. All, it is proposed, will become part of the new NHS Commissioning Board when it is established.2
About 260 clinical commissioning groups have been established in shadow form, and much effort has been expended on planning for them to take on responsibility for commissioning health services.3 Similarly, much work has been done to scope and plan the role and function of Monitor, the proposed new economic regulator, and to plan for the transfer of the public health function from PCTs to local authorities and a new national agency, called Public Health England.
Stopping the Health and Social Care Bill now would mean abandoning most of this preparatory work, on which thousands of civil servants and NHS managers have toiled for the past year or more. It would mean that work on the new structures—the NHS Commissioning Board, Monitor, and clinical commissioning groups—would halt, and the transitional structures that have been put in place would become permanent. But it would have little or no adverse effect on the actual business of the NHS—providing healthcare to patients—which has continued much as usual, despite the negative impact that the turmoil of the health reforms has started to have on NHS performance.4 More positively, stopping the bill now would have three clear benefits.
Firstly, it would put an end to the damaging period of prolonged organisational uncertainty in the NHS that started when the white paper was published 18 months ago, and will otherwise probably continue well into 2013 and beyond. Immediately, those working in the new clustered PCTs and strategic health authorities would know where they would be working in the future, and whether they had a job or not. These new PCTs and strategic health authorities already have management teams and boards in place that could get on with the job of running the NHS. At a local level, they could pick up and take forward much of the work that has been done by nascent clinical commissioning groups to engage general practitioners and others in commissioning. Veterans of past NHS reorganisations would argue that the value of structural change is much over-rated, and that the existing structures could prove just as fit for purpose as those envisaged in the bill.5
Secondly, it would allow NHS organisations to focus on what is the real and urgent problem for the NHS—improving efficiency and productivity, and sustaining performance in the face of years of future financial austerity. Efforts to do this so far have been disappointing,6 and the NHS reforms have been a huge distraction from the task. Making the 4% year on year efficiency savings that are needed requires real and painful service reconfiguration, and that demands consistent, painstaking, and dedicated attention from senior managers and leaders, who have, up to now, been spending far too much time on the details of the NHS reforms.
Thirdly, abandoning the bill would save a lot of money. The government claimed that the proposed NHS reforms would save at least £1.5bn (€1.79bn; $2.35bn) a year in reduced administrative costs,7 largely from abolishing PCTs and strategic health authorities, although the arithmetic in their impact assessment has been contested. However, most of those savings have already been made, through reductions in staff numbers and clustering of PCTs and strategic health authorities, and the current transitional structure is probably leaner and less costly than any the NHS has known in the past two decades. Going ahead with the bill means setting up the NHS Commissioning Board (with an annual running costs of £492m), 260 clinical commissioning groups (with an annual running costs of £1250m), and the new economic regulator, Monitor (with its anticipated annual running costs of £82m). Each of these new statutory organisations will have additional set-up costs—perhaps amounting to a one-off spend of £360m. If the bill were stopped now, it would save all those set-up costs, and at least £650m in annual running costs—just over £1bn in 2013.
Of course, dropping the Health and Social Care Bill would be politically painful and damaging for the government. However, it might be worth paying a short term political cost to avoid some of the longer term political consequences of the legislation and its implementation, if it is passed, which are likely to continue well beyond the next election.
The government could argue that, in the special economic circumstances of the day it makes sense to drop the bill, and that they have already made the substantial savings in NHS administrative costs that they promised. They might get some credit from the media and the public for listening and learning, but they would also neutralise an issue which has become increasingly politically toxic. A plan to accomplish much of their intended reform agenda—greater patient choice, more involvement of general practitioners in commissioning, and increased plurality and competition in healthcare provision—could be implemented using existing legislative provisions. The NHS could then get on with the serious business of delivering healthcare to patients while finding ways to do more with less.
Cite this as: BMJ 2012;344:e748
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.