Implementation of the Health and Social Care Act

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2090 (Published 03 April 2013) Cite this as: BMJ 2013;346:f2090
  1. Nigel Edwards, senior fellow, leadership development and health policy
  1. 1Kings Fund, London W1G 0AN, UK
  1. n.edwards{at}kingsfund.org.uk

Dogged by financial pressures, role uncertainty, and gaps in leadership

The reforms that come into place after implementation of the Health and Social Care Act on 1 April represent the largest set of changes the NHS in England has seen since its formation. The pre-election promise notwithstanding, there have been two huge top down reorganisations—in the NHS and in public health. A vast amount of time and money has been spent on reorganisation and redundancies. Even if the NHS were in a robust financial position this would be a major concern.

The first striking feature is the number of organisations that are new or that have substantially redefined roles. There are 211 clinical commissioning groups (CCGs), 27 area teams, 23 clinical support units, 12 clinical senates, 13 local education and training boards, and 152 health and wellbeing boards. Few of these exactly match any previous jurisdictions and the talk of restructuring further has already begun. The national Commissioning Board (now renamed NHS England), Trust Development Authority, Public Health England, HealthWatch, Health Education England, and academic health science networks are all new. In addition, local authorities will take responsibility for health and wellbeing boards and public health, including sexual health. Monitor and the Care Quality Commission have had their responsibilities redefined, and the Office of Fair Trading and the Competition Commission take on new responsibilities for market regulation.

There is much uncertainty about the relations between these new organisations and the rules of engagement and accountability. Responsibility for commissioning has been fragmented, and in some cases CCGs will be accountable for outcomes that will be commissioned by other bodies. Although this will provide an impetus for more collaborative working, such approaches take time to develop and depend on having the time to build relationships. This will be difficult in the many places that have vacancies: even the NHS Commissioning Board has two director level vacancies.

Several areas require large scale change that has been led by regional authorities in the past. Because these no longer exist, either CCGs will quickly need to learn to collaborate or the regional offices of the NHS Commissioning Board will need to expand into this power vacuum and in doing so will reassert traditional hierarchies. In some cases there will be stasis, and change will be driven by providers themselves or by invoking the failure regime—the process used for the first time recently in response to longstanding financial problems in south east London.

The rules of the new system are still being written. For example, guidance on safeguarding children has been issued less than two weeks before the start of the new system. Rules relating to procurement and competition (section 75) remain contentious and confusing, with reassuring messages from government being contradicted by experts just days before they come into effect. Some CCGs are unclear about exactly what resources they have because money and control have been clawed back as the NHS Commissioning Board has redefined its scope, particularly in the area of specialist commissioning (vascular surgery and cancer, for example).

Trusts that have not yet achieved foundation trust status will probably experience pressure to change, merge, or otherwise accelerate their progress. Whether this is possible is doubtful, and mergers are increasingly being questioned by the competition authorities because of their poor record. The act brings new powers for Monitor to use a failure regime, and it already seems to be preparing to spend a large amount of money to bring this to bear on several distressed foundation trusts. This is compounded by the problem of key leadership roles not being filled.

Relatively little attention has been paid to the transfer of public health responsibilities to local government, which will be trying to incorporate these services at a time when it is also under unprecedented pressure. There is concern about whether local authorities will protect the budget, whether posts can be filled, and whether smaller authorities can sustain the infrastructure needed to deliver appropriate public health services.

There are, however, reasons to be positive. It seems that CCGs are bringing a new perspective to their role. Creative and productive conversations are taking place, although there are questions about the level of engagement by general practitioners.1 Health and wellbeing boards working with CCGs offer the prospect of new and positive approaches.

Even the most charitable would admit that NHS structures are now in an incoherent mess, and that the process that produced this mess was close to disastrous. Even now it is not clear how the reforms will improve the service delivered by the NHS, and the Health Select Committee has found that the pressure to improve efficiencies and reduce costs is cause for profound concern.2 Although the Department of Health continues to assert that the reforms are the solution to the NHS’s problems, it offers little more than assertion and pious hopes. Integration is seen by many as an important part of the solution to many of the challenges facing the NHS, but the new rules on competition and procurement, and the fragmentation of commissioning, work against this.3 The promise of liberation of the NHS through reduced central control seems to be slipping away. Time that could have been better spent on tackling the serious outstanding challenges is consumed by reorganisation.

The NHS is good at making flawed arrangements work. The question is whether it has been so badly disrupted by the current reforms that it will no longer be able to do this effectively. Was this the intention all along? Strong and visionary leadership is usually the answer to this type of problem, but this time the lack of such leadership is part of the problem.


Cite this as: BMJ 2013;346:f2090


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.

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