Reaction: what they say about the health billBMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d413 (Published 20 January 2011) Cite this as: BMJ 2011;342:d413
The Health and Social Care Bill, presented to parliament by secretary of state Andrew Lansley on 19 January (see BMJ 2011;342:d418 doi 10.1136/bmj.d418), has been described variously in media as the “most radical pro-market shake up in its history” and “a natural continuation of structural reforms that have been running, at various speeds, for two decades.” Here, we round up reactions to the bill.
Chris Ham, chief executive of the King’s Fund, said: “GPs are well placed to understand the needs of their patients so giving them a leading role in commissioning services makes sense. By strengthening the link between clinical and financial decision making it could lead to improvements in patient care and could make services more efficient.
“But, while the government’s reforms have the potential to improve the NHS, they will be implemented against the backdrop of the biggest financial challenge in its history. Finding the £20bn (€24bn; $32bn) in efficiency savings needed to maintain services must be the overriding priority, so the very real risk that the speed and scale of the reforms could destabilise the NHS and undermine care must be actively managed.”
Royal College of General Practitioners
Clare Gerada, chair of the Royal College of GPs, said: “Depending on how the reforms are implemented, we must guard against fragmentation and unnecessary duplication within a health service that is run by a wide array of competing public, private, and voluntary sector providers, that delivers less choice and fewer services, reduces integration between primary and secondary care and increases bureaucratic costs.
“While we recognise the principle of patient choice—and know that many patients value being given access to information and choices about their healthcare—the government needs to strike a much fairer balance between the rights of the individual and the efficiency and effectiveness of the NHS as a whole, as well as taking the broader needs of society into account.
“The college is concerned that some of the types of choice outlined in the government’s proposals run a risk of destabilising the NHS and causing long-term harm to patient outcomes, particularly in cases of children with disabilities, those with multiple comorbidities and the frail and elderly.
“While the Government has sought to reassure us, we have yet to be presented with sufficient evidence to underpin these reassurances.”
Royal College of Physicians
Sir Richard Thompson, president of the Royal College of Physicians, said: “We support the shift towards a system that puts clinicians and patients in the driving seat and the emphasis on outcomes and quality. Whilst we welcome the broad provision in the bill to seek professional expertise, the RCP [Royal College of Physicians] is concerned that the bill does not require that specialists are at the heart of the commissioning process. The mandated involvement of secondary care specialists in commissioning is essential . . .
“The scale and pace of change—and the challenge of unprecedented efficiency savings—should not be underestimated. Neither should the risks if we get this wrong. We are also anxious to ensure that the system builds in effective safeguards to protect against service fragmentation. The fragmentation of services would have detrimental impacts on the very areas the reforms seek to improve: the quality of services, education and training, patient choice, efficiency and equity.”
Royal College of Psychiatrists
Laurence Mynors-Wallis, registrar of the Royal College of Psychiatrists, said: “While the college welcomes many aspects of the Bill, it is concerned—along with many others—about the pace of change.
“We are particularly concerned that in some areas the new structures will not have the skills or expertise to support mental health commissioning. We therefore believe, along with all the other medical royal colleges, that commissioning must involve a close working relationship between GPs and specialists. The college would be dismayed if psychiatrists were not closely involved with local consortia of GPs in the development of mental health services.
“There must continue to be an emphasis on the care of mental health patients with complex needs, who will need to access services provided by both health and social care. It is important that their care is not compromised by the need to provide good quality services for more common mental health disorders such as anxiety and depression—the needs of the many must not overwhelm the needs of the few.”
The Nuffield Trust
Jennifer Dixon, director of the Nuffield Trust, said: “Given the reforms over the past 20 years the government’s decision to devolve more responsibility to the front line is logical. However, this approach carries significant risks in today’s financial climate and needs to be managed very carefully.
“GP commissioning consortia will need considerable support if they are to manage public funds on such a large scale effectively, as well as succeed in moving care into the community when faced with the vested interests of powerful hospital providers. Research evidence from the UK and overseas tells us that they will take several years to develop properly, in particular in relation to being able to make a significant impact on hospital services.”
Royal College of Surgeons
John Black, president of the Royal College of Surgeons, said: “The RCS welcomes the opportunity for greater clinician involvement in designing healthcare services ... Strong, unmediated links and sharing of evidence at a local level between GPs and hospital consultants are going to be vital to commission specialist care for complicated conditions, especially for those illnesses where the best quality for patients can only be delivered on a regional basis. The legislation leaves the question of regional level commissioning unanswered with no intermediary structure put in place.
“Education and training of the next generation of surgeons relies on NHS hospitals seeing a mix of patients. If the move to ‘any willing provider’ led to simpler cases being hoovered up by new providers the costs of training new surgeons could soar and the stability of acute NHS services be compromised. All new providers must be mandated to allow access for training and to make sure that when surgeons are working for them they contribute data on their performance to national audits.”
Confederation of British Industry
John Cridland, director-general designate of the Confederation of British Industry, said:
“We support the Government’s plans to modernise the NHS, because this will lead to better services for patients, and ensure taxpayers’ money is spent wisely.
“Allowing the best provider to deliver healthcare services, whether they are a private company or a charity, will spur innovation and choice. But bidders must be able to compete for contracts on a level playing field.”
British Medical Association
Hamish Meldrum, chairman of council at the BMA, said: “Ploughing ahead with these changes as they stand, at such speed, at a time of huge financial pressures, and when NHS staff and experts have so many concerns, is a massive gamble.
“The BMA supports greater involvement of clinicians in planning and shaping NHS services, but the benefits that clinician-led commissioning can bring are threatened by other parts of the Bill. In particular, the legislation will allow competition to be forced on commissioners, even when they believe the best and most appropriate services can be provided by local hospitals.
“Forcing commissioners of care to tender contracts to any willing provider, including NHS providers, voluntary sector organisations and commercial companies, could destabilise local health economies and fragment care for patients. Adding price competition into the mix could also allow large commercial companies to enter the NHS market and chase the most profitable contracts, using their size to undercut on price, which could ultimately damage local services.”
Katherine Murphy, chief executive of the Patients Association, said, “‘No decision about me without me.’ That has been the Department of Health’s mantra for the last few months, and now with the Health and Social Care Bill before parliament it is time to see if they will live up to that promise.
“The Patients Association is deeply concerned by the lack of detail in the bill with regard to how the reforms will work. There are too many unanswered question and too many loose threads. Some aspects of GP commissioning have been explained, but many of those that were of deepest concern to patients are left vague. Will GPs spend too much time being managers and not enough time with their patients? How can we ensure that clinical decisions are made on the basis of what is best for the patient rather than what is best for the consortium’s bank balance?
“The government hopes that these changes will enable savings of over £5bn, but it is essential that these savings do not affect frontline services and patient safety. We have been told that there will be no frontline cuts, but we hear day after day on our helpline from patients and NHS staff who have reported that services are already being withdrawn. Physiotherapy, hernia operations, hysterectomies, and tonsillectomies have all been affected. The squeeze on NHS resources is beginning to bite, and there is no evidence that the health bill will change any of this.”
Nigel Edwards, acting chief executive of the NHS Confederation, said: “We support the objectives behind this legislation but there are huge risks and major uncertainties associated with it.
“The system is already geared up for change and we cannot afford for these reforms to fail —the public will not forgive us. The focus in parliament has to be on making this work on behalf of patients.
“A key issue in the bill is accountability. With central government loosening day to day control, we need to be sure who is going to get a grip when things go wrong.”
Karen Jennings, Unison head of health, said: “This Titanic health bill threatens to sink our NHS. The only survivors will be the private health companies that are circling like sharks, waiting to move in and make a killing. These changes are undemocratic, they were not in any party manifesto and no one has been given the chance to vote on them. The NHS is a service that many take for granted now, but will not be able to in the future. As more private companies pile in to grab their share of the £80bn in taxpayers’ money the NHS will change from a publicly run and accountable service, into a conglomerate of competing private companies outbidding the NHS for patients.”
Brendan Barber, general secretary of the Trades Union Congress, said: “The pace and scale of change will alter the NHS out of all recognition, and will mean large parts of the health service are opened up to private contractors, despite there being little, if any, evidence to suggest the private sector does things better.
“The public should rightly be concerned at what the reforms will mean for them and their families when they get sick—especially as none of what is being suggested was properly put to them in either the Conservative or the Liberal Democrat election manifestos.
“Ministers must listen to the staff who work in our hospitals, surgeries and clinics, and pull back from these costly, damaging and disruptive changes.”
NHS Support Federation
Paul Evans, director of the NHS Support Federation, said: “It is time for [health secretary Andrew] Lansley to come clean about the ideological aims of his plans and for his colleagues in Parliament to stop him from recklessly forcing though this change against the will of the NHS and the public. There is a real danger that the NHS will become just a logo, backed by a pot of public money but leave the delivery of services to non-NHS providers many of them doing it for profit. I don’t believe the public or NHS staff want this.”
Cite this as: BMJ 2011;342:d413