Health and Social Care Bill 2011
Encyclopedia
The Health and Social Care Bill 2011 is proposed health care
reform legislation introduced in the House of Commons
on 19 January 2011. If passed, the Bill would be the most extensive reorganisation of the structure of the National Health Service in England
to date. It proposes to abolish NHS primary care trust
s (PCTs) and Strategic Health Authorities
(SHAs). Thereafter, £60 to £80 billion of "commissioning", or health care funds, would be transferred from the abolished PCTs to several hundred "clinical commissioning groups", partly run by the general practitioners (GPs) in England.
The proposals are primarily the result of policies of the Coalition Secretary of State for Health
, Andrew Lansley
. Writing in the BMJ
, Clive Peedell (co-chairman of the NHS Consultants' Association and a consultant clinical oncologist) compared the policies with academic analyses of privatisation and found "evidence that privatisation is an inevitable consequence of many of the policies contained in the Health and Social Care Bill." Lansley says that claims that the government is attempting to privatise the NHS are "ludicrous scaremongering".
The proposals contained in the Bill are some of the coalition government's most controversial. This is partly because they were not discussed during the 2010 general election campaign and were not contained in the 20 May 2010 Conservative – Liberal Democrat coalition agreement
, which stated that the government would "stop the top-down reorganisations of the NHS that have got in the way of patient care". Within two months of the election a white paper
was published, outlining what the Daily Telegraph called the "biggest revolution in the NHS since its foundation". In April 2011 the government announced a "listening exercise", halting the Bill's legislative progress until after the May local elections
. The "listening exercise" finished by the end of that month. The Bill is presently undergoing scrutiny in the House of Lords
.
, which declared an intention to "stop the top-down reorganisations of the NHS that have got in the way of patient care". However, within two months a white paper outlined what the Daily Telegraph called the "biggest revolution in the NHS since its foundation". The white paper, Equity and Excellence: Liberating the NHS, was followed in December 2010 by an implementation plan in the form of Liberating the NHS: legislative framework and next steps. The bill was introduced into the House of Commons on 19 January 2011 and received its second reading, a vote to approve the general principles of the Bill, by 321-235, a majority of 86, on 31 January 2011.
s (PCTs) and Strategic Health Authorities
(SHAs) will be abolished, with projected redundancy costs of £1 billion for around 21,000 staff. £60 to £80 billion worth of commissioning will be transferred from PCTs to several hundred clinical commissioning groups, partly run by GPs.
When the white paper was presented to Parliament, the Secretary of State for Health Andrew Lansley told MPs of three key principles:
The white paper set out the following timetable. By April 2012 it proposed to:
The Bill foresees all NHS trusts becoming, or being amalgamated into, foundation trust
s. The Bill also abolishes the existing cap on trusts' income from non-NHS sources, which in most cases was previously set at a relatively low single-digit percentage.
Under the Bill's provisions the new commissioning system would be expected to be in place by April 2013, by which time SHAs and PCTs would be abolished.
The Bill has been analysed by Stephen Cragg of Doughty Street Chambers, on behalf of the 38 Degrees campaign, who concluded that "Effectively, the duty to provide a national health service would be lost if the Bill becomes law, and would be replaced by a duty on an unknown number of commissioning consortia with only a duty to make or arrange provision for that section of the population for which it is responsible." It replaces a “duty to provide” with a “Duty to promote”. .
' rank-and-file and the British Medical Association
, the government announced a "listening exercise" with critics. On 4 April 2011, the Government announced a "pause" in the progress of the Bill to allow the government to 'listen, reflect and improve' the proposals.
The Prime Minister
, David Cameron
, has said that "the status quo is not an option" and many within his and Nick Clegg
's coalition have said that certain aspects of the Bill, such as the formation of clinical commissioning groups, are not only not open for discussion, but are also already too far along the path to completion to be stopped now. Cameron has insisted that the Bill is part of his "Big Society
" agenda and that it will not alter the fundamental principles of the NHS.
Part of the "listening exercise" saw the creation on 6 April 2011 of the "NHS Future Forum". The Forum, according to Private Eye
, "brings together 43 hand-picked individuals, many of whom are known as supporters of Lansley's approach". At the same time, David Cameron set up a separate panel to advise him on the reforms; members of this panel include Lord Crisp
(NHS chief executive 2000-2006), Bill Moyes (a former head of Monitor
), and the head of global health systems at McKinsey
, as well as Mark Britnell
, the head of health policy at KPMG
. Six months previously Britnell had told a conference of private healthcare executives that "In future, the NHS will be a state insurance provider not a state deliverer," and emphasised the role of Lansley's reforms in making this possible: "The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years." KPMG issued a press statement on behalf of Britnell on 16 May 2011 stating
In June 2011 Cameron announced that the original deadline of 2013 would no longer be part of the reforms. There will also be changes to the Bill to make clear that the main duty of the health regulator, Monitor, will be to promote the interests of patients rather than promoting competition.
The Future Forum report suggested that any organisation that treats NHS patients, including independent hospitals, should be forced to hold meetings in public and publish minutes. It also wants the establishment of a Citizens’ Panel to report on how easy it is to choose services, while patients would be given a right to challenge poor treatment. The original Bill sought to abolish two tiers of management and hand power to new bodies led by GPs, called commissioning consortia, to buy £60 billion a year in treatment. Professor Steve Field, a GP who chaired the forum, said many of the fears the public and medical profession had about the Health and Social Care Bill had been "justified" as it contained "insufficient safeguards" against private companies exploiting the NHS.
supports the bill, declaring that "Allowing the best provider to deliver healthcare services, whether they are a private company or a charity, will spur innovation and choice."
In May 2011, a number of doctors from GP consortia wrote a letter to the Daily Telegraph in which they expressed their support for the bill, calling its plans "a natural conclusion of the GP commissioning role that began with fundholding in the 1990s and, more recently, of the previous government's agenda of GP polysystems and pratice-based commissioning". On 14 May 2011, The Guardian
published an article reporting that the GP appointed to head the NHS "listening exercise" has unilaterally condemned the bill. The article says that Steve Field has "dismissed" the plans "as unworkable" and that these statements were "provisional conclusions that could fatally undermine the plans". The Royal College of General Practitioners
(RCGP) has also denounced the bill.
The Royal College of Physicians
and Royal College of Surgeons have welcomed in principle the idea of medical professionals determining the direction of NHS services, but they question the Bill's implementation of the principle, particularly in regard to the approach of making GP consortia the primary commissioning deciders, and also in regard to requiring competition. The British Medical Association
has said similarly. Neither of these organisations supports the bill.
In February 2011 David Bennett
, newly appointed Chair of Monitor
, said the NHS could become like other privatised utilities, so that Monitor would potentially be a regulator like Ofcom
, Ofgem and Ofwat: "We, in the UK, have done this in other sectors before. We did it in gas, we did it in power, we did it in telecoms […] We've done it in rail, we've done it in water, so there's actually 20 years of experience in taking monopolistic, monolithic markets and providers and exposing them to economic regulation." The House of Commons Select Committee on Health condemned the comparison as not "accurate or helpful."
has said that "Forcing commissioners of care to tender contracts to any willing provider, including ... 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."
Layla Jader, a public health physician, said in the early months of 2011 that "The NHS needs evolution not revolution – these reforms are very threatening to the future of the NHS. If they go through, our children will look back and say how could you allow this to happen?" And Barry Miller, an anaesthetist from Bolton
, added: "The potential to do phenomenal damage is profound. I haven't seen any evidence these proposals will improve healthcare in the long-term."
s the direct overseers of NHS funds, rather than having those funds channelled through neighbourhood- and region-based Primary Care Trusts, as is currently done.
There are concerns about fragmentation of the NHS and a loss of coordination and planning. The Royal College of General Practitioners
said it was "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." Similarly, the Royal College of Physicians
said that "Whilst we welcome the broad provision in the bill to seek professional expertise, the RCP is concerned that the bill does not require that specialists are at the heart of the commissioning process." The Royal College of Psychiatrists
said it "would be dismayed if psychiatrists were not closely involved with local consortia of GPs in the development of mental health services." The Royal College of Surgeons said that "the legislation leaves the question of regional level commissioning unanswered with no intermediary structure put in place." And there are concerns about management expertise, particularly by looking at the US. The BMJ
wrote that
The House of Commons health committee has suggested the government let experts other than the consortia GPs and their direct allies get involved in the running of the consortia, including hospital doctors, public health chiefs, social care staff, and councillors. That idea has received some wider support and the government has agreed to give it consideration. Those close to Health Secretary Andrew Lansley have said, however, that Lansley is concerned adding too many people to consortia decision-making risks making the consortia too unwieldy." In 2010 the same committee had gone so far as to declare that "if reliable figures for the costs of commissioning prove that it is uneconomic and if it does not begin to improve soon, after 20 years of costly failure, the purchaser/provider split may need to be abolished."
, have argued that "At a national level, it is difficult to see who, if anyone, will be in charge of the NHS. There will be five key national bodies: the Department of Health, the National Institute for Health and Clinical Excellence, the Care Quality Commission, the NHS Commissioning Board, and the economic regulator Monitor. Although the remit of each is set out in legislation, it is not clear how these national bodies will interact or how they will provide coordinated and consistent governance of the NHS."
In addition, GP consortia under this system restructuring would be privately-run businesses, meeting in private, which risks damaging accountability instead of increasing it. "Ministers have argued that they will be forced to produce accessible annual accounts and will have to answer freedom of information requests." Primary Care Trusts are public bodies with public meetings, and thus have no such accountability grey-area problems.
said that "the very real risk that the speed and scale of the reforms could destabilise the NHS and undermine care must be actively managed."
The BMJ
said in January 2011 that "The bill promises that all general practices will be part of consortiums by April 2012, yet it took six years for 56% of general practices to become fundholders after the introduction of the internal market. Nearly seven years after the first NHS trust was granted foundation status, there are still more than half to go—within two years. And there’s more. The replacement for the 10 strategic health authorities—the NHS Commissioning Board—needs to be fully operational by next April. By then, GP consortiums should have developed relationships with local authorities, which will assume ultimate responsibility for public health via their new health and wellbeing boards, working alongside Public Health England, a completely new entity." The BMA believes such targets to be either wholly impossible or, at best, able to be done only in a very roughshod manner, which could in turn have very serious on-the-ground consequences to NHS functioning.
opposes the bill, and held its first emergency meeting in 19 years, which asked the government to withdraw the bill and reconsider the reforms, although a motion of no confidence
in Andrew Lansley by the BMA failed. A later motion of no confidence in Lansley by attendees at the Royal College of Nursing
Conference in 2011, however, succeeded, with 96% voting in favour of the motion, and several speeches thereafter condemning Lansley threefold: the Health and Social Care Bill 2011 as-written; Lansley's decision not to address the entire Conference with a speech, but instead to hold a separate meeting with 40 Conference attendees in a separate space (taken as an insult to nurses, and leading to accusations of 'gutlessness'); and the current separate "efficiency savings" measures being undertaken across the NHS
and those actions' material impact on frontline medical services, especially as contrasted with several prominent officials, including NHS leaders and Lansley himself, repeatedly assuring that NHS frontline services are 'protected' at all times regardless of these "savings" measures.
, and the trade union
Unite
. 38 Degrees' petition against the reforms passed 250,000 signatures by 21 April 2011. In March 2011 a near-unanimous motion at the Liberal Democrat
spring conference called for changes to the Bill to ensure greater accountability and prevent cherry-picking by private providers, among other demands aimed at reducing marketisation of the NHS. UNISON
sponsored rapper NxtGen to create an unflattering hip hop track about the bill, which has now been viewed over 390,000 times on YouTube.
On 9 October 2011, a sit-down protest organised by UK Uncut
took place on Westminster Bridge
. 2,000 health workers and activists attended the protest. The location of the protest was symbolic as the bridge lies between the Houses of Parliament
and St Thomas' Hospital
, one of the main NHS hospitals in Central London.
Health care
Health care is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans. Health care is delivered by practitioners in medicine, chiropractic, dentistry, nursing, pharmacy, allied health, and other care providers...
reform legislation introduced in the House of Commons
British House of Commons
The House of Commons is the lower house of the Parliament of the United Kingdom, which also comprises the Sovereign and the House of Lords . Both Commons and Lords meet in the Palace of Westminster. The Commons is a democratically elected body, consisting of 650 members , who are known as Members...
on 19 January 2011. If passed, the Bill would be the most extensive reorganisation of the structure of the National Health Service in England
National Health Service (England)
The National Health Service or NHS is the publicly funded healthcare system in England. It is both the largest and oldest single-payer healthcare system in the world. It is able to function in the way that it does because it is primarily funded through the general taxation system, similar to how...
to date. It proposes to abolish NHS primary care trust
NHS Primary Care Trust
An NHS primary care trust is a type of NHS trust, part of the National Health Service in England. PCTs commission primary, community and secondary care from providers. Until 31 may2011 they also provided community services directly. Collectively PCT are responsible for spending around 80% of the...
s (PCTs) and Strategic Health Authorities
NHS Strategic Health Authority
NHS strategic health authorities are part of the structure of the National Health Service in England. Each SHA is responsible for enacting the directives and implementing fiscal policy as dictated by the Department of Health at a regional level. In turn each SHA area contains various NHS trusts...
(SHAs). Thereafter, £60 to £80 billion of "commissioning", or health care funds, would be transferred from the abolished PCTs to several hundred "clinical commissioning groups", partly run by the general practitioners (GPs) in England.
The proposals are primarily the result of policies of the Coalition Secretary of State for Health
Secretary of State for Health
Secretary of State for Health is a UK cabinet position responsible for the Department of Health.The first Boards of Health were created by Orders in Council dated 21 June, 14 November, and 21 November 1831. In 1848 a General Board of Health was created with the First Commissioner of Woods and...
, Andrew Lansley
Andrew Lansley
Andrew David Lansley, CBE, MP is the UK Secretary of State for Health, who has been the Conservative Member of Parliament for South Cambridgeshire since the 1997 general election, and was Shadow Secretary of State for Health from June 2004 until becoming Secretary of State for Health in May 2010...
. Writing in the BMJ
BMJ
BMJ is a partially open-access peer-reviewed medical journal. Originally called the British Medical Journal, the title was officially shortened to BMJ in 1988. The journal is published by the BMJ Group, a wholly owned subsidiary of the British Medical Association...
, Clive Peedell (co-chairman of the NHS Consultants' Association and a consultant clinical oncologist) compared the policies with academic analyses of privatisation and found "evidence that privatisation is an inevitable consequence of many of the policies contained in the Health and Social Care Bill." Lansley says that claims that the government is attempting to privatise the NHS are "ludicrous scaremongering".
The proposals contained in the Bill are some of the coalition government's most controversial. This is partly because they were not discussed during the 2010 general election campaign and were not contained in the 20 May 2010 Conservative – Liberal Democrat coalition agreement
Conservative – Liberal Democrat Coalition Agreement
The Conservative – Liberal Democrat Coalition Agreement was a policy document drawn up following the 2010 general election in the United Kingdom...
, which stated that the government would "stop the top-down reorganisations of the NHS that have got in the way of patient care". Within two months of the election a white paper
White paper
A white paper is an authoritative report or guide that helps solve a problem. White papers are used to educate readers and help people make decisions, and are often requested and used in politics, policy, business, and technical fields. In commercial use, the term has also come to refer to...
was published, outlining what the Daily Telegraph called the "biggest revolution in the NHS since its foundation". In April 2011 the government announced a "listening exercise", halting the Bill's legislative progress until after the May local elections
United Kingdom local elections, 2011
The 2011 United Kingdom local elections were held on Thursday 5 May 2011. In England, direct elections were held in all 36 Metropolitan boroughs, 194 Second-tier district authorities, 49 unitary authorities and various mayoral posts, meaning local elections took place in all parts of England with...
. The "listening exercise" finished by the end of that month. The Bill is presently undergoing scrutiny in the House of Lords
House of Lords
The House of Lords is the upper house of the Parliament of the United Kingdom. Like the House of Commons, it meets in the Palace of Westminster....
.
Origins
The bill's proposals were not discussed during the 2010 general election campaign and were not contained in the 20 May 2010 Conservative – Liberal Democrat coalition agreementConservative – Liberal Democrat Coalition Agreement
The Conservative – Liberal Democrat Coalition Agreement was a policy document drawn up following the 2010 general election in the United Kingdom...
, which declared an intention to "stop the top-down reorganisations of the NHS that have got in the way of patient care". However, within two months a white paper outlined what the Daily Telegraph called the "biggest revolution in the NHS since its foundation". The white paper, Equity and Excellence: Liberating the NHS, was followed in December 2010 by an implementation plan in the form of Liberating the NHS: legislative framework and next steps. The bill was introduced into the House of Commons on 19 January 2011 and received its second reading, a vote to approve the general principles of the Bill, by 321-235, a majority of 86, on 31 January 2011.
Contents and revisions
The Bill has implications for the entire NHS. NHS primary care trustNHS Primary Care Trust
An NHS primary care trust is a type of NHS trust, part of the National Health Service in England. PCTs commission primary, community and secondary care from providers. Until 31 may2011 they also provided community services directly. Collectively PCT are responsible for spending around 80% of the...
s (PCTs) and Strategic Health Authorities
NHS Strategic Health Authority
NHS strategic health authorities are part of the structure of the National Health Service in England. Each SHA is responsible for enacting the directives and implementing fiscal policy as dictated by the Department of Health at a regional level. In turn each SHA area contains various NHS trusts...
(SHAs) will be abolished, with projected redundancy costs of £1 billion for around 21,000 staff. £60 to £80 billion worth of commissioning will be transferred from PCTs to several hundred clinical commissioning groups, partly run by GPs.
When the white paper was presented to Parliament, the Secretary of State for Health Andrew Lansley told MPs of three key principles:
- patients at the centre of the NHS
- changing the emphasis of measurement to clinical outcomes
- empowering health professionals, in particular GPs.
The white paper set out the following timetable. By April 2012 it proposed to:
- establish the independent NHS Commissioning Board
- establish new local authority health and well-being boards
- develop MonitorMonitor (NHS)Monitor, also known as the Independent Regulator for NHS Foundation Trusts, is a non-departmental public body in the United Kingdom. Its purpose is to regulate NHS Foundation Trusts or Foundation Hospitals - hospitals that have opted out of direct governmental control. The body was established in...
as an economic regulator.
The Bill foresees all NHS trusts becoming, or being amalgamated into, foundation trust
NHS Foundation Trust
An NHS foundation trust is part of the National Health Service in England and has gained a degree of independence from the Department of Health and local NHS strategic health authority.Foundation Trusts are represented by the , .-Function:...
s. The Bill also abolishes the existing cap on trusts' income from non-NHS sources, which in most cases was previously set at a relatively low single-digit percentage.
Under the Bill's provisions the new commissioning system would be expected to be in place by April 2013, by which time SHAs and PCTs would be abolished.
The Bill has been analysed by Stephen Cragg of Doughty Street Chambers, on behalf of the 38 Degrees campaign, who concluded that "Effectively, the duty to provide a national health service would be lost if the Bill becomes law, and would be replaced by a duty on an unknown number of commissioning consortia with only a duty to make or arrange provision for that section of the population for which it is responsible." It replaces a “duty to provide” with a “Duty to promote”. .
"Listening exercise"
After an increase in opposition pressure, including from both the Liberal DemocratsLiberal Democrats
The Liberal Democrats are a social liberal political party in the United Kingdom which supports constitutional and electoral reform, progressive taxation, wealth taxation, human rights laws, cultural liberalism, banking reform and civil liberties .The party was formed in 1988 by a merger of the...
' rank-and-file and the British Medical Association
British Medical Association
The British Medical Association is the professional association and registered trade union for doctors in the United Kingdom. The association does not regulate or certify doctors, a responsibility which lies with the General Medical Council. The association’s headquarters are located in BMA House,...
, the government announced a "listening exercise" with critics. On 4 April 2011, the Government announced a "pause" in the progress of the Bill to allow the government to 'listen, reflect and improve' the proposals.
The Prime Minister
Prime Minister of the United Kingdom
The Prime Minister of the United Kingdom of Great Britain and Northern Ireland is the Head of Her Majesty's Government in the United Kingdom. The Prime Minister and Cabinet are collectively accountable for their policies and actions to the Sovereign, to Parliament, to their political party and...
, David Cameron
David Cameron
David William Donald Cameron is the current Prime Minister of the United Kingdom, First Lord of the Treasury, Minister for the Civil Service and Leader of the Conservative Party. Cameron represents Witney as its Member of Parliament ....
, has said that "the status quo is not an option" and many within his and Nick Clegg
Nick Clegg
Nicholas William Peter "Nick" Clegg is a British Liberal Democrat politician who is currently the Deputy Prime Minister, Lord President of the Council and Minister for Constitutional and Political Reform in the coalition government of which David Cameron is the Prime Minister...
's coalition have said that certain aspects of the Bill, such as the formation of clinical commissioning groups, are not only not open for discussion, but are also already too far along the path to completion to be stopped now. Cameron has insisted that the Bill is part of his "Big Society
Big Society
The Big Society was the flagship policy idea of the 2010 UK Conservative Party general election manifesto. It now forms part of the legislative programme of the Conservative – Liberal Democrat Coalition Agreement. The aim is "to create a climate that empowers local people and communities, building...
" agenda and that it will not alter the fundamental principles of the NHS.
Part of the "listening exercise" saw the creation on 6 April 2011 of the "NHS Future Forum". The Forum, according to Private Eye
Private Eye
Private Eye is a fortnightly British satirical and current affairs magazine, edited by Ian Hislop.Since its first publication in 1961, Private Eye has been a prominent critic and lampooner of public figures and entities that it deemed guilty of any of the sins of incompetence, inefficiency,...
, "brings together 43 hand-picked individuals, many of whom are known as supporters of Lansley's approach". At the same time, David Cameron set up a separate panel to advise him on the reforms; members of this panel include Lord Crisp
Nigel Crisp, Baron Crisp
Sir Edmund Nigel Ramsay Crisp, Baron Crisp KCB , is a British former senior civil servant in the Department of Health and Senior Manager in the NHS. He was awarded a life peerage upon retirement, and sits as a crossbencher in the House of Lords...
(NHS chief executive 2000-2006), Bill Moyes (a former head of Monitor
Monitor (NHS)
Monitor, also known as the Independent Regulator for NHS Foundation Trusts, is a non-departmental public body in the United Kingdom. Its purpose is to regulate NHS Foundation Trusts or Foundation Hospitals - hospitals that have opted out of direct governmental control. The body was established in...
), and the head of global health systems at McKinsey
McKinsey & Company
McKinsey & Company, Inc. is a global management consulting firm that focuses on solving issues of concern to senior management. McKinsey serves as an adviser to many businesses, governments, and institutions...
, as well as Mark Britnell
Mark Britnell
Mark Britnell is a partner and Head of Healthcare, Europe & UK for advisory firm KPMG. He was previously Director-General for Commissioning and System Management for the National Health Service of England .-Career:Britnell is a graduate of the University of Warwick; during his time there he was...
, the head of health policy at KPMG
KPMG
KPMG is one of the largest professional services networks in the world and one of the Big Four auditors, along with Deloitte, Ernst & Young and PwC. Its global headquarters is located in Amstelveen, Netherlands....
. Six months previously Britnell had told a conference of private healthcare executives that "In future, the NHS will be a state insurance provider not a state deliverer," and emphasised the role of Lansley's reforms in making this possible: "The NHS will be shown no mercy and the best time to take advantage of this will be in the next couple of years." KPMG issued a press statement on behalf of Britnell on 16 May 2011 stating
"The article in The Observer attributes quotes to me that do not properly reflect discussions held at a private conference last October. Nor was I given the opportunity to respond ahead of publication. I worked in the NHS for twenty years and now work alongside it. I have always been a passionate advocate of the NHS and believe that it has a great future. Like many other countries throughout the world, the pressure facing healthcare funding and provision are enormous. If the NHS is to change and modernise the public, private and voluntary sectors will all need to play their part."
In June 2011 Cameron announced that the original deadline of 2013 would no longer be part of the reforms. There will also be changes to the Bill to make clear that the main duty of the health regulator, Monitor, will be to promote the interests of patients rather than promoting competition.
The Future Forum report suggested that any organisation that treats NHS patients, including independent hospitals, should be forced to hold meetings in public and publish minutes. It also wants the establishment of a Citizens’ Panel to report on how easy it is to choose services, while patients would be given a right to challenge poor treatment. The original Bill sought to abolish two tiers of management and hand power to new bodies led by GPs, called commissioning consortia, to buy £60 billion a year in treatment. Professor Steve Field, a GP who chaired the forum, said many of the fears the public and medical profession had about the Health and Social Care Bill had been "justified" as it contained "insufficient safeguards" against private companies exploiting the NHS.
Further legislative progress
Following the completion of the listening exercise, the Bill was recommitted to a public bill committee on 21 June 2011. On 7th September, the Bill passed the House of Commons and received its third reading by 316-251. On 12 October 2011, the Bill was approved in principle at second reading in the House of Lords by 354-220. An amendment moved by Lord Owen to commit the most controversial clauses of the Bill to a select committee was defeated by 330-262. The Bill was subsequently committed to a committee of the whole House for detailed scrutiny.General
The Confederation of British IndustryConfederation of British Industry
The Confederation of British Industry is a British not for profit organisation incorporated by Royal charter which promotes the interests of its members, some 200,000 British businesses, a figure which includes some 80% of FTSE 100 companies and around 50% of FTSE 350 companies.-Role:The CBI works...
supports the bill, declaring that "Allowing the best provider to deliver healthcare services, whether they are a private company or a charity, will spur innovation and choice."
In May 2011, a number of doctors from GP consortia wrote a letter to the Daily Telegraph in which they expressed their support for the bill, calling its plans "a natural conclusion of the GP commissioning role that began with fundholding in the 1990s and, more recently, of the previous government's agenda of GP polysystems and pratice-based commissioning". On 14 May 2011, The Guardian
The Guardian
The Guardian, formerly known as The Manchester Guardian , is a British national daily newspaper in the Berliner format...
published an article reporting that the GP appointed to head the NHS "listening exercise" has unilaterally condemned the bill. The article says that Steve Field has "dismissed" the plans "as unworkable" and that these statements were "provisional conclusions that could fatally undermine the plans". The Royal College of General Practitioners
Royal College of General Practitioners
The Royal College of General Practitioners is the professional body for general practitioners in the United Kingdom. The RCGP represents and supports GPs on key issues including licensing, education, training, research and clinical standards. It is the largest of the medical royal colleges, with...
(RCGP) has also denounced the bill.
The Royal College of Physicians
Royal College of Physicians
The Royal College of Physicians of London was founded in 1518 as the College of Physicians by royal charter of King Henry VIII in 1518 - the first medical institution in England to receive a royal charter...
and Royal College of Surgeons have welcomed in principle the idea of medical professionals determining the direction of NHS services, but they question the Bill's implementation of the principle, particularly in regard to the approach of making GP consortia the primary commissioning deciders, and also in regard to requiring competition. The British Medical Association
British Medical Association
The British Medical Association is the professional association and registered trade union for doctors in the United Kingdom. The association does not regulate or certify doctors, a responsibility which lies with the General Medical Council. The association’s headquarters are located in BMA House,...
has said similarly. Neither of these organisations supports the bill.
In February 2011 David Bennett
David Bennett (consultant)
David Bennett is the Chairman of Monitor, the regulator of the National Health Service in England, having been appointed in February 2011. He had been Monitor's Interim Chief Executive since March 2010....
, newly appointed Chair of Monitor
Monitor (NHS)
Monitor, also known as the Independent Regulator for NHS Foundation Trusts, is a non-departmental public body in the United Kingdom. Its purpose is to regulate NHS Foundation Trusts or Foundation Hospitals - hospitals that have opted out of direct governmental control. The body was established in...
, said the NHS could become like other privatised utilities, so that Monitor would potentially be a regulator like Ofcom
Ofcom
Ofcom is the government-approved regulatory authority for the broadcasting and telecommunications industries in the United Kingdom. Ofcom was initially established by the Office of Communications Act 2002. It received its full authority from the Communications Act 2003...
, Ofgem and Ofwat: "We, in the UK, have done this in other sectors before. We did it in gas, we did it in power, we did it in telecoms […] We've done it in rail, we've done it in water, so there's actually 20 years of experience in taking monopolistic, monolithic markets and providers and exposing them to economic regulation." The House of Commons Select Committee on Health condemned the comparison as not "accurate or helpful."
"Any willing provider"
Physicians and others employees of the NHS are primarily worried about the bill's intention to amend one of the founding pillars of the NHS to read "any willing provider" rather than the current language guaranteeing a needed service exclusively via the NHS and its direct affiliates and partners. Changing of the language of the NHS tenets to read "any willing provider" takes away that requirement and allows private sector providers to have a potentially major say inside the NHS, potentially introducing private-sector operations and pricing within the NHS and even opening up local NHS operations to the possibility of forced closure because the private industry could out-compete them and corral the NHS services into bankruptcy. The British Medical AssociationBritish Medical Association
The British Medical Association is the professional association and registered trade union for doctors in the United Kingdom. The association does not regulate or certify doctors, a responsibility which lies with the General Medical Council. The association’s headquarters are located in BMA House,...
has said that "Forcing commissioners of care to tender contracts to any willing provider, including ... 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."
Layla Jader, a public health physician, said in the early months of 2011 that "The NHS needs evolution not revolution – these reforms are very threatening to the future of the NHS. If they go through, our children will look back and say how could you allow this to happen?" And Barry Miller, an anaesthetist from Bolton
Bolton
Bolton is a town in Greater Manchester, in the North West of England. Close to the West Pennine Moors, it is north west of the city of Manchester. Bolton is surrounded by several smaller towns and villages which together form the Metropolitan Borough of Bolton, of which Bolton is the...
, added: "The potential to do phenomenal damage is profound. I haven't seen any evidence these proposals will improve healthcare in the long-term."
GPs as commissioners
The bill intends to make general practitionerGeneral practitioner
A general practitioner is a medical practitioner who treats acute and chronic illnesses and provides preventive care and health education for all ages and both sexes. They have particular skills in treating people with multiple health issues and comorbidities...
s the direct overseers of NHS funds, rather than having those funds channelled through neighbourhood- and region-based Primary Care Trusts, as is currently done.
There are concerns about fragmentation of the NHS and a loss of coordination and planning. The Royal College of General Practitioners
Royal College of General Practitioners
The Royal College of General Practitioners is the professional body for general practitioners in the United Kingdom. The RCGP represents and supports GPs on key issues including licensing, education, training, research and clinical standards. It is the largest of the medical royal colleges, with...
said it was "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." Similarly, the Royal College of Physicians
Royal College of Physicians
The Royal College of Physicians of London was founded in 1518 as the College of Physicians by royal charter of King Henry VIII in 1518 - the first medical institution in England to receive a royal charter...
said that "Whilst we welcome the broad provision in the bill to seek professional expertise, the RCP is concerned that the bill does not require that specialists are at the heart of the commissioning process." The Royal College of Psychiatrists
Royal College of Psychiatrists
The Royal College of Psychiatrists is the main professional organisation of psychiatrists in the United Kingdom responsible for representing psychiatrists, psychiatric research and providing public information about mental health problems...
said it "would be dismayed if psychiatrists were not closely involved with local consortia of GPs in the development of mental health services." The Royal College of Surgeons said that "the legislation leaves the question of regional level commissioning unanswered with no intermediary structure put in place." And there are concerns about management expertise, particularly by looking at the US. The BMJ
BMJ
BMJ is a partially open-access peer-reviewed medical journal. Originally called the British Medical Journal, the title was officially shortened to BMJ in 1988. The journal is published by the BMJ Group, a wholly owned subsidiary of the British Medical Association...
wrote that
"No matter how many GP consortiums eventually emerge, their number will probably greatly exceed the 152 primary care trusts they are replacing, which brings a set of new challenges. Smaller populations increase the chances that a few very expensive patients will blow a hole in budgets. More consortiums mean that commissioning skills, already in short supply nationally, will be spread even more thinly. Denied economies of scale, smaller consortiums may be tempted to cut corners on high quality infrastructure and management, thereby endangering their survival. These points emerge clearly from an examination of 20 years of US experience of handing the equivalent of commissioning budgets to groups of doctors. Some groups had severely underestimated the importance of high quality professional management support in their early days and gone bankrupt as a result."
The House of Commons health committee has suggested the government let experts other than the consortia GPs and their direct allies get involved in the running of the consortia, including hospital doctors, public health chiefs, social care staff, and councillors. That idea has received some wider support and the government has agreed to give it consideration. Those close to Health Secretary Andrew Lansley have said, however, that Lansley is concerned adding too many people to consortia decision-making risks making the consortia too unwieldy." In 2010 the same committee had gone so far as to declare that "if reliable figures for the costs of commissioning prove that it is uneconomic and if it does not begin to improve soon, after 20 years of costly failure, the purchaser/provider split may need to be abolished."
Accountability
Kieran Walshe, professor of health policy and management and Chris Ham, chief executive of the King's FundKing's Fund
The King's Fund is a charitable foundation in England. Founded as the Prince of Wales Hospital Fund for London in 1897, the fund changed its name in 1902 to King Edward's Hospital Fund after the accession to the throne of King Edward VII...
, have argued that "At a national level, it is difficult to see who, if anyone, will be in charge of the NHS. There will be five key national bodies: the Department of Health, the National Institute for Health and Clinical Excellence, the Care Quality Commission, the NHS Commissioning Board, and the economic regulator Monitor. Although the remit of each is set out in legislation, it is not clear how these national bodies will interact or how they will provide coordinated and consistent governance of the NHS."
In addition, GP consortia under this system restructuring would be privately-run businesses, meeting in private, which risks damaging accountability instead of increasing it. "Ministers have argued that they will be forced to produce accessible annual accounts and will have to answer freedom of information requests." Primary Care Trusts are public bodies with public meetings, and thus have no such accountability grey-area problems.
Pace and timing of change
The King's FundKing's Fund
The King's Fund is a charitable foundation in England. Founded as the Prince of Wales Hospital Fund for London in 1897, the fund changed its name in 1902 to King Edward's Hospital Fund after the accession to the throne of King Edward VII...
said that "the very real risk that the speed and scale of the reforms could destabilise the NHS and undermine care must be actively managed."
The BMJ
BMJ
BMJ is a partially open-access peer-reviewed medical journal. Originally called the British Medical Journal, the title was officially shortened to BMJ in 1988. The journal is published by the BMJ Group, a wholly owned subsidiary of the British Medical Association...
said in January 2011 that "The bill promises that all general practices will be part of consortiums by April 2012, yet it took six years for 56% of general practices to become fundholders after the introduction of the internal market. Nearly seven years after the first NHS trust was granted foundation status, there are still more than half to go—within two years. And there’s more. The replacement for the 10 strategic health authorities—the NHS Commissioning Board—needs to be fully operational by next April. By then, GP consortiums should have developed relationships with local authorities, which will assume ultimate responsibility for public health via their new health and wellbeing boards, working alongside Public Health England, a completely new entity." The BMA believes such targets to be either wholly impossible or, at best, able to be done only in a very roughshod manner, which could in turn have very serious on-the-ground consequences to NHS functioning.
Medical establishment reaction
The British Medical AssociationBritish Medical Association
The British Medical Association is the professional association and registered trade union for doctors in the United Kingdom. The association does not regulate or certify doctors, a responsibility which lies with the General Medical Council. The association’s headquarters are located in BMA House,...
opposes the bill, and held its first emergency meeting in 19 years, which asked the government to withdraw the bill and reconsider the reforms, although a motion of no confidence
Motion of no confidence
A motion of no confidence is a parliamentary motion whose passing would demonstrate to the head of state that the elected parliament no longer has confidence in the appointed government.-Overview:Typically, when a parliament passes a vote of no...
in Andrew Lansley by the BMA failed. A later motion of no confidence in Lansley by attendees at the Royal College of Nursing
Royal College of Nursing
The Royal College of Nursing is a union membership organisation with over 395,000 members in the United Kingdom. It was founded in 1916, receiving its Royal Charter in 1928, Queen Elizabeth II is the patron...
Conference in 2011, however, succeeded, with 96% voting in favour of the motion, and several speeches thereafter condemning Lansley threefold: the Health and Social Care Bill 2011 as-written; Lansley's decision not to address the entire Conference with a speech, but instead to hold a separate meeting with 40 Conference attendees in a separate space (taken as an insult to nurses, and leading to accusations of 'gutlessness'); and the current separate "efficiency savings" measures being undertaken across the NHS
Nicholson challenge
The term "Nicholson challenge" refers to a set of mandates that the 2011 leader of the National Health Service in England, Sir David Nicholson, has put forth to the entirety of the NHS in a drive to find "efficiency savings" amidst a UK economy in upheaval...
and those actions' material impact on frontline medical services, especially as contrasted with several prominent officials, including NHS leaders and Lansley himself, repeatedly assuring that NHS frontline services are 'protected' at all times regardless of these "savings" measures.
Grassroots groups
Various grassroots groups oppose the bill, including NHS Direct Action, Keep Our NHS Public, 38 Degrees38 Degrees
38 Degrees is a UK non-profit, progressive, political activism organisation that campaigns on a diverse range of issues, such as protecting the environment and tackling climate change, democratic media ownership, child poverty and political reform...
, and the trade union
Trade union
A trade union, trades union or labor union is an organization of workers that have banded together to achieve common goals such as better working conditions. The trade union, through its leadership, bargains with the employer on behalf of union members and negotiates labour contracts with...
Unite
Unite the Union
Unite – the Union, known as Unite, is a British and Irish trade union, formed on 1 May 2007, by the merger of Amicus and the Transport and General Workers' Union...
. 38 Degrees' petition against the reforms passed 250,000 signatures by 21 April 2011. In March 2011 a near-unanimous motion at the Liberal Democrat
Liberal Democrats
The Liberal Democrats are a social liberal political party in the United Kingdom which supports constitutional and electoral reform, progressive taxation, wealth taxation, human rights laws, cultural liberalism, banking reform and civil liberties .The party was formed in 1988 by a merger of the...
spring conference called for changes to the Bill to ensure greater accountability and prevent cherry-picking by private providers, among other demands aimed at reducing marketisation of the NHS. UNISON
UNISON
UNISON is the largest trade union in the United Kingdom with over 1.3 million members.The union was formed in 1993 when three public sector trade unions, the National and Local Government Officers Association , the National Union of Public Employees and the Confederation of Health Service...
sponsored rapper NxtGen to create an unflattering hip hop track about the bill, which has now been viewed over 390,000 times on YouTube.
On 9 October 2011, a sit-down protest organised by UK Uncut
UK Uncut
UK Uncut is a United Kingdom-based protest group established in October 2010 to protest against tax avoidance in the UK and to raise awareness about cuts to public services. Various sources have described the group as left-wing in its political orientation...
took place on Westminster Bridge
Westminster Bridge
Westminster Bridge is a road and foot traffic bridge over the River Thames between Westminster on the north side and Lambeth on the south side, in London, England....
. 2,000 health workers and activists attended the protest. The location of the protest was symbolic as the bridge lies between the Houses of Parliament
Palace of Westminster
The Palace of Westminster, also known as the Houses of Parliament or Westminster Palace, is the meeting place of the two houses of the Parliament of the United Kingdom—the House of Lords and the House of Commons...
and St Thomas' Hospital
St Thomas' Hospital
St Thomas' Hospital is a large NHS hospital in London, England. It is administratively a part of Guy's & St Thomas' NHS Foundation Trust. It has provided health care freely or under charitable auspices since the 12th century and was originally located in Southwark.St Thomas' Hospital is accessible...
, one of the main NHS hospitals in Central London.
See also
- Nicholson challengeNicholson challengeThe term "Nicholson challenge" refers to a set of mandates that the 2011 leader of the National Health Service in England, Sir David Nicholson, has put forth to the entirety of the NHS in a drive to find "efficiency savings" amidst a UK economy in upheaval...
- National Health Service Act 2006National Health Service Act 2006The National Health Service Act 2006 is an Act of the Parliament of the United Kingdom. It sets out the structure of the National Health Service in England.If the Health and Social Care Bill 2011 passes it will be significantly altered....
- National Health Service Act 1977 (c 49)
- National Health Service and Community Care Act 1990National Health Service and Community Care Act 1990The National Health Service and Community Care Act 1990 is a piece of legislation which governs health care and social care in the United Kingdom...
(c 19) - National Health Service Act 1997 (c 56)(c 46)
- National Health Service Act 1966 (c 8) section 10, on GP remuneration
- NHS Redress Act 2006NHS Redress Act 2006The NHS Redress Act 2006 is an Act of the Parliament of the United Kingdom.The title of the Act establishes tort based liability as the necessary condition for obtaining redress....
External links
- Bill as introduced in the House of Commons
- Bill as introduced in the House of Lords (reflecting changes made after the Listening Exercise)
- Bill progress page on parliament.uk
- BMJ minisite focusing on reforms to the NHS