Kailash Chand: The Health and Social Care Bill remains flawed and unpopular

Kailash ChandThe government has set out its stall in detail on the changes it will make to the Health and Social Care Bill. Many of the BMA’s concerns were addressed by the NHS Future Forum and the government’s response. This includes restoring health secretary’s responsibilities, modifying Monitor’s duty to promote competition, and the need for clinicians other than GPs to be involved in commissioning. But, will it be enough to save the NHS?
 
Last week at a commissioning show in London, Andrew Lansley would still not accept that his proposals were riddled with flaws and he continues to insist that the “fundamental principles” of the Health and Social Care Bill remain intact. His critics rightly claim that the listening exercise, led by Steve Field, was mainly about public relations and changes to Lansley’s original plans are merely cosmetic. I believe further changes will have to be considered and revised as unintended consequences emerge (the devil is in the detail). This is a recipe for further distraction and confusion and the casualties will be quality and efficiency in the NHS. This is a huge challenge for the BMA ARM in Cardiff next week as the Health the Health and Social Care Bill remains politically, economically, and professionally flawed.
 
The amended bill will still allow clinical commissioning groups to pick and choose patients and services. It is no longer mandatory to provide comprehensive care, and allows commissioning groups to recruit members, and introduce charges and private health insurance, as well as enter into joint ventures with private companies to outsource most work to private companies with vested interests, beyond the scope of full public scrutiny.
 
There will be particular confusion about commissioning responsibilities. In some areas clinical commissioning groups will be up and running in April 2013, others will be operating partially, and others in shadow form only. In addition there will now be more than one commissioning model that will not only create uncertainty, but a two tier service that will also create a costly and duplicative bureaucracy. We will have a Department of Health, a National Commissioning board, four SHA clusters, fifty PCT clusters, hundreds of clinical commissioning boards, dozens of clinical senates, and over 100 Health and Wellbeing boards. And we are suppose to achieve this with management budget that has been reduced by 45%. Where in all of this is the “bureaucracy busting” that Lansley has spoken of? Furthermore, there are huge risks that the abolition of primary care trusts and SHAs will cost millions in redundancies and subsequent re-employment of staff in NHS commissioning boards. It is a complete myth that GPs in commissioning groups will have a huge impact on designing services. Emergency services like A&E will be commissioned at a certain level around a million population. Tertiary services like neurosurgery, will be commissioned by the NHS Commissioning Board. Elective care such as cataract and orthopaedic surgery, will be via patient choice arrangements. The bill may have some influence on long term conditions, but this too may be tricky as the providers with one eye on profit will come with a fixed package with very little leverage to change especially if that increases their costs and is therefore bad for profits.
 
GPs will become rationers of care, which will irrevocably damage the GP-patient relationship for good.
 
The any qualified provider clause will encourage clinicians and nurses to enter the marketplace to try their hand at turning tax-payer’s money into profits through a “right to provide” initiative. This will allow specialist healthcare professionals access to start-up funds to set up their own organisations, which would exist outside the NHS but be contracted to provide, essentially cherry pick health care for profit.
 
Contrary to what has been said, Monitor’s role remains much the same. The plan is to rebrand competition as choice. So, the emphasis of the role has been slightly toned down which can easily be redirected once the well orchestrated political dust has settled.
 
Under the disguise of reconfigurations, the SHA and primary care trusts continue to plan and execute the closure of NHS hospitals. Financial pressure, flat budgets until 2015, and an ongoing £20bn savings drive, means that at least 20 to 30 hospitals in England, about 10 % of total number of hospitals, are simply not financially viable in their current form and soon will be bankrupt and forced to totally shut or reduce services significantly. It is inevitable that people will link the closures to the NHS reforms.

As a GP for 30 years I have survived numerous meaningless reorganisations, but this reform by a knowledgeable but not wise health secretary, is unique in its messiness and apparent incoherence. Most of the critics of the reforms had hoped that the bill would effectively be scrapped and David Cameron would start from a clean slate. This has not happened, and tweaking the bill produces a result that is far from satisfactory. The Future Forum has provided politically acceptable language to Lansley’s NHS reforms, but the reforms remain destabilising and wasteful. David Cameron’s mission for the public to accept that the NHS is safe in the Tories hands has been totally undermined by Andrew Lansley, who has created institutional chaos and uncertainty since he took over as health secretary. A Populus poll for The Times shows that one in four people believe that the government’s plans to reform the NHS will make waiting lists longer, while a third think it will put a further financial squeeze on the NHS.  How David Cameron, with all his PR skills and sharp political antennae, could ever have allowed this to happen is still something of a mystery. He should expect to arrive at the next election with his promise that the NHS is safe in his hands totally shattered.
 
The BMA leadership too should note that the Health and Social Care Bill remains flawed, unpopular, and has not met the demands voiced at an emergency BMA ARM in March.

Kailash Chand has been a GP for last 30 years and is now chair of the NHS Trust Tameside & Glossop. He was on the BMA council and general practitioner’s committee until last year. He was awarded an OBE in 2010 for services to the NHS. He writes for the Guardian, and other regional and national publications on health matters.

  • garcliffe

    I hope BMA leadership take notice of very valid concerns raised in this blog.

  • everythingyouknowiswrong

    As usual, an insightful piece by Dr Chand. The increased innovation and efficiency that is nominally being touted as the basis for the introduction of more competition into UK healthcare provision is predicated on the promise of a level playing field for both the NHS bodies that will be providers of services, and the private firms that will compete with it. However, that field is of course far from level,  if cherry picking of services is allowed.

    But of more concern is the fact that the potential catastrophic effects of this drive towards “efficiency” on under- and postgraduate medical training have not even been paid lip service, let alone studied in depth. At its heart, undergraduate medical training in the UK has already seen significant restructuring. UK medical education has just about managed to maintain its excellence (arguably) and survive such re-booting of its curricula due to the large training opportunities offered by NHS hospitals providing students the opportunity to gain apprenticeship in a wide variety of clinical settings and services. I fear the death blows will finally be dealt to the worn spine of medical education with this latest unnecessary reshuffle.

    All this in a clinical environment where the European Working Time Directive has already placed restrictions on the amount of time junior doctors may have to learn, and also to teach, despite the theoretical constructs laid out in the Temple report.

    Further away from the hospital, what will the effect on GP training be of a GP service struggling to take the Health Economics 101 course on Healthcare commissioning? Can GPs help train future GPs with such demands placed on their time? And, coming full circle, how can this truly be said to be @garcliffe:disqus
    efficient” if it results in less time for training?

    As with all previous governments, the true detriment of these reforms will not be fully felt till this government is but a distant footnote in history, and hence, the impunity, arrogance and total abandonment of accountability displayed by them is hardly surprising. What is perhaps sadder is that it is happening under the auspices of a coalition government- the lunatics have truly taken over the asylum, and the guards have joined them.