Health and Social Care Bill

Memorandum submitted by Dr Penelope Jarrett GP (HS 121)

My Understanding of the Proposed Reforms

This huge piece of legislation (288 clauses) changes all parts of the NHS – refoms so big that they will be "visible from space" (according to David Nicholson, NHS Chief Executive). At the same time, there are White Papers proposing major changes to the Public Health Service, and to the training of doctors.

· PCTs and Strategic Health Authorities to be abolished

· New commissioning consortia of GPs

· New NHS Commissioning Board; working only on an annual mandate (so not opportunity for long term planning) to commission GPs as providers, and to judge commissioners.

· All hospitals to achieve Foundation Trusts status, with no obligation to observe national pay and conditions, and removal of the cap in private earnings.

· Establishment of Monitor, a new economic and licensing regulator, with a duty to promote competition; and powers to investigate commissioner and providers, and to fine or impose change on them.

· New Health Education England, new "local skills networks" for training

· New Health and Wellbeing Boards in each Local Authority

· Abolition of the Health Protection Agency, new Public Health England

· Replacement of Local Involvement Networks (LINks, themselves only 3 years old and just getting established) with local HealthWatch, with unclear lines of accountability, and no specification to ensure the bodies are representative of the local population. It is unclear if they can investigate services

· Hospital procedures will be paid for on a local or a national tariff (as brought in by the Labour Government under so-called "payment by results" – actually a payment for activity)

· There are number of clauses requiring information to be shared or disclosed, including clinical information which could compromise patient confidentiality.

· A greater role for the Care Quality Commission

The government is committed to patient choice, any willing provider policies, competitive tendering, and the Secretary of State will have the power to create regulations to ensure that these happen.

The Bill is Unnecessary

Andrew Lansley and David Cameron have said that the Bill is necessary because outcomes in the NHS are not as good as in some other countries. This is true of the outcome they picked out (death rates after a heart attack are lower in France than in any other European Country), but you can pick out many figures in international comparisons, and easily find others in which the UK performs better than France. In fact, on trends since 1979, the UK rate of death after a heart attack will fall below the French rate by 2012 (Organisation of Economic Co-operation and Development (OECD) reports).

Overall, life expectancy at birth in the UK in 2007 was 79.5 years, similar to most European Countries and slightly above the OECD average of 79.1 years. European countries have health care systems which are called insurance based, but they are all compulsory and to a great extent underwritten by Governments, which makes them effectively funded by taxation. The OECD country which has the most developed market and least socialised system is the United States. It stands out from the other countries in having a below average life expectancy of 78.1 years, and spending over $9,000 per capita to achieve this in 2007 while most other OECD countries spent $2,000-4,000 per capita. The UK spent about $3,000 per capita.

In the years of increased funding there have been significant improvements in health outcomes in the UK. Most clinicians would agree that these improvements have come about due to evidence based policies as promulgated by NICE, some aspects of QOF, waiting time targets, and funding for networks of stroke, cardiac and cancer care which enabled coordinated evidence based pathways to be put in place. All of these are threatened by the bill.

Patients have recognised the difference: according to the Britsh Household Survey, patient satisfaction levels soared from a low of 35 % (quite or very satisfied) in 1997 to an all time high of 64% in 2009 (the latest reported survey ). Politicians have commented how the NHS was not an issue during the election campaign of 2010, because people were generally happy (personal communication).

Despite the increased funding put in by the previous government, we still lag behind the OECD average, because expenditure has risen in other countries too.

No-one would argue that the NHS is perfect. However, there are many existing examples of good practice and successful projects, some of which have been touted by the reformers as arguments for the reforms. It must be remembered that these projects have all taken place under the present legislative framework. Passage of the Bill is not necessary.

The Reforms will be Expensive

In the context of the current economic recession, it has already been recognised that health expenditure would be a problem. NHS chief executive David Nicholson’s 2008/09 annual report says the health service should expect to have to make ‘unprecedented’ efficiency savings of £15bn to £20bn between 2011 and 2014. He writes: ‘This is so that we can deal with changing demographics, the implementation of the [NHS next stage review strategic health authority] regional visions and cost pressures in the system.’ This has become known as "The Nicholson Challenge". It means that although the Coalition have promised not to cut NHS spending in real terms, because there will be more older people, and healthcare inflation is more than consumer or retail inflation, £20bn has to be saved over the next 3 years, from a budget of about £300 bn.

The DH estimates that the proposed reforms will cost £1.3bn to implement. Independent academics have estimated it could easily cost as much as £3bn. This is on top of the £20bn of the Nicholson Challenge.

The Health Select Committee has recently estimated that the transaction costs of the NHS have gone up from 5% of total NHS expenditure to 14% over the last 20 years in which the internal market has been operating.

There is absolutely no evidence that the changes will save money, and plenty of evidence to the contarary.

The Reforms are Risky

The whole process is very risky: changing all the structures at once means that there will be no safety net if one of them fails. Indeed, in the market the expectation is that some consortia and hospitals WILL fail. The presumption is that other consortia or hospitals (or private providers) will take over the failing bodies - or they will close. Where will patient choice be in all this? Or indeed, any patient rights?

There are very many unanswered questions about how the proposed new bodies will be constituted, exactly which body will have which duty, and where lines of accountability will lie. I am speaking of financial accountability, clinical accountability (and clinical governance) and data sharing (confidentialty, IT systems, Caldicott Guardians and data protection). Indeed, it rather looks to staff on the ground as if the people writing the Bill were unaware of the many and complex functions and responsibilties that are carried out in the modern health service, as so many functions seem to be without a home in the proposed structures.

This is going to be difficult for staff and patients alike. When there are problems, and there always are problems in healthcare delivery, it is likely that no-one will be accountable.

The process of GP commissioning carries inherent conflicts of interest, since GPs will be commissioning services which overlap with the services that they themselves provide. For example, a diabetic may be cared for at the GP surgery, or may be referred to hospital. This is even before one considers the problems when GPs set up companies to provide services such as physiotherapy, or minor injuries (which is already happening); or if GPs are rewarded for saving money on prescribing or referral budgets.

The Reforms will be Ineffective.

The proposed changes have not been tested nor piloted. There is some evidence that fundholding in the 1990s allowed GPs to make some savings by lowering the demand for clinical services, but this was at the cost of higher managerial and transaction costs, and a substantial drop in patient satisfaction (Zack Cooper). There is evidence from health economists to show that competition on price reduces quality. This happens in other markets too: we do not generally go to the Poundshop if we want good quality goods. The Government have backed off a little, and said that there would only be two tariffs for hospital procedures (a local and a national tariff). However, it has been estimated that 70% of NHS activity is not covered by the tariff system (Leys), hence would be subject to this drive to minimum quality.

The Government’s vision is "to modernise the NHS so that it is built around patients, led by health professionals and focused on delivering world-class healthcare outcomes". This sounds fine, but there is no evidence that the proposed changes will achieve this. The BMA commissioned Ipsos MORI to do a survey in January 2011. 1,645 doctors participated in this. A majority thought that enactment of the Bill would lead to increased competition (88%), which will lead to fragmentation of services (89%), reduce the quality of patient care (65%) and will damage NHS values (66%). They also thought that the reforms would increase health inequalities (66%). These concerns, and many others, were also articulated at the BMA Special Representative Meeting on 15th March. Over 400 doctors, representing medical staff throughout the UK, voted for motions criticising every aspect of the Bill, and agreeing to campaign against it..

So, it comes down to whom you believe: Lansley says it will work, the majority of doctors, including myself, say it will not.

March 2011