The white paper ‘Equity and Excellence: Liberating the NHS’ was published in July 2010. The 6000 responses to the flawed consultation have not been published but many, if not most, of the responses were critical of the Bill. The Bill had it first reading on 10th January. Its second reading on 31st January was passed by a majority of 86. Voting was strictly on party lines with Labour voting against the Bill and coalition MPs voting for it — apart from one Lib Dem, Andrew George, who abstained.
Committee stage ran from 10 February to 31st March. Report stage was expected soon thereafter but on 4 April, Andrew Lansley announced an unprecedented pause in the passage of the Health and Social Care Bill to allow the government to ‘reflect and engage’. This was enlivened over the last fortnight. First by Nick Clegg’s statement on 8th May that ‘no Bill is better than a bad Bill’, then Dr Steve Field who is leading the ‘Futures Forum’ saying on 14th May that the Bill was unworkable (partial retraction I am told on the 15th). Last Monday the Prime Minister, speaking to health workers, changed the goalposts, saying that no change is not an option, and how much he loves the NHS. Yesterday, Nick Clegg said all references to Monitor being an economic regulator should be removed.
The Bill, published on 19 January, is 353 pages long and has 288 clauses. There are 234 pages of explanatory notes and 380 pages of Impact Assessment papers. How many MPs have time to read through all that? Liberal Democrat MP John Pugh suggested on Newsnight last week that Nick Clegg had not read either the White Paper or the Bill before he signed the forewords.
Aims and implementation:
The Bill aims to remove the responsibility of the Secretary of State to provide a comprehensive health service. This would be delegated to the proposed National Commissioning Board, a quango appointed by the Secretary of State and to the proposed GP consortia who are supposed to replace Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs). Lansley has already appointed the chair — David Nicholson, the current head of the NHS.
Even before the Bill had reached the House of Commons parts of it were being implemented with staff in SHAs and PCTs given enhanced redundancy if they opted for this in November 2010, just after the flawed consultation had closed. At the time of the second reading Lansley announced that about half the country was covered by ‘Pathfinder’ GP consortia — he did not mention the money that GPs received for joining these. Some no doubt have done this because they feared the vacuum left as Primary Care Trusts (PCTs) were dissolved; some leaders of consortia are enthusiastic and naively believe they will be able to do better at commissioning services than the PCTs; and the majority are just getting on with their real work of looking after patients as yet another re-organisation hits them.
A cynical pause and a flawed consultation:
The unprecedented pause before report stage and third reading — to allow time to ‘listen, reflect and engage’ — was due to mounting pressure both within and outside parliament.
I am co-chair of Keep our NHS Public, which was started in 2005 because the process of setting up a market using the private health care sector was growing. This Bill is the culmination of a decade of their infiltration into the Department of Health, as Colin Leys and Stewart Player explain brilliantly in their book ‘The Plot against the NHS’.
We believe that this pause is a cynical PR exercise and that Lansley has no intention of changing the direction of the Bill. A committee known as ‘The Futures Forum’ has been set up. It is chaired by the former chair of the Royal College of GPs, who is a supporter of GP commissioning, and who on May 14th expressed concern about aspects of the Bill — before his group had finished their deliberations. The events for the public were not advertised on the Department of Health website. Citizens could participate through an on-line Q&A, loaded with leading questions. 4000 have apparently attended the meetings. How were they selected?
A week later a group of ten policy makers were drafted in by 10 Downing Street, one of whom, Mark Britnell, has said publicly that the NHS should go for an insurance based system. In Prime Minister’s Question Time on 19 May, David Cameron said he had never heard of him . . .
Why should we scrap the bill?
Our view is that the Bill cannot be amended, it is all of a piece, and so we want to get 48 Coalition MPs and all those from the smaller parties to vote against it at third reading, which may not be in June as expected. As Baroness Shirley Williams pointed out, most of the proposed reforms were not in the Coalition agreement, so Lib Dems can vote against the Bill. We must push them to do that.
We must use this opportunity to let MPs know how we feel about this Bill, which will complete the process of creating a market in health care and destroy our National Health Service (see Bill Committee evidence on 10 February on the Parliament TV Channel and The Plot against the NHS).
Lansley’s stated aims — to put patients at the centre of care, clinicians in control and reduce bureaucracy — could be achieved without the massive upheaval which his reforms will cause.
To be clear, the Bill will:
• Transfer the responsibility for the NHS from the Secretary of State for Health to a new NHS Commissioning Board appointed by SoS
• Abolish Strategic Health Authorities (SHAs) responsible for planning services for a region and overseeing PCTs
• Abolish all 152 Primary Care Trusts (PCTs), which receive money from the SHAs and buy services for their population
• Create 300-600 groups of GPs called consortia which would take on the commissioning (purchasing) of services. A number of pathfinder groups, sometimes called ‘pilots’, were set up in late January.
• Force all hospitals to become Foundation Trusts (FTs) and encourage them to become employee-led social enterprises.
• Remove the cap on private patients in FTs
• Increase the powers of the Monitor (who oversees FTs) as sole economic regulator and enforce competition
• Encourage ‘any willing provider’ who will be licensed by Monitor and the Care Quality Commission (CQC)
• Strengthen CQC to -become effective regulator and license provider (with no extra money)
• Transfer Public Health to Local Authorities and set up a new body Public Health England
• Set up Health and Wellbeing Boards (without powers to oversee GP Consortia) without any community or professional representation
Lansley claims the reorganisation will reduce NHS management costs by 45 per cent over the next four years. The estimated cost of re-organisation is £1.7bn in the first year alone according to government figures and up to £3bn according to the King’s Fund. Previous reorganisations have cost more than estimated and not produced the planned savings.
During PMQs on 16 March, David Cameron denied that this amounted to wholesale re-organisation. “We are not re-organising”, he said, “we are abolishing SHAs and PCTs”.
The proposals have been widely criticized. Lord David Owen (a former Health Secretary) has declared this to be a bill of ‘staggering ineptitude’ (Fatally Flawed, 31 March). In its report of 5 April, even the Health Select Committee, chaired by conservative MP (and also a former Health Secretary) Stephen Dorrell, recommends major changes, though it fails to tackle the role of the Monitor, a key part of the privatisation agenda.
In the words of Kingsley Manning, business development director of outsourcing company Tribal:
“This white paper could amount to the denationalisation of healthcare services in England and is the most important redirection of the NHS in more than a generation, going further than any Secretary of State has gone before.”
Despite the 6000 responses to the flawed consultation, only one significant change was made: midwifery was to have been the responsibility of the proposed NCB but has been returned to the proposed GP consortia.
The BMA at its Special Representative meeting called to discuss the Bill (which had been published after its annual representative meeting last June) voted on 15 March to ask Lansley to withdraw the Bill and passed motions all day criticizing many aspects of it. Both The Lancet and the BMJ (which called the Bill Dr Lansley’s Monster) came out strongly against the reforms. The criticisms of the Health Select Committee (17 January) were more muted, but Stephen Dorrell is on record as saying that the first priority is the Nicholson Challenge ie the £20bn saving the NHS is supposed to make in the next three years to cover the cost of dealing with our aging population and the higher inflation in the prices of drugs and equipment. This sort of saving has never been achieved anywhere in the world. The weekly litany of cuts and closures can be observed all round the country.
In a speech at Ealing Hospital on May 16th — reported in advance across the national and local press — David Cameron insisted ‘It’s because I love the NHS so much that I want to change it’. Remember he was in PR before politics. We must defeat this Bill at 3rd reading, which was due to take place before this Parliamentary session ends in July but it is rumoured that it may be postponed till the autumn. So, go and see your MP and tell him that we do not want the NHS turned into a market — and to vote against the Bill at 3rd reading.
Image by Steve Bell, whose work can be found at Belltoons.co.uk.