The Health and Social Care Bill – still a toxic mess
Despite the ‘listening exercise’ and the Government’s claims to have made significant changes to the Health and Social Care Bill, the Bill that MPs will vote on this evening is still toxic and messy, and threatens the future of the NHS as we know it.
Earlier this year, it seemed that the Government had scored a significant and somewhat unlikely PR coup. They were pushed into a ‘listening exercise’ due to widespread opposition to the Bill and concerns from the Liberal Democrats which came to the fore at their spring conference. The Future Forum set up to look at the reforms made some useful recommendations about ways to improve the Bill, but didn’t go anywhere near far enough to deal with the fundamental concerns about the Bill. But the media was keen for a story about the political machinations behind the coalition, and so the Government managed to present themselves as having listened and responded to concerns and having overhauled the Bill.
In fact, the Bill that returned to the Commons yesterday is still a toxic combination of competition, markets and fragmentation that could shake the foundations of the NHS. The changes made following the listening exercise make minor improvements in some areas, but in others they leave the Bill more complex and muddled and make the system more bureaucratic and unaccountable.
To take just a few examples of the areas where we still have serious concerns:
The Bill still means competition instead of collaboration. The Government hasn’t followed through on the Future Forum recommendation to strengthen the emphasis on collaboration as the best way to improve care for patients. Instead, it still has a big focus on competition. This is despite evidence that the NHS is one of the most cost effective health care systems in the world – in a recent academic study it fared much better than the system in the USA, where competition is central. Much of Part 3 of the Bill, which includes the arrangements for the powerful economic regulator, Monitor, remains unchanged. In the original Bill Monitor had a duty to promote competition. That has now been amended to a duty to ‘prevent anti-competitive behaviour’ – which appears to have virtually the same meaning in practice. The Government is also pushing ahead with plans to allow ‘Any Qualified Provider’ to deliver NHS services, opening up swathes of the NHS to private and voluntary sector providers.
It still means private patients jumping the queue. The Bill removes the cap on the amount of money NHS hospitals can make from private patients. This wasn’t mentioned in the Future Forum report, although the Chair of the Forum, Steve Field, has said he now regrets not mentioning it. Professor Field said that the “gut feeling” from the listening exercise was that “the private cap should stay because people felt that would provide the protection”. What the removal of the cap could mean in practice is NHS patients being pushed to the back of the queue for care, while private patients jump to the front. With foundation trusts strapped for cash, the temptation to prioritise paying patients will be strong. It also makes it more likely that hospitals will be opened up to EU and UK competition law.
The Bill still means a fragmented system and a lack of accountability. Despite the Government’s assurances to the contrary, independent legal advice obtained by campaign group 38 Degrees has confirmed that, if the Bill goes ahead as currently drafted, the Secretary of State would no longer have the duty to provide a comprehensive health service. It would be up to local commissioning groups to determine not only what needs to be provided to meet the needs of the local population, but what is ‘appropriate’ to provide as part of the NHS. This was one of the issues highlighted this weekend by Baroness Shirley Williams, who believes it will lead to fragmentation, postcode variation and a lack of accountability.
There are still fears about lack of transparency. Private and voluntary sector providers will have a much bigger role delivering NHS services if the Bill goes through, but the Bill doesn’t hold them to the same standards of transparency as NHS providers. Foundation Trusts and commissioning groups will be required to hold their board meetings in public – although loopholes in the Bill will allow them to exclude members of the public in some circumstances. But it does not seem that even these relatively weak requirements will apply to non-NHS providers.
The reform is getting even more expensive. All of this comes at a time when the NHS has the tightest financial settlement in many years and is being asked to make ‘efficiency savings’ worth £20bn by 2014-15 and to cut management costs by 45 per cent. The cost of the reorganisation is estimated to be up to £3bn, and the Department of Health’s own figures show this is rising by £1 million a day. The Government hasn’t yet produced a revised impact assessment to show what they estimate the latest cost of the reorganisation will be – this is expected later this week, after the MPs have debated the reforms. We already know that tens of thousands of jobs are being cut, including clinical posts.
The Government continues to claim they have the support of health bodies – David Cameron repeated this line at PMQs today. But the evidence all points in the opposite direction: to massive concern and opposition from across the health service. Unions and professional bodies representing doctors, nurses, physiotherapists, midwives, cleaners, administrators, managers, porters, radiographers, community and mental health professionals and many, many more have spoken out. The fight for the future of the NHS won’t end in the Commons, and we’ll continue to lobby and campaign if the Bill heads to the Lords after this evening’s vote.