A brief FAQ on the proposed changes to the NHS in England. I’ve done my best to strike a balanced voice, but apologise if cynicism takes over at various points. Equally, I’ve tried to cover lots of ground in as short a space as possible, but this necessarily means missing some things out.
1. How exactly is the bill going to change the NHS?
Well it’s complicated (!). In principle, the bill will abolish Primary Care Trusts (which purchase care as well as providing some of it at present in community health services), and replace them with GP commissioning groups instead. It will also shrink the number of Strategic Health Authorities and increase the potential involvement of the private health sector in the NHS both in terms of provision, but also in terms of offering advice to the new GP commisioners. However, the bill’s amendments have resulted in commissioning organisations having several tiers of management – possibly meaning the whole thing will be more bureaucratic than before. Equally, the benefits of extending private provision are contested (see below). Finally, the argument is that commissioning groups will mean a smaller role for the Secretary of State. Many of those against the Bill have argued that this means the Secretary of State will no longer responsible for the NHS, which could create something of a democratic gap, and have sought assurances that this will not be the case.
2. Why ask GPs to purchase care for their patients?
Advocates of this system say that GPs are closest to patients and so know what they want. Those against wonder why we are asking people whose primary job is to care for people to do something related, by very different (like asking a pilot to design and purchase an aeroplane). Equally, the bill’s opponents are often concerned that by making commissioning bodies smaller, they will not be able to pool risks. What this means is that those who need the most expensive treatments will take up a bigger proportion of a small commissioning body than they would if there was a big one, with a bigger budget. Small commissioning bodies should be more responsive to their particular community’s needs, but have a smaller total budget, and so a reduced ability to pool risks. This at least theoretically, has a problem that where a community has a disproportionate amount of expensive illness, their commissioning body might run out of money. A bigger commissioning body is better able to pool risks, and so is less likely to be affected by a disproportionate amount of expensive illness, but is less able to be sensitive to particular communities.
3.Why make greater use of competition?
Advocates of competition claim that there is evidence that it has saved lives since patient choice was introduced by Labour in 2006 (as in http://blogs.independent.co.uk/2011/04/10/competition-in-health-care-saves-lives/). This research was picked up by the government, and appears to have been used by them to legitimise and justify the reforms. Andrew Lansley has suggested that competition will act as a spur to medical innovation as well (HSJ piece).
Those who disagree have written pieces showing this research is, in their view, flawed (http://www.lancet.com/journals/lancet/article/PIIS0140-6736(11)61553-5/fulltext (where there is are responses from the authors and the critics as well). The responses to Lansley’s piece above suggest his view is not without dissenters.
4. Will making greater use of the private sector improve the NHS?
Those in favour say it asks as a spur to driving up standards and reduce waiting lists (http://m.hsj.co.uk/5040671.article). Those against argue that they’ve already seen private sector disasters like Southern Cross, PIP and that there are other big problems as well (https://t1ber1us.wordpress.com/2012/02/10/the-problem-of-the-private-sector-in-nhs-reform/).
5. What about if hospitals or other providers fail (go bankrupt) in the new competitive marketplace?
The government have put together a ‘failure regime’ in the NHS bill to try and deal with this. Critics argue that it is unlikely that large healthcare providers will be allowed to ‘fail’ (closing NHS facilities has always been politically contentious, and finding sufficient capacity to take all the patients from a large provider is unlikely), and that non-public providers will simply form sub-companies, limiting their explosure and commitment to providing NHS care (as happened, for example, in the failed East coast mainline franchise). It is possible private organisations could be asked to take over failing NHS organisations (as has happened at Hinchingbrooke hospital), but then that would potentially leave taxpayers ‘on the hook’ should they run into trouble, and it proved impossible for them to be closed.
In sum, unless healthcare providers are allowed to fail, it is hard to see how market-based incentives can work, and it is hard to see how big providers can be allowed to fail.
6. What evidence is there in favour of the reforms?
The government have repeatedly claimed that their reforms are evidence-based, based mostly on the competition-based research discussed above. There are pretty strong refutations of the evidence underpinning the reforms from Ben Goldacare at http://www.guardian.co.uk/commentisfree/2011/feb/05/lansley-use-word-evidence and from Chris Mason at (http://justanotherbleedingblog.blogspot.com/2011/04/nhs-reform-from-liberating-to.html).
7. How much will the reforms cost?
The government originally claimed that the reforms would cost about £1.5bn. However, claims from others vary widely up to about £4.5bn at the top. In either case, the NHS needs to find savings of around £20bn in the coming years, and the costs of the reform add further to the savings needed. The government argue that the reforms will make the savings more attainable. Opponents wonder at the sense of undergoing significant structural reform at a time when the NHS is trying to find savings.
8. If the reforms don’t work out, can we just get rid of them?
Competition law means that, once areas of public service have been opened to non-public competitors, it is very difficult to remove competition subsequently. This may mean that the changes may be irreversible.
9. Why are we reforming the NHS now?
The government argues that the NHS needs to make £20bn of savings, and so major reforms are needed to achieve that goal. Those against the reforms wonder how you can change an organisation so much and still expect it to save money, and ask why the NHS reforms weren’t publicised and debated in the 2010 General Election if the Conservatives knew they were going to do this (the White Paper was published just six weeks after the government was formed).
10. Who supports the bill, and who is against it?
The BBC have a good list of clinical organisations at
Newspapers of the left (for example, the Guardian), have argued against the reforms for some time. In recent weeks, more right-of-centre publications such as the Spectator (http://www.spectator.co.uk/coffeehouse/7642848/lansleys-battle-shouldve-never-been-fought.thtml) have argued that the bill is becoming a liability, and the ConservativeHome website also published editorials against the reforms last week (http://conservativehome.blogs.com/thetorydiary/2012/02/the-unnecessary-and-unpopular-nhs-bill-could-cost-the-conservative-party-the-next-election-cameron-m.html).
There are media voices in favour of the Bill (John Rentoul of the Independent seems to support at least some aspects of it (see http://www.independent.co.uk/opinion/commentators/john-rentoul/john-rentoul-lansleys-bill-is-safe-but-he-is-not-6785686.html?origin=internalSearch).
11. Is it too late to not go ahead with the bill now?
The NHS is already some way through implementing the changes contained in the bill, and it will be difficult to go back to how things were in 2010 – staff have been made redundant, building leases sold off. However, commentators and academics have proposed a ‘Plan B’ including this one from Kieran Walshe http://www.guardian.co.uk/commentisfree/2012/feb/01/nhs-reform-plan-b