NHS: a guide through the wreckage

Andrew Lansley’s Health & Social Care Act, which eventually passed through parliament in March despite massive and growing opposition – not just from health unions and campaigners, or the wider public, but also from GPs and from hospital doctors.

It’s set to change the landscape of the NHS. The changes are not instant, but will be imposed at a forced march, with most to be implemented within a year.

It will sweep away the 150 or so Primary Care Trusts that currently hold the budgets to commission services for defined population areas, and also carry out over 120 Statutory Duties, many of which involve protecting patients’ rights, protecting the vulnerable and properly accounting for hundreds of millions of pounds of public money.

Also disappearing are Strategic Health Authorities, whose role included coordinating PCTs, overseeing NHS Trusts, and organising the education of medical and professional staff.

Neither set of bodies was especially popular with the public or a model of democracy, although PCTs and SHAs are at least obliged to meet in public and publish their board papers: they have been the main vehicle for unpopular government policies, and recently for driving through spending cuts and imposing cutbacks and closures on local hospitals. But they currently plan and control budgets of around £80 billion, and are set to be wound up by April 1 next year.

Their replacement will be far worse:  a new and even more complex many layered bureaucracy, including:

A new National Commissioning Board

This will have 3,500 staff, nine national directorates and “a national network of local offices”, and will initially work through 52 transitional “clusters” of PCTs to oversee the establishment of Clinical Commissioning Groups (CCGs) (see below).

The NCB will be the body that commissions primary care services, specialist health services, and oversees CCGs, with extensive powers to select their leaders,  intervene and to decide whether or not to agree CCG proposals.

237 Clinical Commissioning Groups

These will be the local level commissioners, composed largely of GPs, with a token involvement of a hospital consultant and a nurse from outside the area, and in many cases management roles taken by non-GPs. CCGs need to seek authorisation from the NCB, which will be considered in “waves” from autumn 2012 through to January 2013.

Up to 40 Commissioning Support Organisations

CCGs will be advised, and in many cases much of their commissioning work would be shaped, by up to 40 Commissioning Support Organisations, initially to be hosted by the National Commissioning Board, but no later than 2016 these will be hived off as commercial concerns, selling their services to CCGs. These have to present business plans in August 2012 and seek authorisation, with decisions announced in October.

Referral Management Centres

GPs’ clinical decisions on which patients to refer where, and for what treatment will also be second-guessed by a growing network of “referral management” organisations, some operated by the private sector, which already cover at least one in four GP practices.

15 ‘Clinical Senates’

The composition, role and purpose of these has still not really been explained except as a sop to placate marginalised hospital consultants for their exclusion from any role in commissioning.

108 NHS Trusts

Those that have not been able to make the transition to Foundation Trusts are now on a forced march towards Foundation status – or face the threat of dismemberment and mergers by 2014.

For many of them the process will be painful, because the stumbling block to FT status is their parlous state of finances – in many cases centred on the massive cost of PFI hospitals.

143 Foundation Trusts

These were originally the high-flying, financially strongest Trusts, but the cash squeeze has meant that a growing number are struggling to balance the books.

Any Qualified Provider

Between them, Monitor and the CQC will be charged with drawing up a register of organisations deemed “qualified” to be licensed to deliver health care in England: GPs will be required to offer patients the option of “any qualified provider” in an increasing range of services, beginning with three locally-chosen community and mental health services from September this year.

Up to 152 Health & Wellbeing Boards

These are to be run by local councils. 138 are already operational, although the form is likely to vary widely from one council to the next.

In theory, according to the Department of Health “Board members will collaborate to understand their local community’s needs, agree priorities and encourage commissioners to work in a more joined up way.

As a result, patients and the public should experience more joined-up services from the NHS and local councils in the future.”

In practice, HWBs can be composed of as few as six people, only one of whom may be an elected councillor, and their actual powers, which come in from April 2013, will be limited, especially where the political leadership of the council clashes with the leadership of its local CCG(s).

Council Health Oversight and Scrutiny Committees

Still running, although of varying effectiveness, these survive the new Act: composed of elected councillors, who have the power to co-opt, they  will continue to offer a forum to which health and social care managers and services can potentially be held to account, but in sadly few HOSCs are these powers used effectively.

Public Health England

This new special health authority is to be set up to oversee the transfer of public health functions (and the staff with the knowledge on planning services for whole populations) from PCTs to local councils.

There will be an allocation to councils of allegedly ‘ringfenced’ funding from April 2013 for public health services – while every other council service is facing a massive and continuing squeeze in the drive for 28% cuts.


The body that regulates Foundation Trusts is to have new powers. It is required first and foremost to “exercise its functions with a view to preventing anti-competitive behaviour in the provision of health care services.” So despite a formal requirement not to discriminate between public and private provision, its task is to ensure maximum private sector challenge to existing NHS providers.

But the Act also says that where it chooses to do so, it is also free to decide whether or not to “exercise its functions with a view to enabling health care services provided for the purposes of the NHS to be provided in an integrated way”. Nobody really expects this to happen: it was one of the LibDems’ token, toothless amendments.

Cooperation & Competition Panel

This grim relic of New Labour’s eagerness to turn the NHS increasingly into a competitive market lingers on under the chairmanship of fanatical privatiser Lord Carter of Coles. It will continue to act as a complaints panel for aggrieved private sector companies demanding the right to a slice of NHS budgets in profitable services, and will serve as an advisory panel to Monitor.

Care Quality Commission

This was formed in 2009 from the merger of three previous regulators and is supposed to regulate the quality and safety of over 21,000 care providers , but according to the Commons Public Accounts Committee it has “failed to fulfil this role effectively”.  The PAC declared it has serious concerns about the CQC’s “governance, leadership and culture”.

Its effectiveness is certainly questionable. Later this year the CQC is required to register 10,000 GP practices – by asking  GPs themselves to declare whether or not they are meeting the essential standards.

The CQC chair Dame Jo Williams recently complained that it had been obliged to abandon 580 planned inspections in order to comply with Andrew Lansley’s instruction to conduct a spot check on 250 abortion clinics (at a cost of over £1 million) – indicating how little independence the CQC actually has from government.

The CQC has admitted an “unforgivable error of judgment” in failing to act on a whistle-blower’s “grave” concerns about the behaviour of staff at Winterbourne View care home, later exposed in footage shown on Panorama.

The PAC points out that while whistleblowers have to be a key source of intelligence in helping the CQC to monitor the quality of care, but it has closed its dedicated whistleblowing hotline.

In March, Celia Bower, the CQC chief executive resigned after a Department of Health report said the CQC had faced “operational and strategic difficulties” with delays having “seriously challenged public confidence in its role”.

Baroness Young, its previous chairman, resigned after Basildon Hospital, in Essex, was exposed for having filthy wards and a high death rate despite being rated as “good” a month previously.

Healthwatch England

This new quango, is to be a subordinate “independent” part of the Care Quality Commission, to be followed by local Healthwatch groups.

Healthwatch is the latest, even more  toothless incarnation of a “patients’ voice” and follows a growing list of inadequate and marginalised bodies set up after Labour scrapped Community Health Councils and stripped away their extensive statutory powers.

Exploit the few loopholes in the Act

Foundation Trust members and Governors

Foundation Trusts are obliged to have members and a board of governors.  To be a member, you have to be over 16 and live in the catchment area of the FT. The trust will define what “catchment” means.

As a member you will be able to speak at members’ meetings and attend trust board meetings – which means that you’ll be able to ask the board questions.

Members can also stand to be governors: the governors have to approve the trust strategy and appoint the auditors. They also appoint non-executive directors (NEDs, including the Chair of the trust) who sit on the trust board.

The government says that before an FT can increase its private patient income to over 5% it has to have the approval of the Council of Governors.

Governors should also monitor all of the trust’s finances carefully.

Health and Wellbeing Boards

Councillors (district, county or unitary) can stand to be a member of the local Health and Wellbeing Board, which will be able to challenge local commissioners (CCGs) on their commissioning decisions, including those that involve transferring NHS services to private companies.

HWBs also have discretion to widen their participation: campaigners should press their local councils to make them big, vocal and active.


HealthWatch will be local organisations with a mandate to inspect their health and social care services. Local HealthWatch will be hosted by local councils and are intended to be largely toothless.

However, HW will put together reports on local services, which can be escalated to the national HealthWatch and CQC (Care Quality Commission).

A HW member will also sit on the local HWB and can challenge commissioning decisions.

HW will also have a mandate to inspect all providers.

Patient involvement

The Act says that there has to be patient involvement in commissioning. Your local GP will have a patient participation group (if not, then it will have very soon).

The actual commissioning decisions will be carried out by the CCG, but you may find that the GP group will give you access to the CCG patient involvement group.

CCGs have to have a policy on patient involvement. Ask your local CCG what patient consultation they are carrying out, and ask to be involved.

If you are involved in the formulation of the CCG policy and the CCG decides to use the private sector you could make this public and spark a local debate.

Countdown to Tory health care market

“Spring” 2012:  Consultation on a public health workforce strategy: appointment of chief executive designate for Public Health England and agree PHE structure

May:  National Commissioning Board’s “new organisational design” takes shape.

June: Health Education England kicks off in shadow form

NHS Trust Development Authority (NTDA) launched “to create a dynamic organisation able to provide oversight and accountability for the remaining NHS trusts”.

July:  Authorisation of CCGs begins (further waves in September , October and November)

August:  Commissioning Support Organisations (CSOs) must submit business plans to NCB

September:  Patients must be offered “Any Qualified Provider” for at least three locally chosen services

Healthwatch England launches

October:  CSOs hear if they have been authorised

April 2013

CCGs established with statutory powers

Public Health England launched

Local Healthwatch launched

New NCB system operational

Health Education England operational

NHS Trust Development Authority operational


CSOs hosted by NCB


NHS Trust status abolished