National Health Service Bill

Both the SHA and the Labour Party have developed policies that are designed to remove the market structures from the NHS and to return to an integrated managed system with a Secretary of State politically and legally accountable for its performance. Both have argued that a top down reorganisation is unnecessary and to be avoided; legislation is required to repeal the market related part of the 2012 Act but the broader aims can be achieved by allowing existing structures and organisations to develop in the appropriate way. In fact this is already happening in many parts of the country with Manchester as one example. People and relationships are more important than structures – structural change has never achieved what was intended.

The major difference is that the NHS Bill approach requires the closing down of hundreds of organisations and the creation of an unknown number of new ones based on a nationally defined model for regional and area bodies all with a largely appointed senior management. This is a much larger reorganisation than any undertaken so far and would be expensive, time consuming and a divergence from a focus on delivering and improving care. It would destabilise every part of the system and it is not necessary.

The Bill will not be passed. Even if it did the issues around implementation have never been thought through and there is no impact analysis or comparison of costs and benefits. Far more work is necessary to make any judgements about the true scale of change required.

The Secretary of State has never had the responsibility to PROVIDE the NHS. The word used in the 1948 Act is PROMOTE. Provision of a comprehensive NHS has always been limited by factors such as available resources and has never been absolute. What is required is a SoS with the powers to direct any part of the system – thus making it truly a single (albeit very complex) organisation able to make arrangements that are not covered by competition of procurement law.

The NHS has always had to make arrangements for services provided by small business based GPs, for ophthalmology, for pharmacy, for dentistry and services provided by private organisations, local authorities and voluntary bodies. The NHS has always treated some private patients. This requires some function of “commissioning” – it has always existed in the system and always will. The NHS has never provided all the services required and so some form of commissioning or even purchasing is necessary. What is required is proper democratic control over the planning/commissioning of services backed by proper openness and transparency.

There is no evidence that huge savings would be made by removing the market structures and this did not happen in Wales or Scotland, although over time some savings should be realised.

The way to prevent privatisation is to elect a government that does not do it. Passing an Act cannot in itself prevent privatisation, a new government could replace the legislation as the Tories did in 1990’s or else they could use guidance, regulation and the appointment of suitable people into key positions to drive outsourcing and privatisation as was done to local authorities during the 1980s. Legislation is Wales and Scotland does not make privatisation impossible but it would be very unlikely to happen.

Current developments around devolution around vanguards, success regimes, pathfinders and various other locally determined change programmes all rely on some flexibility over local structures – none could fit within the rigid structures of the NHS Bill. This would be yet another source of major disorganisation if the Bill passed.

The Bill is very weak on public and patient involvement, on regulation and on opening up structures to any form of genuine democratic accountability – perhaps because these are features that did not exist in the 1970s.

The Bill does not allow for there to be public bodies which only provide services as for example with the Trusts in Wales. Breaking up major teaching hospitals and reforming them somehow into some other structures under different management would be hugely complex, disruptive and contested. It is not necessary; there should be some bodies which are providers of services and some of these will be major public bodies. They will be involved in planning but there will be a requirement for some form of commissioning and some separation of this function from the delivery function is both valuable and necessary.

The SHA polices developed over some years provide a better framework for solutions than the NHS Bill and we should continue to develop our policies as we have agreed through the process agreed by Central Council. Supporting the Bill as opposed to merely sympathy with some of its aims negates much of the work done so far.