Still Fatally Flawed

The need for hundreds of amendments to their own Bill shows how fatally flawed the Coalition’s Health and Social Care Bill is.  Whilst Version 1 had some degree of coherence Version 5 is incomprehensible – nobody understands how the new structures will fit together or how accountability will work.  And nobody is able to explain why the Bill is actually needed.  The Bill has no support and no compelling case for change.

The fact is that the Bill is needed to convert our NHS from a publicly accountable, managed system into a market – driving reform through competition.  Despite hundreds of amendments to the Bill the core, based on the drive for market led reform, remains.  Part 3 of the Bill dealing with all the ramifications of economic regulation is still there.  That is the part of the Bill that poses the real threat to our NHS, the rest just makes it easier for it to come about. But even if you supported market led reform you would still have to say the Bill is now hopelessly compromised and incoherent – and so dangerous. To mention just the most glaring stupidities:-

Monitor, which currently regulates Foundation Trusts, is to become the Economic Regulator of all providers to the NHS – giving it an insurmountable conflict of interest.

Market regulation requires a failure regime so bad organisations and poor services “exit” and are replaced by new ones.  The failure regime in the Bill has already been comprehensively re-written but after further surgery it remains simply daft.  It replaces an NHS where risks are pooled across the entire population with some string and sellotape arrangement with premiums and levies and risk assessments carried out by credit rating agencies.  Untried and probably unworkable.

The NHS Commissioning Board is to regulate commissioning (authorising and overseeing the new Clinical Commissioning Groups) but also commissions £20bn of services – again huge conflict in roles.

To support the drive for “integration” (which is still undefined – unlike competition) the commissioning functions are fragmented. To drive integration at local level – if this is not deemed anti-competitive – we have Health and Wellbeing Boards made up of the great and the good with one elected Member.  The Board is allowed to have a strategy but not given any powers to ensure the strategy is turned into proper plans or delivered.  Toothless – and probably irrelevant as far as health care delivery is concerned given it would have to compete with the bloated top down management structure of the NHS Commissioning Board and its outposts.

To support making commissioning more local the job of commissioning the most local services, those in primary care, is given to a national quango.

GPs and a few token others will be able to form the governance light Clinical Commissioning Groups.  They will be given a lead role in some of the commissioning tasks for some local services (but by no means all) but can only do so within a regime which gets more complicated and constrained all the time – they will be buried under regulations and guidance just as the PCTs were.  They will also face major issues around how to resolve their conflicts of interest – as commissioners and providers – and also as impartial advisors to patients but also Budget managers.  Despite reassurances, nothing in the Bill will protect Clinical Commissioning Groups from legal challenge if they do not use competition properly.

The extensive skills and knowledge built up in PCTs in the area of commissioning support will be fragmented, parcelled up and then sold off so as to have a “market” for support in competition with the major consultancy and accounting firms who already infest every part of the NHS.  NHS Staff will be made redundant and then either re-employed or re-hired.

To reduce bureaucracy extra layers of bureaucracy have been introduced and the Bill ensures we have far more organisations and far more complex transactional structures – so costs of system management have to go up.

To stop top-down management a new structure with the most regimented top down structure possible is put in place.  There is no longer any place for independent and properly appointed non-executive directors in the structure just Managers.  No doubt there will be Regional Directors (and locality Directors) employed by the NHS Commissioning Board – but there won’t be independent Chairs who have a public accountability – and might be difficult.  Commissar Sir David Nicolson reigns supreme.

And that is without looking at a highly botched carve up of Public Health duties; a half-baked attempt to form Health Watch without proper funding or proper independence, etc,etc.

The Bill is a complete mess.  The NHS would be less damaged if it was stopped.  Drop the Bill.

Irwin Brown, February 2012