Modify the Bill, move on and focus on real challenges facing the NHS

Disagreements surrounding the Health and Social Care Bill must be settled quickly so that clinicians, managers and political leaders can focus on the challenge of meeting NHS efficiency savings.

Press release

Published: 27/05/2011

Disagreements surrounding the Health and Social Care Bill must be settled quickly so that clinicians, managers and political leaders can focus on the more pressing challenge of meeting the unprecedented efficiency savings required of the NHS, the Nuffield Trust has concluded in its submission to the NHS Listening Exercise.

It suggests that with the reorganisation already underway in the health service, a modified Bill should be allowed to move ahead, calculating that further uncertainty around the commissioning landscape would make it more difficult for NHS trusts to get on with the urgent business of making ends meet while improving the quality of patient care. 

To move forward, the Nuffield Trust recommends the Government develops a narrative for keeping the health service on the rails during the period between 2011 and 2015. This should include first, an acknowledgment that the structural reforms proposed in the Bill will not have much impact on the extent of financial control or quality of care during this time frame. Second, interim measures to help maintain quality of care in the face of significant budgetary pressures should also lay the foundations for a sustainable NHS in future. 

The Nuffield Trust report: The Health and Social Care Bill: where next?, makes a number of key recommendations arranged around the major flashpoints in the legislation, including:

Concerns about competition and role of the economic regulator:

  • Competition has a role in health care, and proposals to encourage it are right. But there should be no big bang. Markets do not work well in health care and it would be better to proceed cautiously over the next few years, helped by an intelligent regulator;
  • Competition has a role in health care, and proposals to encourage it are right. But there should be no big bang. Markets do not work well in health care and it would be better to proceed cautiously over the next few years, helped by an intelligent regulator;
  • Calls to scrap plans for an economic regulator for health care should be rejected. Applying the principles and right blend of competition alongside other tools that promote equity, access and efficiency to a complex field like health care will require significant analysis, evaluation and experience. This is more likely to come from a health care specific regulator;
  • Increasing collaboration between providers in health care may achieve as much or more benefit for patients than competition. The over-riding duty of Monitor should be amended to manage the health care system in the public interest by promoting competition and collaboration subject to a public interest test.

Concerns about the pace and implementation of reform:

  • Implementing a large scale reform programme as proposed in the Bill in this financial climate is a high-risk strategy. If managed poorly, organisational failure in parts of the health system are likely. Strong financial controls and effective quality surveillance will be required to reduce the risk of deteriorating quality and access to care (e.g. waiting times);
  • GP consortia should take on their new responsibilities gradually, depending on the extent of their capacity as judged by the authorisation process (for example for elective care only, or excluding mental health);
  • Some hospitals are unlikely to be financially viable as they are currently configured. For these, thoughtful, clinically led reconfiguration of care is needed. The Government should consider whether decisions on major service changes can be made more swiftly than in the past, perhaps by decoupling politicians from the decision-making process as has happened in, for example, Canada;
  • There is a strong case for assuring that PCT clusters have a longer-term future beyond 2013 to help consortia commission services not in the purview of specific consortia, and provide vital strategic leadership for service changes.

Concerns about GP-led commissioning:

  • The Government should publish the criteria proposed for authorisation, such as governance arrangements, how conflicts of interest will be handled and accountability, alongside the Bill;
  • Membership of a consortium by a practice should be mandatory (as outlined in the Bill), not voluntary. Otherwise commissioning the hospital care for the populations registered with practices which do not join consortia is likely to be far more difficult and fragmented;
  • The Bill should be amended to allow for the emergence of a diversity of integrated provider models which have the potential to align incentives across practices and hospitals and other providers to help a population stay well, and reduce the costs of care.

Dr Jennifer Dixon, Director of the Nuffield Trust said: ‘It may be helpful to think of two phases to NHS reform. ‘Phase 1’ is the period to 2014 when there will be acute financial pressure on the NHS, with the need to make efficiency savings that have never been achieved before. We are already seeing job losses and wage freezes, but significant service reconfigurations will also be needed, which have been blocked in the past. The Government needs to consider very carefully how decisions on service changes could be made more swiftly, or risk indefinite subsidy for hospitals that are not viable in their current form. This may include decoupling politicians from the process as has been successfully tried elsewhere.

‘Phase 2 is a reform agenda for the medium term which attempts to put the NHS on a more sustainable footing into the future. This is very important and the Bill largely speaks to this agenda. It is therefore critical that disagreements over the Bill, albeit important, are settled as soon as possible so that political and managerial effort can be redirected towards the phase 1 agenda – achieving effective financial control and maintaining the quality of care in the coming four years. Without this there is a real risk that the quality of patient care and access to services could deteriorate in the short term.’

She added: ‘On phase 2, there has been much concern about moves to greater competition and the role of the economic regulator. The research evidence suggests that competition in health care can be beneficial for patients if regulated appropriately. It is right to encourage more competition, but we should proceed cautiously with a health care sector regulator (as proposed in the Bill) applying a public interest test. Collaboration is also very important to encourage and may produce just as much gain for patients, and so the economic regulator should have a duty to promote competition and collaboration where appropriate.’

Notes to editors

  1. The report, The Health and Social Care Bill: where next?, follows a series of recent briefings from the Nuffield Trust on the Government’s NHS reforms, including: NHS reforms in England: managing the transitionNHS resources and reform: response to the White Paper Equity and Excellence: Liberating the NHS, and a parliamentary briefing published ahead of the second reading of the Health and Social Care Bill, which are all free to download from: www.nuffieldtrust.org.uk/publications.

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