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23 February 2011

All change: NHS reform in England

All change: NHS reform in England

This article is published in accordance with the Alliance's Basis of Faith; however, this is a comment piece and therefore is unable to reflect every detail and nuance of belief held by Alliance members. Comment pieces may express views on which there is a divergence of opinion or understanding among evangelicals

The Health and Social Care Bill currently going through Parliament lays the foundations for the biggest upheaval of the NHS since it was founded in 1948. It is a complex and wide-ranging piece of legislation, reflecting the far-reaching nature of the Government's programme of reform for the NHS in England, which was first set out in the NHS White Paper Equity and Excellence: Liberating the NHS in July 2010. Sir David Nicholson, the NHS Chief Executive, is widely quoted as describing the proposals as the biggest change management programme in the world-the only one so large "that you can actually see it from space".

At their heart, the Government's plans build on previous NHS reforms to devolve more responsibility to front line doctors. Groups of General Practitioners (GPs), known as commissioning consortia, will be given real budgets to buy (or "commission") hospital care on behalf of patients in their local communities, and together will be responsible for handling around £80 billion of the NHS budget. Consortia will be able to purchase packages of care from "any willing provider", including the private sector, in order to promote competition between suppliers, for example hospitals, and increase choice for patients.

At the same time, Secretary of State for Health Andrew Lansley has announced plans to abolish regional strategic health authorities (SHAs) and the 152 primary care trusts (PCTs) that currently commission care for patients in England. Within three years, all hospitals will also have to become foundation trusts- independent, self-governing organisations with financial freedoms to raise their own funds. The Bill will also see the Department of Health lose many of its current functions, and see healthcare regulation mechanisms overhauled. Virtually no NHS structures will remain untouched, despite David Cameron's repeated promise prior to the General Election that he would put a stop to "top-down reorganisations of the NHS".

NHS reforms are by no means a new thing, but a number of groups, including the British Medical Association and the Patient's Association, have expressed concern about the magnitude of the proposals, and the speed with which they are being implemented. The chairman of the Royal College of General Practitioners, Dr Clare Gerada, also noted that it will be important to "guard against fragmentation and unnecessary duplication within a health service that is run by a wide array of competing… providers".

The independent health think tank the Nuffield Trust has described the principle of giving doctors more responsibility as "a logical one" because GPs are already responsible for most NHS spending through prescribing, patient referrals to hospital, and other clinical decisions. However, GP practices are used to acting as small businesses, not large conglomerates, handling millions of pounds. [1] Many GPs lack the skills and experience necessary to assume commissioning responsibilities by the April 2013 deadline specified in the White Paper. This document also contained a pledge to reduce NHS management costs by more than 45 per cent, but this fails to recognise the behind-the-scenes analytical support currently provided by PCT staff involved in the commissioning process - often dismissed as bureaucrats - and GP consortia will need to be furnished with this expertise in some form or another, potentially from the private sector.

Andrew Lansley has claimed that the proposed reforms are necessary in order to drive up the UK's poor health outcomes compared with the rest of Europe. The official ministerial briefing for the Health and Social Care Bill stated that, despite spending the same on healthcare, the rate of death from heart disease in England is double that in France. However, writing in the British Medical Journal, John Appleby, chief economist at the health think tank the Kings Fund, called the secretary of state's use of this data into question. He noted that, not only did the UK see the largest fall in death rates from coronary heart disease between 1980 and 2006 of any European country, if trends from the past 30 years continue, the UK will have a lower death rate than France as soon as 2012. [2]

At the same time, evidence from similar, but less radical reforms in the past, such as GP fund-holding in the 1990s and practice-based commissioning more recently, shows that such reorganisations took several years to embed properly and there is little evidence that they produced much, or any, improvement in patient care. [3] It is therefore unclear whether these new proposals will in fact improve patient outcomes as the Government claims.

However, perhaps the biggest challenge is whether or not the reforms can deliver sustained improvements in care during a period of major financial challenge for the NHS. The cost of the reorganisation has been estimated at £2 to 3 billion3 at a time when the NHS is already required to make £15 to £20 billion of efficiency savings by 2014-15. Major reorganisations also inevitably involve other costs, including the loss of organisational memory and time taken up by the process of implementing change, distracting staff from their core activities. There is already disruption to service delivery as many experienced staff currently employed by SHAs and PCTs are now leaving the NHS following the announcement of the reforms, and are unlikely to be replaced prior to the abolition of these bodies.

In conclusion, the reforms set out by the Government represent an unprecedented upheaval of the NHS. There is widespread unease about the scale of the proposed changes and the speed with which they are being implemented, as well as concern that such a radical reorganisation may adversely affect service delivery. Although some of the principles, such as greater GP involvement in commissioning, may be a step in the right direction, the Government has yet to put forward evidence that the proposals will be effective at improving either the quality of care or patient outcomes, particularly at a time when the NHS needs to make extensive efficiency savings.

Dr Helen Barratt is a Wellcome Trust Fellow, currently working in health services research at University College London

[1] The Nuffield Trust. Parliamentary Briefing: Health and Social Care Bill Second Reading (http://www.nuffieldtrust.org.uk/uploadedFiles/Projects/Health-and-Social-Care-Bill-Second-reading_Jan11.pdf)

[2] Appleby J. Does poor health justify NHS reform? BMJ 2011; 342:d566

[3] Walshe K. Reorganisation of the NHS in England. BMJ 2010; 341:c3843