Reforms to the NHS in England: a brief introduction

In the first of a two-part series, guest blogger Kate Thomson  provides helpful background on the proposed reforms to the NHS, as embodied in the Health and Social Care Bill. Also outlined are the major concerns and debates surrounding the Bill. Kate is a Senior Lecturer in the Department of Public Health at Birmingham City University and is currently researching health reforms in the Russian Federation.

What’s going on with the English National Health Service (NHS)? If you’re based outside of the UK but follow health policy discussions on social media, you may well have noticed that major changes are afoot, in the  shape of the Health and Social Care Bill.

The NHS’s origins in the immediate aftermath of  World War 2, have generated a fierce sense of loyalty, or at least, ownership, among the population over successive generations. It was said that even the most forthright and radical of Prime Ministers, Margaret Thatcher, declined to make significant changes to it, understanding that politicians ‘meddle with the NHS’ at their peril.  In fact the system has changed in many ways over the past 60 or so years, and perhaps most dramatically within the past 15 years, during the term of the Labour administration (1997-2010).

The most significant change made by the Labour government was structural: a radical extension of the ‘purchaser –provider’ split introduced in the early 1990s. What came to be called Primary Care Trusts (PCTs) handled the NHS budget for each locality. They planned and bought (‘commissioned’) services appropriate for their populations –including hospital services. Combined with stronger entitlements for patients to choose where they had treatment, this generated an ever more competitive environment- crudely put, hospitals had to compete for patients by demonstrating good outcomes and satisfaction levels. Services could be commissioned from the private sector (e.g. private hospitals) too. Health policy making powers were devolved to the constituent parts of the UK; the NHS in Scotland, Northern Ireland and Wales started pursuing and structuring services in different ways.

Equity & Excellence

In May 2010 a Conservative – Liberal Democrat Coalition government was formed. July of that year saw publication of White Paper, Equity and Excellence: Liberating the NHS. Major re-organisation of NHS services in England was proposed.  This caused some disgruntlement given that pre-election promises had included ‘no top-down reorganisation’ of the NHS.

Of particular note were the proposals to abolish Primary Care Trusts (PCTs) and move to a system of commissioning care based around ‘consortia’ of General Practitioners. GPs are primary care physicians and usually the first point of  contact with the health system. The ten Strategic Health Authorities (which oversee the NHS in regions) were also to go, to be replaced eventually (2013) by a single Commissioning Board. Over the following months, NHS organisations started gearing up for these changes, with some PCTs divesting themselves of resources and merging with others. GP practices started forming groups with other local practices to ultimately form Consortia. Some had already been involved in planning and commissioning services as a result of the ‘practice-based commissioning’ policy, but this principle was to be rolled out on a much greater scale.

The White Paper formed the basis of the Health and Social Care Bill which was presented to Parliament in January 2011. Rumblings of discontent from professional groups and other commentators, about the direction and speed of the proposed changes, led to the announcement of a ‘pause’ in the progress of the Bill. This prompted a ‘listening exercise’ – an extended consultation period, led by the NHS Future Forum, which reported back to the Department of Health in June.  After the listening exercise, amendments were made to the bill (some of which are outlined below), and it progressed through the House of Commons (lower chamber) in September.

Post ‘listening exercise’, the new commissioning bodies are now called ‘clinical commissioning groups’ (CCGs), rather than ‘GP’ consortia. This is to emphasise the involvement of other members of clinical teams-not just doctors- in providing expertise to, and making decisions within, CCGs. CCGs now have to have at least one nurse representative and must also consult with a range of other experts in making their decisions. ‘Pathway’ CCGs have been identified to try out the mechanisms.  Other amendments include tweaks to terminology (e.g. from ‘any willing’ to ‘any qualified’ provider); some clarifications about roles and responsibilities (e.g. the national Commissioning Board); and alterations to the timeline for implementation.

In October, the Health and Social Care Bill had a second reading in the House of Lords (the upper chamber). Unions and others had campaigned to persuade members of the Lords to reject the Bill.  However, this motion, and another to refer it to a Select Committee (which would significantly delay its progress as well as making significant amendments likely), were defeated. At the time of writing, the Bill is progressing through the ‘Committee stage’ in the Lords, which involves very close scrutiny of the details in the legislation.

Reaction and debates

There has been considerable resistance to the proposed changes from professional and public sector groups. The Keep Our NHS Public campaign (a public organisation); the British Medical Association (representing doctors), Royal College of Nursing ,Royal College of GPs and a collective of public health specialists, among others, have written very considered and constructive, yet in places quite damning responses.  Some summaries of professionals’ and academics’ responses to the Bill are available here and here.

Major concerns and debates around the bill include:

  • the extent of market competition – the role of the private sector, impact on NHS services and smaller-scale providers (charities, social enterprises);
  • vulnerability of services (or even population groups) not regarded as priorities by commissioners;
  • the blurring of roles (especially for GPs) leading to potential conflict of interests, and to reduced time caring for patients;
  • extent to which the proposed changes will really reduce ‘bureaucracy’;
  • cost of implementing the changes in a time of financial austerity;
  • perceived fragmentation of the NHS as a national institution; and withdrawal of ultimate responsibility of ‘state’ to provide health services;
  • the place of public health responsibilities within the new structures.

Some of these issues are going to be discussed in greater detail in my next blog post.

  1. British Medical Association (2011) BMA Statement on the Health and Social Care Bill, 20 July 2011 http://www.bma.org.uk/healthcare_policy/nhs_white_paper/latestnhsreformstatement.jsp    [accessed 17 October 2011]
  2. Royal College of Nursing (2011) RCN Briefing on the Health and Social Care Bill, October 2011 http://www.rcn.org.uk/__data/assets/pdf_file/0003/408351/Health_and_Social_Care_Bill_Update.pdf [accessed 17 October 2011]
  3. Beckford, M. (2011) Nearly 400 public health experts warn Lords to reject NHS reforms, 3 October 2011 http://www.telegraph.co.uk/health/healthnews/8804619/Nearly-400-public-health-experts-warn-Lords-to-reject-NHS-reforms.html [accessed 17 October 2011]
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  1. [...] in England, ‘the NHS’ has meant the local Primary Care Trust, although these structures are now in flux.  Lansley’s Conference announcement clarified that the initial target group for personal health [...]

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