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Picking up the Bill: the revised programme for NHS reform

The Coalition Government has proposed a number of modifications to its Health and Social Care Bill in response to the NHS Future Forum’s recent report. The proposals address concerns within both the NHS and the Coalition about aspects of the original legislation. Significant changes are proposed to key aspects of the Bill, including clinical involvement in commissioning and the role of private healthcare providers in the NHS.

Andrew Lansley

Listening and responding

To see what is new in the revisions, it’s important to consider their drivers. David Cameron, presenting the Government’s revised plans for NHS reform, said that “the fundamentals” have not changed: what has changed is “the detail of how we’re going to make all this work.” Broadly speaking, the new proposals have kept those features of the Bill that were welcomed by the medical profession and revised those features that were strongly criticised by it.

Since the Health Bill placed emphasis on giving control over decision-making to GPs, the criticisms made by the BMA have impacted strongly on the Government – and in particular, on the Liberal Democrats. The BMA welcomed the White Paper’s emphasis on empowering clinicians and patients, integrating health and social care, and focusing on health outcomes rather than processes. However, as the Health Bill worked its way through Parliament, the BMA became more forceful in its criticisms of what it said would be a fragmentation of the NHS into competing bodies, with private healthcare providers poised to take over when NHS hospitals failed. It recommended a model of ‘integrated’ care, with hospital specialists and nurses working alongside GPs to provide consistent care nationwide, without making NHS providers compete with each other and with the private sector for franchise-style contracts.

The Government’s eight-week ‘listening exercise’ paid close attention to those stakeholders – primarily GPs – on whom the success of the reforms would depend. The result is a significant drawing back of the proposals on provider competition, alongside a more nuanced plan for devolving responsibility from PCTs to clinician groups, with more time and resources being committed to ensuring continuity of services during and after the transition.

Less invasive surgery

The proposed changes to the Health Bill come under six headings, all of which relate to concerns raised by the BMA and other clinician bodies:

Overall accountability for the NHS. The DH will have a duty “to promote a comprehensive health service” (but not, as in previous legislation, to provide it). All NHS organisations will promote the “core principles and values” of the NHS, including the 18-week limit on waiting times (which Andrew Lansley abolished in 2010).

Clinical advice and leadership. The Government commits to a “more ambitious” plan whereby GP consortia, now termed “clinical commissioning groups” (CCGs), will have governing bodies with at least one nurse and one specialist doctor. They will be supported by national specialist “clinical networks” and regional non-specialist “clinical senates”.

Public accountability and patient involvement. There will be clearer duties across the NHS to involve “the public, patients and carers”, including representation in the governing bodies of CCGs and a stronger role for health and wellbeing boards in local councils.

Choice and competition. The new proposals rein back the role of competition in the provision of NHS services, accepting the BMA’s view that competition should widen choice but not be “an end in itself”. Monitor will now have a core duty to “protect and promote the interests of patients” rather than to promote competition. The Government promises “new safeguards against price competition, cherry picking and privatisation”. Significantly for industry, there are positive commitments: CCGs will have “stronger duties” to promote “care that is integrated around the needs of users”, while the new NHS Commissioning Board “will promote innovative ways to integrate care for patients”.

Developing the healthcare workforce. More detailed plans are presented to ensure continuity of staffing and expertise levels during and after the transition period, including “retaining the best talent from PCTs and SHAs”.

The timetable for change. The new CCGs must be established by April 2013, but they will not have to take on commissioning responsibilities until they are “ready and willing” to do so. Until that point, the NHS Commissioning Board will commission on their behalf. The transition will be managed to “avoid instability”.

Work in progress

The positive Liberal Democrat response to the revisions suggests that the new Health and Social Care Bill has better prospects of becoming legislation. However, the BMA has voted to call for further changes, saying that the proposed revisions do not “satisfactorily address” their concerns over competition and the need to maintain a comprehensive service.

As the details of the new Bill are worked out over the coming months, medtech suppliers should pay close attention to further changes – particularly in relation to its new focus on “integrated care” and the role of innovation in achieving that ideal.

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