At the beginning of this year, the coalition government published its Health and Social Care Bill, which has now gone through its committee stage in the House of Commons. It will emerge from Parliament in the late autumn with a number of perhaps significant changes, but since the government has a large majority of seats, it is likely that something very like the Bill that was introduced will emerge.
Why, then, is there such a feeling of uncertainty about whether the reforms will actually take place? Surely a Bill becoming an Act trumps everything?
Well, no, not in the NHS. If you want NHS reforms to work, you need active support from people in the system. For example, when commissioning was introduced to the NHS it took several years for it to become at all effective because we failed to ensure that the skills and culture necessary to commission care were a significant part of the system. On the other hand, by the time the legislation creating Foundation Trusts had passed through Parliament, there was enthusiastic support from the best acute trusts to become the new public bodies.
The government’s main problem is that it has not explained why these reforms are necessary or precisely what they will achieve. The failure to explain this to the country may create a political problem at the next election, but the more immediate problem for NHS reform is that few people within the NHS know why it is happening.
This is partly because the government has changed its tune. What it described as a revolution in healthcare in its July White Paper, it militantly called an evolution in January when the Bill was introduced. Equally, what was in July portrayed as a crusade against NHS bosses, by January became a change that needed the active support of the very bosses it demonised a few months earlier.
Above all, the government has not explained why the NHS has to carry out these reforms, with this speed, at this time. There are many who recognise the need for NHS reforms but don’t understand either their speed or extent.
New commissioning organisations
The core aim of the reform is to give the majority of the NHS commissioning budget to groups of GPs called the GP Commissioning Consortia. Many GPs are keen to do this, so most people agree that putting them in charge of commissioning is a good idea. But the reform’s intention to abolish the existing commissioning organisations (PCTs) in April 2013 assumes that in the next 24 months the GP Commissioning Consortia can successfully grow to cover the whole country.
The question many people raise is: why make this a compulsion for all GPs when it would be better if only those who were willing and most capable were to develop the policy?
The rise of Foundation Trusts
On the provider side of the NHS, the government has said that all NHS hospitals should become Foundation Trusts (FTs) by April 2014. Foundation Trusts are publicly owned organisations that are independent of state ownership. At the moment, just over half of the acute and mental health trusts in the country are Foundation Trusts. To become FTs they have to prove to the regulator Monitor that they are up to the task. If all trusts are to become FTs by April 2014, this means they must have accounts ready to submit to Monitor for authorisation in 24 months’ time. A number of NHS Trusts – nearer 35 than 20 – will not reach the level of self-organisation necessary to become a Foundation Trust. Some trusts are either in the wrong place or of the wrong size to become financially viable and will therefore not meet Monitor’s tests for self-regulation.
Those that do not succeed in becoming FTs will need to be taken over and transformed in the next two years, creating an unprecedented wave of change in hospitals over that period.
The Health Select Committee has pointed out that trying to achieve this level of change at a time when there is the smallest increase in resources in the history of the NHS makes for a much bigger challenge. Will the NHS run out of money before the reforms kick in?
Given the various challenges and forces at work, it is likely the government’s intentions will take place, but probably not everywhere in the NHS.
