The new Health and Care Bill is a veritable curate’s egg. We do need to link the NHS and social care to achieve a smooth transition between the two. We do need to remove the close to a decade old burdensome bureaucracy when outsourcing work to the private sector. We do need to remove the ambiguity of NHS England; as a Non-Departmental Public Body it is both answerable and not answerable to the Secretary of State at the same time.
It should either become an independent public corporation, like the Bank of England, or an Executive Agency which would be a separate organisation within the Department of Health and Social Care. NHS England staff would become civil, rather than public, servants. Given that “the Bill also includes proposals from the February 2021 White Paper to give the Secretary of State for Health and Social Care powers to direct NHS England”, it appears the Executive Agency option is being taken. It would have been sensible for the Bill to say so.
The addition to the powers of the Secretary of State, however, is a worrying feature of the Bill. According to the Commons Library briefing (p.8) the Health Foundation, NHS Providers and the NHS Confederation have all expressed concerns on that score. No ground rules are set for when the Secretary of State can move in to direct NHS England matters. The House of Lords may also be concerned with Clause 130 which “gives the Secretary of State some general regulation making powers consequential on the Bill. In particular, the power may be used to amend, repeal, revoke or otherwise modify any provision within this Bill or any provision made by or under primary legislation passed or made either before this Act is passed or later in the same Parliamentary session.” The worry is that a politician playing to the media may conflict with a CEO trying to run the NHS the country needs.
The Bill is a curious mixture of strategy and technical detail with some of the most important strategic issues omitted altogether. For example, there is no word on how the chronic shortage of doctors, nurses and care workers will be corrected. This problem has been exacerbated by the pandemic backlog and new immigration controls. Too many, maybe all, of the changes lack precision or justification in the explanatory notes. Integrating health and social care would be fine if the long-awaited social care Green (or White) Paper had appeared and given us any idea on what social care will look like. The Nuffield Trust put it this way “the hope that the NHS will cooperate more with social care services will also come to nothing without proper reform so that more people receive help, more staff join the sector, and stability is restored after years of desperation.”
42 Integrated Care Systems (ICSs) now cover England but they have grown like Topsy, each in it’s own way with no standard pattern. “As a result, there are significant differences in the size of systems and the arrangements they have put in place, as well as wide variation in the maturity of partnership working across systems.” Whilst the objective of a joined-up health care interface is incontestable, they involve a plethora of meetings. Taking GPs away from dealing with patients, as the 2012 Act did, may help some patients but harm others.
The boundaries for ICS responsibilities vary; some include housing, some do not. In short, we have no idea, and nor does the DHSC, which ISC models are better than others? Devolution has its merits but the Bill should define what will be devolved to ICSs and what will not be. Nor is the national versus local logic trap addressed. ICSs move decision-making, e.g. on how budgets are spent, from national to local. Tailoring the provision to local needs makes sense but it also means that some benefits with be available in some localities but not others, at which point the tabloids will cry “post-code lottery”. What is the answer?
The Bill sets a very broad remit for NHS England, namely the “Triple Aim” of “better health and wellbeing, better quality health care and ensuring financial sustainability”. No one will argue with the NHS living within its means, topped up in time of emergency. If the NHS is really responsible for our individual health, rather than us, the government should adopt the Chinese model and resource the NHS when we are fit and not when we are sick. If the aim refers to public health in general, why should the NHS do that when we have a plethora of other public health bodies at national and local government levels?
“Well-being” should only be a matter for the NHS when we are ill or at risk of becoming ill. The dictionary defines well-being as good spiritual and human relationships, having a (financially) comfortable way of life and being happy. That’s a tall order for the NHS. “Better quality health care” is not just a matter for the NHS: it is a matter for the ICSs.
With the cost of the NHS soaring to heights that will become unaffordable, we should be thinking about trimming, not adding, responsibilities. Should it simply be concerned with the treatment and cure of physical and mental health conditions, i.e. the sick, or should it be responsible for wider user demands, e.g. fertility and cosmetic surgery? Or for primary research, and reduce over-treatment of the dying, tonsillectomies, over-prescription of antibiotics and over-testing?The Taxpayers Alliance reported one Foundation Trust spending £360,000 on a failed music festival, No doubt it would have been good for the wellbeing of the citizens of Derby.
Hospital Foundation Trusts, with their layers of governance, are both independent and not independent of the NHS and DHSC at the same time. In 2003, NHS Foundation Trusts were “established in law as new legally independent organisations called Public Benefit Corporations.” The Boards were to “be made up of local people, patients and carers and staff.” Has anyone investigated whether this local democracy is worthwhile or whether it just distracts the CEOs from running their hospitals? The 2012 Act encouraged all Hospital Trusts to shift to Foundation status but one third have not done so. The current Bill affirms all this, stopping NHS England from limiting Foundation Trust capital, but not revenue, spending if NHS England thinks the Foundation Trust is about to spend more than its fair share of ICS capital money.
Many of the changes in this long and complex Bill are to be applauded, notably those which tidy up the 2012 Act. No doubt there will be another before long as a future Secretary of State makes his mark. As one wit put it “What changes all the time but stays the same? The NHS.” The central issue of this Bill is the redistribution of responsibility. We all know who will take the credit or blame when things go right or wrong. Do we really want a politician, without relevant experience and changing with every reshuffle and election, to direct NHS England rather than a seasoned executive from that sector?
Now look at it with the perspective of an incoming CEO once this Bill is enacted. On paper, one has charge of the largest organisation in the UK, 1.5M people, and the fifth largest in the world. As the staff are now civil servants, you do not set the wages nor even negotiate them. The 2019/20 NHS England budget was £139 billion and the Trusts, mostly Foundation Trusts, had £92 billion of that. But they do not report to you. GPs’ surgeries cost about £13 billion, and probably should be double that, but GPs do not report to you either. The only parts of NHS England that do report to you are the parts that do not actually treat or cure people.
The DHSC has 14 arm’s length bodies apart from NHS England, though they come and go so fast it is hard to keep track. The new Bill gives powers to the Secretary of State to change any of them whenever, but that is probably a good idea. Nowadays, IT is an integral part of any large organisation with the rare exception of NHS England. NHS Digital and NHS Business Services are separate arm’s length bodies reporting directly to the Secretary of State. No wonder major NHS IT initiatives have such a chequered history. Social care has no arm’s length bodies at all. These bodies will all keep the Secretary of State well versed on the NHS matters he can micro-manage, even when the media are quiet. ICSs will be taking care of dealing with all the people who actually need health care and they will be run by hospital Trusts, GPs and local authorities, none of whom answer to the NHS CEO. Overruled and unsupported, one has to question the wisdom of anyone who wants the job.