It is almost a decade since former Conservative health secretary Andrew Lansley attempted to sell the merits of his vision for the NHS – the Health and Social Care Act, to patients and those at the heart of the health service.
Writing to trust chief executives and CCG (clinical commissioning group) leaders back in early 2012, Lansley spoke reassuringly of how his revolution would improve care for patients by ‘freeing’ the NHS from political interference and Whitehall imposed directives.
What actually followed proved to be one of the most divisive and damaging reorganisations of the NHS in its lifetime, paving the way for significant outsourcing of contracts and embracing of the private sector working in healthcare as well as years of underinvestment.
While the effect of the 2012 act’s destructive legacy on health services in England can still be seen, the NHS is facing another politically driven, top-down reorganisation of its structures through the Government’s proposed Health and Care Bill.
All this is being done in the middle of a devastating pandemic where doctors have worked flat out for 18 months and have little ability to focus on a major reorganisation of the NHS in England.
Still being considered by the Commons, on the face of it the bill appears to seek to reverse some of the 2012 act’s most harmful aspects, such as enforced competition and automatic service tendering and promote greater collaboration and integration across different parts of the health service.
Diving into the detail though tells a different story. The BMA has decided therefore that in its present form, the bill fails to go far enough in addressing the many outstanding issues that blight the NHS.
This includes the fact that the wording of the bill says nothing about addressing the years of underinvestment and a workforce crisis that includes a shortage of around 50,000 doctors.
The bill also threatens to empower private health providers through its pledge to repeal section 75 of the 2012 Act, which enforced competitive tendering of services and contracts, without explicitly stating that the NHS should be the default first-choice provider when commissioning services. Worryingly the bill fails to rule out allowing private firms a seat on ICS (integrated care system) boards where decisions are made over commissioning care and awarding contracts.
The bill could also result in increased political influence in NHS decision making and undermine long-term planning by failing to balance increased powers for the health secretary such as intervening in service reconfigurations and redirecting the NHS outside of the annual mandate, with responsibility for providing care.
BMA council chair Chaand Nagpaul has already made clear to members of the Parliamentary Health and Care Bill select committee, that he and the association believe that, in its present form, the Health and Care Bill is not fit for purpose.
Put simply; it is the wrong bill at the wrong time. It is all the more egregious that ministers are apparently attempting to hurry through this Bill – the most significant piece of healthcare legislation since the 2012 act, at a time when the NHS is still struggling to contend with the greatest public health crisis it has ever faced.
Quite apart from the ongoing daily infections and hospitalisations resulting from COVID, the health service is staring down the barrel of patient waiting lists in excess of five million and rising.
While many aspects of the health service require change, expecting doctors and other healthcare staff to be able to meaningfully participate in scrutinising and engaging with this Bill under the circumstances outlined above is laughable.
In light of these concerns, the BMA is calling for significant amendments to the wording of the proposed legislation across a number of areas:
- Protecting the NHS from further privatisation by ensuring that the bill explicitly cites the NHS as first choice provider when awarding contracts as well as blocking access to seats on ICS boards for private providers
- To ensure that the bill includes a responsibility for the health secretary to produce to Parliament ongoing, accurate and transparent workforce assessments to directly inform recruitment needs
- To strive for a truly collaborative and integrated healthcare system by ensuring that clinical and patients views are represented at all levels of ICS structures through the appointment of primary, secondary care and public health doctors independent of NHS management
- Safeguarding against political interference in policy setting by limiting the powers available to the secretary of state.
To this end, the BMA continues to lobby members of parliament and collaborate with fellow healthcare bodies such as the Royal College of Nursing and Royal College of Physicians.
Evidence submitted by Dr Nagpaul earlier this month to the Health and Care Bill committee has already resulted in some potentially promising signs that our concerns and suggestions are taking hold in the minds of those who will ultimately vote on the Bill in Parliament.
There was sign of some cut-through with Government during a debate on 14 September, when the minister committed to look at an amendment to address concerns that private companies would be able to influence commissioning decisions via membership of ICS boards.
During a debate of the bill in the Commons on 27 September, opposition MPs put forward a number of amendments drawing specifically from points made by the BMA, including shadow health minister Justin Madders who proposed a new clause 12 that would establish the NHS as the preferred provider of services.
Meanwhile, on 22 September, Conservative MP Chris Skidmore tabled an amendment jointly proposed by the BMA, Royal College of Nursing, Royal College of Physicians and others calling for the health secretary to be subject to greater accountability for workforce planning, via a duty to produce ongoing, accurate and transparent workforce assessments to directly inform recruitment needs.
While these are welcome and encouraging developments, we understand that this is a process in which we cannot allow complacency, and I and my colleagues will continue to press either for further changes or a delay to this bill.
With everything that we, the NHS and our patients have been through during the past 18 months, the consequences of another badly thought-out and enacted NHS reorganisation do not bear thinking about.
The bill will next be debated by the committee on 19 October. We will continue our work and press hard for meaningful change.
David Wrigley is BMA deputy representative body chair