England

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Act one: the splintering effect

When the NHS was founded 66 years ago its objective was clear — free accessible healthcare for all.

It is a premise that does not sit comfortably with the idea of competition, so when the Health and Social Care Act 2012 was formally implemented last year, fears were sparked that the NHS as we knew it was gone. A shattered window pane, showing a window behind

Many were concerned that the act would fuel greater competition and privatisation.

Doctors argued opening up contracts to the private and voluntary sectors would lead to fragmentation of services making it harder for the NHS to deliver high quality, integrated patient care. Opposition ran so high that, at last year’s BMA annual representative meeting, it was ruled that the act be repealed. 

One year on, when the dust is starting to settle, it is time to question whether there are any parts of the act that are working and where change is needed most.


Competitive tendering impact

London consultant physician in sexual health and HIV Iain Reeves believes the use of greater competitive tendering has had a negative impact on patient care. Some local authorities in London have joined up to commission together; others are going alone. Thus, a confusing patchwork of different contracts and service specifications exist across the city

Some local authorities in London have joined up to commission together; others are going alone. Thus, a confusing patchwork of different contracts and service specifications exist across the city 

‘Outside of London we have seen commissioners undertake competitive tenders for sexual health services. These contracts have then been awarded to non-NHS providers,’ he says.

‘Unfortunately the system has failed to account for the synergies and efficiencies inherent in the co-location and co-delivery by the same staff working in HIV and sexual health services. 

‘The result has been that NHS providers are then left with a destabilised HIV treatment service, which is financially unviable and not in their interests to continue to provide, threatening the care of HIV-positive people.’


Service fragmentation

Dr Reeves says there has undoubtedly been fragmentation to the detriment of individuals and public health in his specialty.

‘Local authorities have taken over the commissioning of sexual health services but how they do this is subject to local determination. The services themselves must remain open access, regardless of whether the people using those services are resident in the borough.

‘Some local authorities in London have joined up to commission together; others are going alone. Thus, a confusing patchwork of different contracts and service specifications exist across the city, threatening the provision of a joined-up, consistent service for people using sexual health services in London,’ he says. 


Public health hit hard

The provision of public health saw far-reaching changes with some services being commissioned by local authorities and around 5,000 staff being transferred from the NHS.

A new statutory body, PHE (Public Health England), has taken responsibility for strategic planning of public health services. 

A BMA survey of 590 public health staff, including 340 doctors, published this month, showed little support for the reforms. 

Seventy-one per cent of those surveyed thought bureaucracy had increased, while only 23 per cent of those in local authorities and 18 per cent in PHE thought the reforms had benefited public health in England.


Lack of understanding

BMA public health committee co-chair Penelope Toff says: ‘All the recent surveys paint a picture of widespread lack of understanding and valuing of public health and its workforce, often resulting in local politics taking precedence over public need and a lack of public health input to health service commissioning.’ 

Surveys paint
a picture of widespread lack
of understanding of public health ...
often resulting in local politics taking precedence over public need 

Although relationships with local CCGs (clinical commissioning groups) were generally seen as good, the perceived ability to influence commissioning decisions effectively is lagging behind.

Since the act came in last year two thirds of non-trainees and more than half of trainees had considered leaving the profession. 

A lack of professional fulfilment, poor work-life balance, an unsupportive work environment, fear of future deterioration of terms and conditions, and disagreement with the overall direction in which the organisation is going, were cited as reasons.


Long-term effects

There was also a perceived lack of understanding of public health roles in the wider organisation and a feeling skills were not valued by senior management. Both problems are significantly worse among non-trainees working for local authorities. BMA public health committee co-chair Penelope Toff

Only 29 per cent of medics surveyed agreed the unique skill set of physicians was sufficiently valued in public health.

Dr Toff says: ‘Most consultants responding to the BMA and other surveys felt that neither individual consultants nor PHE were able to speak out independently on public health issues, that bureaucracy had increased and that there was a lack of national public health leadership.

‘Public health expertise appears to have been sidelined at a time when it is most needed, to mitigate the effects of public service cuts and to navigate a proposed future of more integrated care. The likely long-term effects of the reforms on both the profession and the public’s health are of grave concern.'


Roles split down middle

One example of a doctor adversely affected by the changes is public health medicine consultant Linda Sheridan, who up until March last year was deputy regional director in the east of England.

She says: ‘The act splintered my role completely. NHS emergency planning and resilience went to NHS England, in which the leadership decided that no public health consultants should be employed except in management roles on secondment from PHE, the lead consultants from screening and immunisations. 

‘The health protection role of the HPA (Health Protection Agency) went to PHE along with some other aspects of my former role; governance of health protection went to local authorities.’


Early retirement

Dr Sheridan was eventually forced to take early retirement after being unable to find an alternative role. 

I could find no suitable alternative employment, was stressed and probably depressed with complete loss of self-esteem as a result of all the emotional kicks in the process, and eventually accepted being made redundant and taking retirement

She says: ‘I could find no suitable alternative employment, was stressed and probably depressed with complete loss of self-esteem as a result of all the emotional kicks in the process, and eventually accepted being made redundant and taking retirement.’

She is now working again on a fixed-term contract, part time in a local authority overseeing the health protection portfolio for the director of public health and also as a non-executive director in an NHS community trust. 

She says: ‘However, this change cost me personally in terms of my health, which, one year on, has now recovered, but, very importantly financially to the NHS, I had 22 continuous years of NHS service and was a senior consultant so I gained, but it gives me no pleasure.’


Patchy picture for GPs

England’s 211 CCGs have taken over from PCTs (primary care trusts) and are responsible for £65bn of the £95bn NHS commissioning budget. They now plan and commission hospital care and community and mental health services. 

However this has led to a ‘patchy national picture’, according to BMA GPs committee chair Chaand Nagpaul (pictured). 

Although every GP practice must be a member of their CCG, he argues the system is working better in some areas than others. Divisions between the grassroots GPs and governing boards in some areas leads some GPs to feel disenfranchised. 

Although CCGs are intended to have autonomy to shape local services within a budget, Dr Nagpaul argues this is not happening in practice because of cost pressures and targets set by the quality and outcomes framework and quality premium (incentives intended to reward CCGs for improvements in the quality of the services they commission and associated improvements in health outcomes).


Rising tensions

‘There are tensions between emerging collaborative GP provider organisations and CCGs as commissioners,’ he says. Dr Chaand Nagpaul is Chairman of the General Practitioners Committee

‘GP engagement is vital yet  one in two GPs is reporting less engagement due to feeling overworked and overwhelmed,’ he adds, referring to a BMA survey from 2013.

The reforms have also increased pressures on GPs according to GPC deputy chair Richard Vautrey: ‘GPs have seen their workload increase as a result of the reforms with more meetings to attend within CCGs. 

‘Those who are involved in decision making have found the increased fragmentation of NHS management very frustrating. 

‘It is too early yet in many cases to know whether any significant changes have been achieved when in most cases the focus for the year has been on organisational establishment. This is the usual pattern with NHS reorganisations and one reason why many raised concerns.’


More meetings

This tallies with the experience of London GP Imogen Bloor, who says the new commissioning structure has meant more meetings, which take away from time spent with patients and spread resources thinly. 

The new model relies on ... the input of representatives from all local GP practices, which means an enormous number of cumulative GP, practice nurse and manager hours in consultative meetings 

‘Prior to the formation of CCGs we had strong GP input into PCT commissioning decisions, with locality forums for this. We are fortunate to have excellent people at the helm of our CCG now and for it to be energetic and innovative.

‘However, the new model is predicated on and relies upon active GP clinical leadership and the input of representatives from all local GP practices, which means an enormous number of cumulative GP, practice nurse and manager hours in consultative meetings.

‘Even if back fill is paid for one’s time, having to regularly use locums to cover sessions affects continuity and quality of patient care. 


Fundamental flaws

‘As one of four locality clinical leaders, all of us with different work rotas, trying to find a time to meet with relevant agencies and personnel from the CCG is very challenging. The model is fundamentally flawed as it is very difficult to run a practice and do the day job while attending meetings at varied times, often at short notice, without impacting adversely on patient care. 

‘To some extent there is an economy of scale issue here, it may be easier in a large practice to release one or two clinicians, but it is neither desirable nor realistic to expect clinical leadership representation from only large practices.’


Commissioning clashes

The conflict-of-interest rules mean that CCGs cannot appoint clinicians employed by any organisation they may be commissioning care from.

A BMA survey carried out last year shows that 77 per cent of consultants were not satisfied with the degree of secondary care involvement with commissioning. One in 10 respondents was aware of CCGs in their area that had no secondary care input.

BMA consultants committee joint deputy chair Tom Kane says: ‘I remain concerned that the conflict-of-interest rule is preventing consultants from becoming involved in CCGs, as they can’t apply for any CCG that may commission work from their employer.

‘I am equally concerned that the process for CCGs to appoint a consultant remains in many areas very opaque.’

After one year it is clear the Health and Social Act has caused many issues that need to be addressed. 

Another wholesale reorganisation may help to solve some of those issues, but it is important to ensure the reforms do not have a negative impact on patient care so the NHS can continue to live up to the simple aim of its founder — free universal healthcare.