March 27, 2015, by Public Social Policy
Reforming the NHS reforms – the quiet side-lining of the Health and Social Care Act 2012
By Ian Shaw
As widely anticipated the Health and Social Care Act has been a bit of a disaster… There has been more clinical engagement, especially with GPs, which is a good thing but the re-organisation led to a very complex organisational and governance structure (for example anyone know what clinical councils actually do? – I know someone in one who isn’t sure…). This has been distracting to the NHS, to say the least, when it’s also been in a period of financial turmoil resulting from a fixed budget and the Quality Innovation Productivity and Prevention Programme (QIPP), which is linked to cost and efficiency savings. What’s more the leadership of commissioning has been stripped out at a time when major service change is needed. Things are so bad that even the King’s Fund (who were cautiously optimistic about its introduction at the time) have been critical of its outcomes.
However, all is not yet lost as the new Chief Executive of the NHS, Simon Stevens (appointed in 2014) has been quietly side- lining the reforms. What’s my basis for arguing this? Let’s look at what’s been happening:
One of the first steps in the process was to create `Units of Planning’ around each `health community’. This new body comprised of the chief execs of all the NHS and local authority social services in each health community area and it has the job of planning health services and has the authority to make decisions on behalf of the individual health and social care organisations. It can make decisions that will be binding on a Clinical Commissioning Group (CCG) for example. It’s very unwieldy and certainly has its own governance issues, but it’s there. How does this relate to the `Health and Wellbeing Boards’ that are meant to be setting local strategy – good question…! Seems they may be being quietly side-lined… Also where are private providers in this – nowhere in sight.
A second change Stevens has brought in is to bring about `shared commissioning – between CCGs and Area NHS Teams – of primary care services’. In practice there is little `shared’ about the commissioning. CCGs will in reality be devolved the responsibility from April this year and will then be performance managed on it by the Area Teams. This creates a whole conflict of interest issue within the CCGs as the GP membership organisation is now responsible for commissioning GP and community health services… In short the CCG is increasingly taking on the role that the old PCT used to do and GPs are very wary of the development. There are significant issues here around the extent to which GP involvement in commissioning may reduce as a result. In short, though the freedom of clinical commissioning groups is being `reigned in’ to an extent by the new developments.
However, it’s the Five Year Forward View (FYFV) (and the Manchester devolution) that sets out the new direction and, yes, this is essentially reforming the reforms. The NHS has realised that the diversity and lack of system leadership brought about by the reforms is damaging to what really needs to be done to transform services and to increase efficiencies, which is to integrate health and social care services. The NHS itself is seen as too big to do this so responsibility is being devolved to local communities. The FYFV is essentially inspired by `the Valencia model’. In Valencia all health and social care services have been contracted to a single (private as it happens) provider who has taken on the management of all the services within the health system and its been heralded as a great success. The NHS is essentially adapting the model in its FYFW. It proposes a small number of models, but essentially two stand out. The first one is the PACs (Primary and Acute Care Systems) where one organisation will take responsibility for all services within a defined health community. This could be one NHS organisation or a new organisation that comprises all the organisations within that community. It can be pictured as the local District General Hospital running everything from the Hospital itself to GP services to mental health services and community care services within a single organisation. The other key model is the Multi-Specialty Provider Service (MSPS). Here groups of GP practices would expand, bringing in community health services and hospital specialists within a single organisation within an area to provide integrated out of hospital care. The Valencia provider had a very long term contract and one can see the role of CCGs under these models as reducing to the tasks of commissioning the service then sitting back and quality assuring its performance… Indeed the CCGs were completely side-lined (and without consultation) earlier this month when the whole NHS budget of Manchester was given to the Local Authority to manage. In addition Midwifery Services have now moved to the responsibility of Public Health England so it is clear that they are intended to also be part of a MSSP or PAC service offer.
So although the Green Party’s recent bid to reverse the NHS reforms are likely to fail, the truth is it’s all changing any way. So the remaining issue (apart of course from the funding level of the NHS as a whole) is the extent to which the market and the private sector will have to be involved in the new landscape of the NHS. The reduction of the tariffs and the increasing push for efficiency savings have already seen the private sector bailing out of the NHS as profits are squeezed – see for example Circles withdrawal from the Hinchbrooke Hospital management contract. So the NHS landscape is changing, but whether or not it’s for the better is a little too early to call. Labour has now confirmed it supports the Manchester devolution so the implication is that it also supports the devolution as set out in the FYFW.
The big issue then is the role of the private sector. Labour wants to role it back, but it’s been clear by recent coalition action that they want to increase private involvement. That seems to be the dividing line, along with funding levels. What is clear though is that the 2012 reforms (in themselves) are gradually becoming an irrelevance…
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