undermining the nhs

8/7/2019 Undermining the NHS

1/16

Undermining the NHSThe hidden reality behind DavidCamerons health reforms


2/16

2


3/16

3

Behind the Rhetoric

David Cameron said he was committed to the NHS. Ever keen to say what people wanted to hear

he promised to protect it against top-down reorganisation, and from cuts. But the reality is verydifferent.

When you peel away the rhetoric, the hidden truth is that David Cameron and his Tory-ledGovernment, supported all the way by Nick Clegg and the Liberal Democrats, are taking the NHS

backwards. They are subjecting it to unnecessary, ideological reforms which will take power away

from patients and which threaten standards of care.

David Cameron promised to stop the top-down reorganisations of the NHS that have got in theway of patient care. Less than two months into government he broke that promise, approving

Andrew Lansleys plan for the NHS the hidden reality of which is a wholesale top-downreorganisation of the NHS, including the handing over of commissioning budgets to new GP

consortia and the abolition of existing commissioning structures.

This Health and Social Care Bill will bring about a massive bureaucratic re-organisation which

wont improve patient care.

That would be bad enough. But it gets worse. David Camerons reorganisation isnt just a waste of

money, and an unnecessary distraction to the NHS. It is a bad Bill, built on bad assumptions anddangerous ideology.

David Cameron wants to keep hidden the truth of his Bill: It makes the NHS increasingly subject to

UK and EU competition law, putting NHS services and commissioners at risk of legal challenge. It

puts NHS services at risk of going bust and closing in the face of private sector competition. Itweakens local accountability over service changes, meaning valued local services could be closed

without warning.

No wonder the public, patients, NHS staff and health experts are so worried about the plans. Even

the Liberal Democrats, after happily signing the plans off in Cabinet and voting for them atSecond Reading, are starting to have second thoughts. But the so-called listening exercise the

Government has promised is no more than a sham the reality is the policy is carrying on as ifnothing had happened, and Andrew Lansley is himself refusing to address the Royal College of

Nursings annual conference.

Labour will keep challenging the Tory-led Governments dangerous plans. Its becoming

increasingly clear: You cant trust David Cameron with the NHS.


4/16

4

The Hidden Reality of David Camerons Bill

You cant trust David Cameron with the NHS. The Health and Social Care Bill includesplans to make the NHS increasingly subject to UK and EU competition law, puttingNHS services at risk of legal challenge from private sector competitors. It contains no

protection to stop NHS services going bust in the face of private competition, andincludes new proposals to allow services to be shut down without local consultation. Iteven gives GPs new powers to charge for services.

1. No protection from insolvency for NHS hospitals NHS hospitals could go bust,leaving patients without the services they have relied on.

The Health and Social Care Bill will apply commercial insolvency law to NHS Foundation Trusts.

The Bill details that this is to create a level playing field which is in the best interests of

[Foundation Trusts] creditors not necessarily in the best interests of the patient.1

Under the reforms, there are no provisions to protect NHS services which may be threatened

by competition from the private sector.2There is no clear mechanism to stop NHS hospitals

closing.3

2. EU competition law and fining hospitals NHS hospitals could be fined up to 10%of their turnover by the new economic regulator

According to a recent Parliamentary Answer, the Government plans to make EU competitionrules "increasingly" applicable to the NHS.4

Another recent Parliamentary Answer showed that the Government still doesnt knowwhether and to what extent European Union state aid law will have an impact in the NHS

following its NHS reforms.5 This means that it is unclear whether and on what grounds privatesector competitors of the NHS could subject NHS services to legal challenge.

According to the Explanatory Notes for the Health and Social Care Bill, the design of the newNHS economic regulator, Monitor, is modelled on precedents from the utilities, rail and

telecoms industries, tailoring them to the particular circumstances of the health sector."6

Clause 60 of the Health and Social Care Bill gives Monitor concurrent powers with the Officeof Fair Trading under the Competition Act 1998.7The Office of Fair Trading has a wide range

of powers to investigate businesses suspected of breaching competition law and can take

enforcement action, for example ordering that offending agreements or conduct be stopped,and fining businesses up to 10% of their worldwide turnover.8 Similarly, under the Bill Monitorwill be given powers to fine NHS Trusts up to 10% of turnover for breaches of competition

law.9

3. Weakening local accountability over NHS closures and reconfigurations Local NHSservices could be closed down without any consultation

David Cameron said at Prime Ministers Questions in February that the Government are puttingin arrangements to make sure that local people are listened to when decisions are being made

about local NHS closures and reconfigurations.10

But the Government plans to weaken public accountability for the continuity of services thathave not been designated. Currently, any major service changes have to be consulted on and


5/16

5

decisions referred to the Secretary of State. But following the reforms, providers will have

greater freedom to adapt without recourse to formal public consultation.11 This would allow

local services to be closed down with no public involvement, with no notice, and with no power

to refer the decision to the Secretary of State.

An NHS Service can be designated if the loss of that service could be deemed to have asignificant adverse impact on the health of a population if that service was no longerprovided.12 Health Minister Simon Burns has indicated that A&E services in London may not be

designated services, meaning they could be closed without consultation under theGovernments plans.13

4. Putting private patients first NHS patientscould suffer as hospitals prioritisethose who can affordto pay

Currently, Foundation Trusts can generate a limited percentage of their income from privatepatients. But the Health and Social Care Bill will remove the cap on private income, meaning

that Foundation Trusts can generate as much income as they like from private patients.14

The Department of Healths own impact assessment states that a risk of removing the cap isthat hospitals could divert more of their resources to treating private patients, meaning that

private patients could be prioritised above NHS patients leading to a growth in waiting lists.15

The Royal College of Nursing says that there is no guarantee that private income will not betaken at the expense of NHS patients.16

5. New GP powers to charge for services It is currently the duty of the Secretary of State to decide which services should be provided

by the NHS.

17

But the Bill takes away this duty from the Secretary of State, and hands it overto GP consortia.18

At present, the power to determine charging is given to the Secretary of State. The existinglegislation says that the Secretary of State may make such charge as he considers

appropriate for anything he does in the exercise of any such power and to calculate any such

charge on any basis that he considers to be the appropriate commercial basis.19 Clause 22 of

this Governments Health and Social Care Bill gives this power to GP consortia.20

David Cameron, Nick Clegg and Andrew Lansley have offered no explanation of why thesechanges are needed or what they might mean for patients.


6/16

6

David Camerons Shambles on the NHS

You cant trust David Cameron with the NHS. Despite his high-profile pledge to stoptop-down reorganisations, he pushed ahead rapidly with a plan for massive structuralchange to the NHS. As opposition from patients, NHS staff and the public grew, he

announced a listening exercise in which the Tory-led Government would pause,listen, reflect and improve the plans but in fact the policy is proceeding and, far fromlistening, Andrew Lansley has refused an invitation to address the Royal College ofNursing conference.

Broken promises

David Cameron and Nick Clegg promised in the Coalition Agreement to stop the top-downreorganisations that have got in the way of patient care.21 David Cameron said that there willbe no more of those pointless reorganisations that aim for change but instead bring chaos.22

But they approved Andrew Lansleys plan for a wholesale top-down reorganisation of theNHS, including the handing over of commissioning budgets to new GP consortia, the abolitionof existing commissioning structures, and the application of UK and EU competition law to the

NHS.

Top-down reorganisation

Andrew Lansleys proposals were rushed out within weeks of the Coalition Agreement beingdrawn up. The White Paper Liberating the NHSwas published on 12 July, just two months afterthe Government took office, with a three-month consultation period across the summer. The

Health and Social Care Bill was published in January, only three months after the consultation

closed. With 281 clauses, the Bill is more than three times longer than the Bill which set up the

NHS in 1948.

Sir David Nicholson, Chief Executive of the NHS, said that the scale of the change beingimposed on the NHS was so big that you can actually see [it] from space.23 Robert Creighton,

Chief Executive of Ealing PCT, warned that it could be a bloody awful train crash.24 Peter

Carter, General Secretary of the Royal College of Nursing, says the Bill could well turn out tobe the biggest disaster in the history of our public services.25

Opposition grows

Opposition to the proposals from the public and from expert organisations has grown, withconcerns raised by the Health Select Committee,

26

the British Medical Association, unions andprofessional organisations representing NHS staff, including the British Medical Association,

the RCN, the Royal College of Midwives and Unison,27 the Kings Fund28 and Conservative MPand former GP Dr Sarah Wollaston.29 Even Lord Tebbit, once described as my political hero by

Andrew Lansley,30 expressed serious concerns.31

At Prime Ministers Questions on 16 March, David Cameron was unable to answer Ed Milibandsquestions about the implications of making the NHS subject to EU competition law.32 Asked

later about the same issue, Culture Secretary Jeremy Hunt said, thats an area which I think weneed to ask Andrew Lansley about.33

Pause?

In April, Andrew Lansley announced a pause in the reorganisation but was still unable to sayhow, if at all, the policy would change.34 He said that the plan to abolish Primary Care Trusts


7/16

7

would not be stopped.35 A leaked memo said that a number of red lines must be maintained,

including the creation of GP consortia and the new commissioning board, and the abolition of

PCTs by 2013.36

Despite engaging in a listening exercise, Andrew Lansley has refused to address the RoyalCollege of Nursing conference, choosing instead to hold a Q&A session with just 50 nurses.

Nurses have tabled an emergency motion of no confidence in his ability to direct thereforms.37

Liberal Democrats add to the confusion

The Liberal Democrats have strongly backed the Governments NHS plans. Nick Clegg signedthe foreword to the White Paper in July.38 No Liberal Democrat MP voted against the Health

and Social Care Bill at Second Reading.39 Liberal Democrat Health Minister Paul Burstow hasresisted all attempts by Labour to amend the Bill in Committee.

The Liberal Democrats passed a motion at their Spring Conference in March calling forwholesale changes to be made to the Health and Social Care Bill.

40

Baroness Shirley Williamsdescribed the reforms as stealth privatisation and said that they amounted to a plan to

dismantle one of the most efficient public services of any in Europe.41 But following the vote,

Downing Street said "This is not about significant changes to the policy but about reassuringpeople with minor changes to the language of the bill as it goes through the House".42

After the announcement of a pause in the policy, Nick Clegg told Parliament that there wouldbe substantive changes.43 But Health Minister Simon Burns said it would be inappropriate to

say what changes the Government would make.44

Norman Lamb, chief political adviser to Nick Clegg, said on Sunday that there is no evidenceabout how the new GP consortia will work, and that to do it in one fell swoop would be very

risky.45 He said that this could be a resignation issue for him.46 Nick Clegg said, I couldnt

agree more with Norman, I couldnt agree more with Norman,47 but was unable to say whatchanges he supported to the legislation, saying the devil lies in the detail.48


8/16


9/16

9

Notes

1This would assist in ensuring a level playing field between foundation trusts and other providers, and theprocedures could facilitate the rescue of a failed foundation trust (for example, through administration or a voluntary

arrangement with creditors) or enable the affairs of a trust to be wound up in the best interests of its creditors (for

example, through voluntary or compulsory liquidation). Introducing an effective failure regime would allow for orderly

market exit. It would also mean that trust directors would be under similar obligations to company directors since

offences that may be prosecuted under the insolvency legislation would be applied through regulations and

disqualification proceedings could be taken against directors who were held responsible for misconduct.

Health and Social Care Bill, Explanatory Notes, para 737

2Eddie Mair So if there is no ideal balance, and nothing in the legislation to protect the NHS in terms ofthis balance and if the mantra is to serve the patient and the patient has choice and

control, what happens if ultimately patients always choose private because they find they

like the quality and GPs like it because the price is right?

Andrew Lansley Well I mean, we have a level playing field and we have competition and there will be a range

of providers and who are the appropriate providers will change over time. As I say, what Im

going to do is to make sure that there is a level playing field and actually there are

foundation trusts

Eddie Mair And then [inaudible] the NHS can take its chances?

Andrew Lansley No no, its not a free-for-all because its all you know, clearly there is a continuity of

services to patients and we will.. and the legislation is very clear about the NHS continuing

to provide services to patients and the quality continuously improving. But what we do

need to do is to make sure that we have innovation and the benefits of competition do

bring innovation and drive up quality and were determined thats going to happen.BBC R4 PM, 19 January 2011

3Eddie Mair:::: But under your plan is there any mechanism to stop the demise of say all NHS hospitals?Andrew Lansley: Well I dont know [laughs].

Eddie Mair: Perhaps thats funny?

Andrew Lansley: Well its not funny its just absurd and

Eddie Mair: That would be the logical conclusion [inaudible], you have nothing to put a top

Andrew Lansley: No its not the logical conclusion and there is no evidence to support that proposition

indeed the evidence is completely to the contrary.

Eddie Mair:::: Well theres no evidence, this hasnt been done before.Radio 4 PM, 19 January 2011

4Tom Blenkinsop:Tom Blenkinsop:Tom Blenkinsop:Tom Blenkinsop: To ask the Secretary of State for Health what recent assessment he has made of the likely effectof (a) UK and (b) EU competition rules on the operation of GP consortia. [44028]

Mr Simon Burns:Mr Simon Burns:Mr Simon Burns:Mr Simon Burns: The Health and Social Care Bill itself does not extend the applicability of current United Kingdom or

European Union competition law to the health sector of England.

However, as national health service providers develop and begin to compete actively with other NHS providers and

private and voluntary providers, UK and EU competition laws will increasingly become applicable.

Hansard, 7 March 2011, column 896W

5Mr Barron:Mr Barron:Mr Barron:Mr Barron: To ask the Secretary of State for Health what consideration he has given to the application of state aidin the NHS following the re-establishment of Monitor as an economic regulator. [50942]

Mr Simon Burns:Mr Simon Burns:Mr Simon Burns:Mr Simon Burns: We are currently assessing whether and to what extent European Union state aid law will have an

impact in the national health service, including what the position will be with respect to a health system that will

remain funded by the taxpayer and providing universal coverage, free at the point of need.

Hansard, 5 April 2011, Column 836W

6"This Bill turns Monitor into an economic regulator for all NHS-funded health services. As an economic regulator,Monitors overarching duty would be to protect and promote the interests of people who use health care services, by

promoting competition where appropriate and through regulation where necessary. It would have three corefunctions: promoting competition where appropriate; setting or regulating prices; and supporting the continuity of

services. To support its functions, Monitor would have the power to licence providers of NHS-funded care. These


10/16

10

clauses draw upon precedents from the utilities, rail and telecoms industries, tailoring them to the particular

circumstances of the health sector."


7(1)The functions reoffered to in subsection (2) are concurrent functions of Monitor and the Office of Fair TradingHealth and Social Care Bill, Clause 60, p. 40

8Businesses that break the law can be fined up to 10% of their worldwide turnover and third parties (includinginjured competitors, customers and consumer groups) can bring damages claims against them. In addition, individuals

found to be involved in cartels can be fined and imprisoned for up to five years and directors of companies that

breach the prohibitions can be disqualified for up to 15 years.

Office of Fair Trading, http://www.oft.gov.uk/about-the-oft/legal-powers/legal/competition-act-1998/

9Clause 95 - Discretionary requirements(1) Monitor may impose one or more discretionary requirements on a person(2) In this Chapter, discretionary requirements means (3) A requirement to pay a monetary penalty to Monitor of such amount as Monitor may determine (referred to in

this Chapter as variable monetary penalty.(4) A variable monetary penalty must not exceed 10% of the turnover in England of the person on whom it is

imposed, such amount to be calculated in the prescribed manner.Health and Social Care Bill, Clause 95, p. 89

10Daniel Kawczynski (Shrewsbury and Atcham) (Con):Daniel Kawczynski (Shrewsbury and Atcham) (Con):Daniel Kawczynski (Shrewsbury and Atcham) (Con):Daniel Kawczynski (Shrewsbury and Atcham) (Con): The local NHS trust in Shropshire is proposing majorreconfiguration changes to services throughout the county, including maternity and paediatric services. Those are

causing significant concerns for local Shrewsbury doctors, GPs and patient groups. Can the Prime Minister give an

assurance that those concerns will be taken on board and acted upon before any changes are made? My hon. Friend

the Member for Montgomeryshire (Glyn Davies), whose constituents also use the Royal Shrewsbury hospital, shares

my views.

The Prime Minister:The Prime Minister:The Prime Minister:The Prime Minister: I can certainly given that assurance, because my right hon. Friend the Health Secretary has put in

place much stronger arrangements for making sure that local people are listened to when these discussions aretaking place. No changes will be allowed unless they focus on improving patient outcomes, unless they consider

patient choice and unless they have the support of the GP commissioners, and remember that in the future health

system it will be the decisions of GPs and people that will drive the provision of health services, not top-down

decisions made by Ministers in Whitehall.

Hansard, 2 Feb 2011, column 856

11In future, there will be a clearer distinction between: those services which are designated as subject to additionallicence conditions and which Monitor will ensure continue to be provided, even if the provider fails; and those services

where providers have greater freedom to adapt in line with changing demands, for example through patient choice,

without recourse to formal public consultation.

Liberating the NHS: Legislative framework and next steps, December 2010, p. 109

12Subsection (2) provides that a commissioner may only apply for a service to be designated if a consultation of therelevant persons has been carried out and if the criterion in subsection (3) has been met. That criterion is that or that

this would be likely to cause a failure to prevent or ameliorate such adverse impact. The relevant persons a

commissioner would be required to consult are specified in subsections (9), (10) and (11) . Relevant persons differ

depending on who the commissioner is and include any person who the commissioner considers appropriate, which

might include potential providers of NHS services.


13Shadow health minister Liz Kendall asked Mr Burns whether his definition of designated services meant thataccident and emergency services in London would qualify.

He said: A designated service will be one to ensure that across the country there are appropriate services to meet

the needs of the people. There are a number of A&E services in London, so there would not be a need to designatethem If I was talking about Cornwall, A&E would be designated there.

When questioned, Mr Burns clarified that he was not saying this will happen. I was using it as an illustration to make

a point, it was not a prediction, he said.


11/16

11

HSJ, 3 March 2011, http://www.hsj.co.uk/news/acute-care/burns-london-aes-may-not-be-designated/5026490.article

14abolishing the arbitrary cap on the amount of income foundation trusts may earn from other sources to reinvest intheir services and allowing a broader scope, for example to provide health and care services;

Equity and excellence: Liberating the NHS, July 12 2010, p. 36

15If the latter, there is a risk that private patients may be prioritised above NHS patients resulting in a growth inwaiting lists and waiting times for NHS patients. This is the eventuality that the PPI cap was originally introduced to

prevent.

Health and Social Care Bill, Impact Assessment, 19 January 2011, p. 61

16As the RCNs response to the NHS White Paper stated, the RCN cannot support the removal of the private incomecap, as proposed by Clause 150, until healthcare providers can demonstrate that private income is not taken at the

expense of NHS patients.

The RCN believes that the current arrangements for the cap should remain in place and does not believe that there

has been sufficient analysis to justify the proposed change in this area. The RCN does not support any change in

policy around the private income cap until assurances can be made that NHS patients access to care services will notimpacted. As a result the RCN believes that Clause 150, should be removed from the Bill.

Royal College of Nursing, Memorandum submitted by the Royal College of Nursing (HS 27)

17Secretary of State's duty as to provision of certain services(1)The Secretary of State must provide throughout England, to such extent as he considers necessary to meet all

reasonable requirements

(a)hospital accommodation,

(b)other accommodation for the purpose of any service provided under this Act,

(c)medical, dental, ophthalmic, nursing and ambulance services,

(d)such other services or facilities for the care of pregnant women, women who are breastfeeding and young children

as he considers are appropriate as part of the health service,

(e)such other services or facilities for the prevention of illness, the care of persons suffering from illness and theafter-care of persons who have suffered from illness as he considers are appropriate as part of the health service,

(f)such other services or facilities as are required for the diagnosis and treatment of illness.

(2)For the purposes of the duty in subsection (1), services provided under

(a)section 83(2) (primary medical services), section 99(2) (primary dental services) or section 115(4) (primary

ophthalmic services), or

(b)a general medical services contract, a general dental services contract or a general ophthalmic services contract,

must be regarded as provided by the Secretary of State.

(3)This section does not affect Chapter 1 of Part 7 (pharmaceutical services).

National Health Service Act 2006, clause 3

189 Duties of consortia as to commissioning certain9 Duties of consortia as to commissioning certain9 Duties of consortia as to commissioning certain9 Duties of consortia as to commissioning certain health serviceshealth serviceshealth serviceshealth services

(1) Section 3 of the National Health Service Act 2006 is amended as follows.(2) In subsection (1)

(a) for the words from the beginning to reasonable requirements substitute A commissioning consortium must

arrange for the provision of the following to such extent as it considers necessary to meet the reasonable

requirements of the persons for whom it has responsibility, and (b) in each of paragraphs (d) and (e) for the words as

he considers substitute as the consortium considers.Health and Social Care Bill 2011, Clause 9, p. 5

197 Extension of powers of Secretary of State for financing the Health Service.7 Extension of powers of Secretary of State for financing the Health Service.7 Extension of powers of Secretary of State for financing the Health Service.7 Extension of powers of Secretary of State for financing the Health Service.(1)In order to make more income available for improving the health service (as defined in the M1National Health

Service Act 1977 or the M2National Health Service (Scotland) Act 1978), the Secretary of State shall have the

powers specified in subsection (2) below; but for the avoidance of doubt it is hereby declared that nothing in this

section authorises him or any body to which he gives directions under subsection (3) below to disregard any

enactment or rule of law or to override any persons contractual or proprietary rights.

(2)The powers mentioned in subsection (1) above are powers [F1(exercisable outside as well as within Great

Britain)]


12/16

12

(a)to acquire, produce, manufacture and supply goods;

(b)to acquire land by agreement and manage and deal with land;

(c)to supply accommodation to any person;

(d)to supply services to any person and to provide new services;

(e)to provide instruction for any person;

(f)to develop and exploit ideas and exploit intellectual property;

(g)to do anything whatsoever which appears to him to be calculated to facilitate, or to be conducive or incidental to,the exercise of any power conferred by this subsection; and

(h)to make such charge as he considers appropriate for anything that he does in the exercise of any such power and

to calculate any such charge on any basis that he considers to be the appropriate commercial basis.

Health and Medicines Act 1988, clause 7

2014S Raising additional income14S Raising additional income14S Raising additional income14S Raising additional income(1) A commissioning consortium has power to do anything specified in section 7(2)(a), (b) and (e) to (h) of the Health

and Medicines Act 1988 (provision of goods etc.) for the purpose of making additional income available for improving

the health service.

(2) A commissioning consortium may exercise a power conferred by subsection (1) only to the extent that its exercise

does not to any significant extent interfere with the performance by the consortium of its functions.

Health and Social Care Bill 2011, Clause 22, p. 32

21Coalition Agreement, p. 24

22"There will be no more of those pointless re-organisations that aim for change but instead bring chaos."David Cameron, speech to the Royal College of Nursing, 11 May 2009

23In December 2010 he adopted the same approach when he told NHS finance officers that he had consultedchange management experts from around the world: and no one could come up with a scale of change like the one

we are embarking on at the moment. Someone said to me it is the only change management system you can actually

see from space it is that large

House of Commons Health Committee, Commissioning, Third Report of Session 201011Volume I, Volume I: Report,17

24"This could be a bloody awful train crash. It could collapse. All of us are looking inwards []"Ive got to completely clean out the team and make a whole series of new appointments. I spent 13 hours yesterday

interviewing yesterday, Im spending another six hours today, eight hours tomorrow. In all that time, I am not spending

a moment thinking about patient care or money. It will be very difficult to keep everybody focused in the task in hand.

"This must be working together, but we are at risk of blowing it. Sometimes I feel Im only doing what Im doing

because of a sense of public duty. In two years time, I will probably be out of a job.

"The Government is saying that everything I have done for the past eight years has been bad or should be destroyed.

Wheres the sense of that?"

Robert Creighton, Chief Executive of Ealing PCT, quoted in House of Commons Health Committee, Commissioning,

Third Report of Session 201011 Volume I, Volume I: Report, p. 23

25"The Health and Social Care Bill 'could well turn out to be the biggest disaster in the history of our public services if organisations like the RCN are not listened to, and listened to now,' Mr Carter warned."

Nursing Times, 11 April 2011, http://www.nursingtimes.net/nursing-practice/clinical-specialisms/management/carter-warns-reforms-could-be-biggest-disaster-in-history-of-nhs/5028486.article

26There was a significant policy shift between the Coalition Programme, published on 20 May 2010, and the WhitePaper, published on 12 July 2010. The Coalition Programme anticipated an evolution of existing institutions; the

White Paper announced significant institutional upheaval. The Committee does not believe that this change of policy

has yet been sufficiently explained given the costs and uncertainties generated by the process. The Committee

broadly shares the Governments policy objectives so it therefore welcomes the fact that these are substantially

unchanged. It does not believe however that the approach adopted by the Government represents the most efficientway of delivering those objectives. The failure to plan for the transition is a particular concern in the current financial

context. The Nicholson Challenge was already a high-risk strategy and the White Paper increased the level of risk

considerably without setting out a credible plan for mitigating that risk.


13/16

13

House of Commons Health Committee, Commissioning, Third Report of Session 201011 Volume I, Volume I: Report,p. 3

27Sir,Radical reform of the NHS in England is expected to come a major step closer this week, with publication of the

Health and Social Care Bill. As unions and professional organisations representing the 1.3 million staff who make up

the NHS, we are extremely concerned that the Government is not heeding the warnings about key elements of the

proposals. We recognise the need to provide NHS services more cost-effectively, but we believe this can and must be

achieved without taking unnecessary risks and damaging care.

One of the major concerns is the role that the NHSs economic regulator, Monitor, will be given to ensure that any

willing providers, including NHS and voluntary organisations, and commercial companies, are able to compete to

provide all NHS services. In addition, the 2011-12 operating framework for the NHS, published last month, revealed

that providers will be able to offer services to commissioners at less than the published mandatory tariff price.

There is clear evidence that price competition in healthcare is damaging. Research by economists at Imperial College

shows that, following the introduction of competition in the NHS in the 1990s, under a system that allowed hospitals

to negotiate prices, there was a fall in clinical quality. With scarce resources there is a serious danger that the focus

will be on cost, not quality.

Enforced competition will also make it harder for NHS staff to work collaboratively in multidisciplinary teams, across

organisational boundaries, to create the integrated care pathways that patients want and need, and that will help tomake services more efficient.

Furthermore the sheer scale of the ambitious and costly reform programme, and the pace of change, while at the

same time being expected to make 20 billion of savings, is extremely risky and potentially disastrous.

Dr Peter Carter, Royal College of Nursing

Dr Hamish Meldrum, British Medical Association

Karen Jennings, Unison

Karen Reay, Unite

Professor Cathy Warwick, Royal College of Midwives

Phil Gray, Chartered Society of PhysiotherapyLetter to the Times, 17 January 2011,

http://www.rcn.org.uk/newsevents/news/article/uk/rcn_and_other_unions_express_concern_about_nhs_reform

28"The publication of the Health and Social Care Bill signals the biggest shake-up of the NHS since its inception."The last decade has seen significant progress in the performance of the NHS. While ministers are right to stress the

need for reform to make it truly world class, these gains are at risk from the combination of the funding squeeze and

the speed and scale of the reforms as currently planned."

Chris Ham, Chief Executive, Kings Fund, Press Release, 19 January 2011,

http://www.kingsfund.org.uk/press/press_releases/the_kings_fund_32.html

29An organisation responsible for over 100billion needs people who seriously understand accountancy and, trustme, GPs do not.

Bearing in mind that the NHS Commissioning Board in London will be responsible for commissioning every GP

practice, pharmacy and dental surgery, it is clear that they will need some regional presence. I cannot see that it

makes sense to foot the bill for redundancies for the entire middle layer of NHS management only to be re-employingmany of them within a couple of years. Commissioning consortia will be overwhelmed trying to adapt to their new

roles. Someone needs to get a grip or we will continue to haemorrhage the best staff as a result of intolerable

uncertainty and pointless morale-sapping denigration. It all risks going 'belly up' rather than 'bottom up'.

It is not Greeks that could destroy the NHS, but if Monitor, the new economic regulator, is filled with competition

economists with a zeal for imposing competition at every opportunity, then the NHS could be changed beyond

recognition.

It is no use liberating the NHS from top down political control only to shackle it to an unelected economic regulator.

We have moved from a position of widespread support from patient groups and the professions for the health

reforms to one of outright hostility.

Dr Sarah Wollaston MP, Daily Telegraph, 19 March 2011, http://www.telegraph.co.uk/health/8392564/Why-David-Camerons-plans-for-the-NHS-are-dangerous.html

30My political hero is Norman TebbitAndrew Lansley, The House magazine, 15 November 1999


14/16

14

31"I have known the Secretary of State, Andrew Lansley, for 30 years. In his day he was a very able civil servant, andit seems to me that if anyone could unravel and reform the tangled bureaucracy which holds up the devoted

professionals of the NHS, it ought to be someone with his experience."

What worries me about the reforms however is the difficulty of organising fair competition between the state-

owned hospitals and those in the private sector.

Daily Mirror, 4 April 2011, http://www.mirror.co.uk/news/top-stories/2011/04/04/norman-tebbit-don-t-let-david-

cameron-destroy-our-nhs-115875-23036253/

32Hansard, 16 March 2011, columns 292-294

33Andrew Neil: Why is a Eurosceptic government like yours bringing the NHS under EU competition law?Jeremy Hunt: Well I thats an area which I think we need to ask Andrew Lansley about. I know that one of the

things that even Andrew Lansleys critics would not dispute is his tremendous control and command

of the detail of his subject and I am absolutely sure that what he is trying to do, which is incidentally

very much in the direction of travel of the last Labour government, is to make sure that we can

harness some of the skills in the independent, charitable and private sector. But we obviously need

to do that in a way that allows the core NHS to carry on its functions.

BBC Daily Politics, 16 March 2011

34Our desire is to move forward with the support of doctors, nurses and others who work in the NHS and make adifference to the lives of so many of us, day in and day out. However, we recognise that the speed of progress has

brought with it some substantive concerns, expressed in various quarters. Some of those concerns are misplaced or

based on misrepresentations, but we recognise that some of them are genuine. We want to continue to listen to,

engage with and learn from experts, patients and front-line staff within the NHS and beyond and to respond

accordingly. I can therefore tell the House that we propose to take the opportunity of a natural break in the passage

of the Bill to pause, listen and engage with all those who want the NHS to succeed, and subsequently to bring

forward amendments to improve the plans further in the normal way.

Andrew Lansley, Hansard, 4 April 2011, column 767

35

Andrew Lansley: We are basing commissioning in the legislation and in the overall reforms on the basis ofclinically-led commissioning, doctors and nurses leading commissioning. Primary Care Trusts, the

intention is to continue to abolish Primary Care Trusts and the reason is very straight forward

Eddie Mair: And people cant stop that?

Andrew Lansley: No, were intending to go ahead with legislation

BBC R4 PM, 6 April 2011

36"A two-month 'listening exercise' in which medical professionals will be asked to contribute to a review of changesto the NHS has been thrown into doubt by a confidential memo highlighting a series of government red lines that

must be maintained.

"As David Cameron and Nick Clegg joined the health secretary, Andrew Lansley, on Wednesday to launch the exercise

at a hospital in Surrey, the memo by NHS chief executive David Nicholson indicated there may be little room for

manoeuvre in reworking the health and social care bill."The memo drew a red line beneath the fundamental planks of the bill that are not for changing: GP consortiums, an

independent commissioning board to oversee them, every hospital to become a foundation trust, and Healthwatch

and primary care trusts to be abolished by 2013.

"The memo said there would be delays in setting up Monitor, a regulatory body for bringing competition in the NHS, to

which many object, which will slip to July 2012, and the abolition of strategic health authorities will also be delayed to

the same date."Guardian, 6 April 2011, http://www.guardian.co.uk/society/2011/apr/06/nhs-listening-exercise-thrown-doubt

37"The Health Secretary is facing a vote of no confidence after nurses accused him of not having the 'guts' to speakto thousands of them.

"Andrew Lansley has been heavily criticised for declining an offer to deliver a speech at the Royal College of Nursing

(RCN) conference in Liverpool."Instead, he has decided to hold a 45-minute Q&A with just 50 nurses as part of the Government's 'listening exercise'

on the controversial NHS reforms.


15/16

15

"Angry nurses have demanded to know why he will not deliver a speech during his visit tomorrow, and are to vote on

an emergency motion of no confidence in his ability to direct the reforms."

PA, 12 April 2011

38Department of Health, "Equity and Excellence: Liberating the NHS", July 2010, p. 1

39http://www.publicwhip.org.uk/division.php?date=2011-01-31&number=185&display=allvotes

40The government's plans for a health service shakeup face a radical overhaul after the Liberal Democrat leadershipwas forced to bow to the strength of a grassroots rebellion fuelled by fear of privatisation and an undue emphasis on

competition.

The Lib Dems voted almost unanimously at the party's spring conference in Sheffield to give councillors a central role

in GP commissioning and in scrutinising foundation trusts. They called for a ban on all cherry-picking by private

companies offering treatment services.Guardian, 13 March 2011, http://www.guardian.co.uk/politics/2011/mar/13/nhs-reforms-overhaul-liberal-democrats

41It was, she realised, a plan to dismantle what she calls one of the most efficient public services of any in Europe.She sums up Lansley's agenda as stealth privatisation. There were other aspects that would transform the NHSbeyond recognition, tucked away, such as allowing any willing provider to supply services. The NHS was always seen

as the preferred provider. That is swept away, she says.

The Guardian, 12 March 2011, http://www.guardian.co.uk/politics/2011/mar/12/shirley-williams-nick-clegg-nhs

42"Downing Street said: 'This is not about significant changes to the policy but about reassuring people with minorchanges to the language of the bill as it goes through the House.'"

Guardian, 13 March 2011, http://www.guardian.co.uk/politics/2011/mar/13/nhs-reforms-overhaul-liberal-democrats

43"As the Secretary of State for Health said very clearly yesterday, where there are legitimate concerns, for instanceabout the governance of a GP consortium or the role of the private sector, we will seek to address them. That will

then lead to substantive changes through amendments at the end of the process, in about two months' time."Nick Clegg, Hansard, 5 April 2011, column 883

44"But Simon Burns, the Health Minister and Mr Lansley's deputy, refused to accept there would be substantivechanges, saying there were 'misconceptions' and 'misrepresentations' about the reforms. 'It would be inappropriate of

me at the beginning of an independent process... to start saying categorically what we are definitely going to do,' he

told BBC Radio 4's World at One programme."

Independent, 7 April 2011

45Norman Lamb: The financial risk is that at the moment the plan is to transfer responsibility to GP consortia, neworganisations, there is no evidence about how these organisations will work but they are supposed

to be up and running by April 2013, there is a process to ensure that they have to meet a standard

before they are given full approval, but my preference, my strong preference is to look at what weare doing in the education reforms, in education, schools can opt for academy status, surely we

should be doing the sort of evolutionary approach in health as we are doing in schools.

Jon Sopel: So to be clear you think Andrew Lansley, youve just said it, is going ahead on this on the basis of no

evidence? that is what you just said, no evidence that there will be benefits.

Norman Lamb: I said that the principle at the core of this of giving GPs more power and responsibility is absolutely

right but when you introduce any new structures of course there is no evidence so the sensible

thing to do after this period for reflection is to test it to see how it works and it would gather a

momentum of its own, if it works as we hope it would then others would follow suit but to do it in

one fell swoop would be very risky

Jon Sopel: And keep the Primary Care Trusts in the transitional period?

Norman Lamb: Well we have now got these clusters of Primary Care Trusts, theyve been brought together I think

they have to stay because I think performance management of GPs is going to be really critical

during this period and incidentally for those areas that dont opt in to this, it is not an opt out of

reform, there would still be a progressive devolution of responsibility to GPs, there are different


16/16

16

ways of skinning the cat here, lets stick to the principle which is really good, but lets not destroy it

by getting the process wrong.

BBC Politics Show, 10 April 2011

46Norman Lamb: Well I just think it is essential that we all work to ensure that we get a package that people cansupport, that my party the Liberal Democrats can support

Jon Sopel: Sorry to interrupt you Mr Lamb, of course I understand that point completely but you have to

consider the possibility what if you dont

Norman Lamb: Well this package is not going to work unless we can get people on board and that includes the

addressing the concerns that I have raised.

Jon Sopel: So presumably when you spoke to Nick Clegg you raised the possibility that this could be a

resignation issue?

Norman Lamb: Look, Ive said that if it is impossible for me to carry on in my position I will step down, I dont want to

cause embarrassment, but I feel very strongly about this issue and I think that it is in the

governments interest to get it right in the way that I suggest.

Jon Sopel: But that could happen?

Norman Lamb: It could

BBC Politics Show, 10 April 2011

47"The detail of exactly how you make those principles work in practice are of course things that we want to getright. And I couldnt agree more with Norman, I couldnt agree more with Norman, we have to get this right. The NHS is

too precious, it is too precious to me, it is too precious to everybody else who relies on it in the country to not get the

principle translated properly into practice."

Nick Clegg, BBC R4 Today, 11 April 2011

48"Well there is no point having a pause unless you are prepared to make substantive changes at the end of it wherethose substantive changes are necessary. I totally of course agree with Norman, we talk about this on an almost daily

basis, that the status quo needs to change, we need to change the current system, that everybody agrees that it is

right to put more financial responsibility in that hands of GPs who know patients best. But how you do that is

therein lies... the devil lies in the detail Now Normans got very strong views about a particular aspect of it, other

people have got very particular views about other aspects of it, I think it yes it is unusual that a government is

saying look we are going to have a pause and listen and reflect and then change things where necessary, but it is... I

think it is a good thing that we are listening."

Nick Clegg, BBC R4 Today, 11 April 2011

undermining the nhs

Documents