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7th November 2011

NHS- The shake up explained

Medical student Keir Stone-Brown takes you through the NHS reforms in plain English, and looks at the potential consequences

“What is your opinion of the NHS reforms?” I asked one consultant from Manchester. The response was less than enthusiastic.

“It’ll be a shot to the head of the NHS.” The proposed Health and Social Care Bill 2011 has been dubbed the most radical plan in the history of the health service – and it certainly has proved controversial. It’s been labelled as both the end and the saviour of nationalised British health, but with all the mud slinging between politicians, unions and healthcare groups it’s tricky to know what all the fuss is about? Where do we, as present and future patients and potential employees of the nation’s largest employer, stand?

Perhaps it’s wise just to take a step back and look at how many people it’s going to affect. The University of Manchester is the largest face-to-face teaching university in the country, having over 3,200 current students on nursing, midwifery and medicine courses. Without taking into account psychologists, life scientists and every other student with ambitions of working in the healthcare system, it makes up fewer than 10 percent of our student population. The NHS employs over 1.4 million people- that’s more than 5 percent of UK’s working population. But most importantly, these are changes that affect almost all of us. No matter how strong we think or feel we are, one day we will probably need NHS treatment. As such an important feature in our lives, any change to the NHS needs to be understood and supported by the public. I’m going to explain the current structure, outline the why and how of the reforms and discuss the numerous views surrounding them.

Why are the reforms being proposed?

There’s no getting away from it; the world is in financial meltdown. With governments all over the world scrounging for pennies cuts are being made across the board and the NHS (although technically ‘ring fenced’) is undergoing readjustments to make it ‘more efficient and cost effective’. Essentially, the NHS is attempting to save £20 bn by 2014-2015, which kicks David Cameron’s electoral pledge “Cut the deficit not the NHS” into the dustbin. Considering this reform will be rolled out in 2013 at the earliest, you’re looking at a whopping £10 bn saving per year across the NHS. However, Cameron has promised that the actual money put in to the NHS will still rise year on year. Critics argue that this is a facade; that in reality he’ll be reducing the annual increase in the NHS budget. The extra money that is being put in each year will be swallowed up by rising inflation, meaning that the actual monetary value the NHS gets will decrease.

A quick look back at history has seen spending on the NHS triple since 1999 from £40 bn to over £120 bn. However, looking at figures relative to British GDP per capita we still put in less money per person than almost every other nation in Western Europe and North America. Despite this, all major political parties have described a need to curb the rising costs in the NHS whilst making it more efficient. The Health and Social Care Bill 2011 is the coalition government’s proposal to do this.

How is the NHS currently structured?

At the moment the Department of Health controls the NHS. The Secretary of State for Health, Andrew Lansley, is the head and reports to the Prime Minister. The Department of Health controls England’s 10 Strategic Health Authorities (SHAs), which oversee 152 Primary Care Trusts (PCTs).The PCTs control local NHS activities. The devolved administrations of Scotland, Wales and Northern Ireland run their local NHS services separately.

Primary Care Trusts control approximately 80 percent of the budget and are responsible for distributing the money to GPs and hospitals as well changing their services to suit the needs of their populations. So, if Manchester had an increase in patients with diabetes, then they would be expected to provide more services to support those with diabetes. The PCT would plan effectively how to use their budget to accommodate their new needs.

The role of the Strategic Health Authorities is to provide leadership in the area they serve by organising workforce development and ensuring PCTs are looking after the needs of their populations. Essentially, they are the overseeing body that will dictate the numbers of staff needed across the region in different areas. For example, if the North West were low on anaesthetists they would call on deaneries responsible for training them to increase the numbers they train so that the whole SHA can benefit. They also are responsible for finding specialist services for conditions that some PCTs can’t treat.

Currently there is a large emphasis on cooperation between PCTs to provide the best possible service for patients by taking a national, regional and local perspective on health.

What are the proposed reforms?

The NHS will undergo a radical pro-market shakeup with hospitals, private healthcare providers and family doctors competing for patients who will be able to choose their own treatment and care options.

They will do this by abolishing all PCTs and SHAs, therefore culling more than 24,000 management jobs. Budgets will be directly paid from Department of Health to newly formed GP consortiums, which will be groups of GPs responsible for a certain area. A National Health Commissioning Board will be set up to supervise the GP consortiums to make sure they are doing what they are supposed to.

The increase in competition will provide a change from a unilateral service to one with more ‘choice’. Say for instance someone went to his GP and was told he had a funny looking lump on his shoulder that the GP wanted to have a closer look at. The GP would then request an X-ray. At the moment the patient would go to a local hospital to have it done. If the reforms take affect the GP and patient would now have a choice between several providers. For this example we’ll say a Private Hospital is charging £60 and a local NHS hospital is charging £80. Most likely the GP will try and convince the patient to go to the cheaper one because he is mindful of his budget. If the patient doesn’t, he can then go and complain to the ‘Monitor’, who is there to ensure ‘patient choice’. The powers of the ‘Monitor’ haven’t been well defined so it is not known if they will actually be able to intervene effectively. This also raises questions over the effect it will have on doctor – patient relationships as the patient will know the doctor’s decision may be influenced by the budget the doctor himself set out. He could directly ask him,

“why haven’t you set enough aside for my X-ray?”

This increase in competition you might think could lead to a decrease in NHS patients going to NHS hospitals, causing the NHS to shrink. Well the government has a plan for that. There are already a number of hospitals that have ‘Foundation Trust’ status and the Government are pressing for more and more hospitals to convert into them. These ‘Foundation Trusts’ have several powers that enable them to chase private patients (those with individual health insurance) and therefore bolster their own revenue so that they are not solely dependent on the money given to them by the government for NHS patients, thus enabling NHS hospitals to challenge private healthcare providers. However, this has raised concerns that these ‘Foundation Trusts’ will lead a charge by the NHS for private patients causing a decrease in access to healthcare for NHS ones.

Who is against the reforms?

It all sounds rather good, with more choice for patients and reduced costs over the whole of the NHS. But the plans have drawn sharp criticism from many interest groups. UNISON, the biggest trade union in the UK with over 1.3 million members, said

“NHS patients will be the biggest losers if the Government pushes through its Health and Social Care Bill.”

More opposition comes from the Royal College of Nursing. With over 400,000 members, they took the unprecedented decision to vote 96 percent in favour of a no confidence vote in Andrew Lansley. You might think that the Royal College of General Practitioners (RCGP), whose members will be handed increased power, would be happy but they have also expressed concerns with the changes,

“They [our members] worry about the financial pressures, and the competition culture of ‘Any Willing Provider’. They fear that these reforms could cause irreparable and irreversible damage to the NHS.”

The British Medical Association (BMA) who is to all intents and purposes a trade union for doctors working in the UK said;

“The BMA continues to call for the Bill to be withdrawn or, failing that, to be subject to further significant amendments.”

Finally, Ed Milliband, leader of the Labour party, went a step further and attacked the Prime Minister,

“It is an insult to the people who work in the health service, it is an insult to the people who use it and the Prime Minister should be ashamed of the way he is running the NHS, the proudest institution of Britain.”

It all sounds pretty fiery with anyone and everyone getting hot under the collar about it. So why are so many vehemently against the reform? The issues stem from several key areas.

The first being that GPs are now expected to become managers of their accounts whereas before much of the administration of the NHS was done by trained experts on PCT boards. Dr. Azeer, a GP of the Bury PCT, stated,

“I’ve had 15 years of clinical training, how am I expected to suddenly be an accountant as well?” A concern echoed by Conservative MP and GP, Sarah Wollaston, “It is one thing to rapidly dismantle the entire middle layer of NHS management but it is completely unrealistic to assume several hundred inexperienced commissioning (GP) consortia can take their place.”

Worries have also been raised that GPs will now have even less time with patients as they are forced to spend valuable time organising finances for their regions. Ironically, it is feared that GPs will resort to paying increased fees for managers that originally worked for PCTs absolving GPs of their new responsibilities and completely negating the desired effect. For students there may well be a reduction in training opportunities. Medical training is carried out entirely at NHS hospitals and under new proposals a lot of patients will now be going to Private Hospitals instead. Even Lord Nebbit, a Conservative pier in the House of Lords, has expressed concerns;

“It’s fine for the private sector, which doesn’t have responsibility for teaching and bringing on young surgeons, to take the straightforward and easy stuff. But that means the public sector is then left without the base of work to subsidise the more difficult surgery and the teaching of surgeons.”

With the abolition of the SHAs and PCTs there could be a lack of national oversight on health policy which will leave a fragmented NHS struggling to cope with the needs of patients on a national level as well as a local one. An example of this, is there being no government body to acknowledge the need for changing numbers of different types of doctors.

Regardless of these fears, a massive question remains that these changes may not actually see a decrease in costs in the NHS as the implementation of the reforms will cost over £2 billion in themselves and then the further re-organisation of the NHS could cause costs in the NHS to spiral out of control.

What next?

The reforms have passed through the House of Commons and are now in the House of Lords at a committee stage. This stage can take several months where infinite details are haggled over until a compromise is met before a final amendments stage. Groups such as the Trade Union Congress (TUC) and 38 Degrees have online petitions calling for the Health and Social Care Bill 2011 to be halted. Whether these reforms go through or not could be monumental for the NHS and as one of the future generations it is our responsibility to let our voices be heard. If I am to leave you with one final thought, it is to consider our trans-Atlantic cousins who, also struggling in a financial crisis, have given the go-ahead for a national health service of their own. Is this really the time to start unraveling ours?

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