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Already struggling under the unprecedented impact of the pandemic, the NHS is now mortally threatened by the Health and Care Bill 2021, explains Stephanie Clark

On 6th July, Government plans for a wholesale reorganisation of the English NHS were presented to Parliament in the Health and Care Bill. Sped through to its second reading on 14th July just before the summer break, it is now (from 7th September) under consideration by the House of Commons Public Bill Committee where amendments will be considered, and expected to go to the Lords in early November.

The NHS is reeling from ten years of underfunding across the board, resulting in critical staffing shortages and anger at eroded pay, a maintenance backlog, and reduced capacity – with further reductions in beds and accident and emergency provision planned. And now there is the impact of Covid: a record 5.45 million on NHS waiting lists reported in July, and rising, and increasing demand from long Covid.

So, will the Bill improve our healthcare? Government spin is that this Bill undoes the damaging effects of the last reorganisation created by the 2012 Health and Social Care Act. This fragmented the NHS and imposed costly and wasteful contracting out of NHS services. The Bill is lauded for providing the integration of health and social care. However, there is nothing in the Bill that would improve social care or build on existing coordination between health and social care services.

New organisational structures

The Bill legalises the break-up of the NHS into 42 ‘Integrated Care Systems’ (ICSs). Each ICS will have its own tight budget, forcing cuts in care. ICS Boards will include providers. This will institutionalise a conflict of interest, since the Boards are to decide which services to provide in their area, who provides them and where. Worse still, the Boards can include private companies – Virgin is already on an ICS Board in the South West.

Others potentially eligible are around 200 firms, including at least 30 US health insurance companies, already approved by NHS England (NHSE) to support the development and management of ICSs.

Deregulation

The Bill removes the, in Matt Hancock’s words, “irksome requirement” to put contracts out to tender. It also exempts the NHS from Public Contracts Regulations, which safeguard environmental, social and labour laws (including the right to strike). Thus it replaces a regulated market with an unregulated market: removing vital safeguards including, by removing transparency and accountability, against the kind of corruption we have seen from the Government’s Covid contracts.

The Bill also provides for deregulation of the professions: both the removal of a profession from regulation, and for the abolition of the regulatory body that oversees the conduct and competence of healthcare professionals – so putting patients at risk. Significantly, there is no requirement in the Bill for a seat on the ICS Boards for a medical or nursing representative or finance director.

Democracy undermined, lack of accountability and transparency

The Bill grants the Secretary of State major powers: to exert political control of ICSs by placing senior staff onto their boards, to abolish NHS related bodies, and to intervene directly in local decisions such as imposing local service reconfigurations.

Local authorities have reduced influence in the new organisational structures. Each ICS is set up with a Health and Care Partnership body. This body is supposed to have a responsibility for planning and overseeing local services, but is tied to the strategic planning and resource allocation of the ICS Board. Local authority representation on the ICS board is limited to a single representative for all the LAs in the ICS area (which covers populations of between two and three million).

The Bill removes existing powers of local authorities to scrutinise NHS decision making in their areas. It also gives no guarantee that ICS meetings will be held in public, that papers will be published in advance, or that the public can raise questions. In practice, the decision making of the 42 ICSs will be distanced from local community input.

The Bill repeals the legal requirement to assess patients for their social care needs before discharge. Pressure to free up beds and the crisis in social care has already led to faster discharge, increasingly with no more than a possible offer of “simple access to information, advice and services; including support and access to information to enable self-care and self-management”, but no guarantee even of that before sending vulnerable people home.

So it seems the onus for arranging support is on the patient, their family or carer. The Bill introduces a new model of healthcare, ‘digitally enabled’ and driven by cost-cutting.

What does this mean for patients?
  • More companies given access to confidential patient information, with no clear protection for patient privacy
  • More digital services, creating a two-tier health service, depending on whether you are able to make use of computers or smartphones
  • Fewer face-to-face appointments with GPs and less chance of seeing the same health worker
  • More patient care given by less qualified (cheaper) staff, directed by computers and manuals
  • Growing expectation that patients will “self-care”, using phone apps or websites for information or advice
  • More risk that services will be cut or rationed and non-urgent referrals to hospital delayed or refused because of pressure on ICSs to make savings
What does this mean for staff?
  • Threat to national agreements on pay, terms and conditions as each ICS Board will have their own limited budget and seek to cut costs
  • Flexible working with staff redeployed across and even beyond the ICS area, undermining team working, union organisation, continuity of care, and imposing extra travel costs and stress for staff
  • A deregulated and down-skilled workforce – supposedly justified by new technology but actually risking harm to patients and interfering with professional judgement and staff development
What can we do?

The Government can’t get away with this if enough people are aware of what it means for us – as users of the NHS and as staff. From September, Parliamentary battle will be in two arenas before returning for its final reading in the Commons: the Committee and the House of Lords. In the Lords, the newly elevated Sir Simon Stevens, recently retired head of NHSE and ex-President of Global Health Division of US health corporation UnitedHealth, is mobilising support for the Bill; Joan Bakewell and Michael Cashman are mobilising against. We know that there is some trepidation amongst Tory MPs fearing a public backlash against the Government if there is public understanding.

A call to action:
  • Call on your union to oppose the Bill
  • Write to the House of Commons Public Bill Committee with your concerns. This Committee is considering the Health and Care Bill and any amendments needed. It is now inviting written evidence from people with “relevant expertise and experience or a special interest in the Health and Care Bill”. That includes all of us who use the NHS.

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