Health and Social Care Bill

Memorandum submitted by Frances Crook (HS 56)

I am submitting this letter as written evidence to the Committee considering the Health and Social Care bill. I am a non-executive director on a Barnet primary care trust.

1 The plan to hand over the entire budget of the NHS to GPs, who will then commission services on behalf of individual patients is an up-ending of the system and a more radical overhaul than anything ever envisaged since the very foundation of the NHS. There has been no formal public discussion of the proposals through a green and white paper and the extent of the re-organisation, and commensurate cuts in budget, is only now leaking out. The proposals were not contained in the Conservative party manifesto or the Coalition agreement.

2 The NHS budget is £110 billion and there are around 30,000 GPs working in England and Wales. Currently the budget is divided up amongst the seven strategic health authorities who devolve it down to primary care trusts (PCTs), most of which are coterminous with local authorities. The strategic authorities do "what it says on the tin", by setting strategy and holding the local delivery agents to account for national and local policy. The PCTs commission services from hospitals, GPs, opticians and primary services. Trusts increasingly have strong links with local authorities to provide social care to the elderly and people with disabilities or other health needs. This infrastructure would be demolished and the strategic health authorities will be abolished. The PCTs might survive but with reduced powers and with little or no authority over budgets or services; it is most likely that they might be simply employed by doctors as the administrative mechanism to purchase health services for individual patients.

3 The last major reorganisation of the NHS took place in 2002 and has therefore had less than a decade to settle. The PCTs are mid way through a restructuring that will separate the provider arm from the commissioners and no one seems to be clear whether this will be stalled or will proceed. There are undoubtedly bureaucratic tangles but these are not insurmountable.

4 The new vision for GP led commissioning envisages both sole practitioners and groups handling the entire budget and commissioning services for their patients from hospitals, local authorities, private companies and primary services. There are so many big questions concerning the detailed arrangements. Ho will single GPs delegate to a consortium of local doctors? Will GPs sub-contract the commissioning process to the big private companies involved in healthcare on the fringes and so bring privatisation to the heart of the NHS by stealth? Indeed, will GPs want to take on this responsibility?

5 It is not clear where public consultation and strategic decision making fit into the GP led model. The secretary of state may argue that as decisions are made about and with individual patients then this is inherently a form of public consultation and therefore unnecessary to conduct other forms of involvement. This is a fragmentation of public consultation as there would be no forum for leading discussion on, for example, investing in new specialist trauma services at particular hospitals or reconfiguration of specialist stroke services. The strategic health authorities have been the lead agency in conducting public consultation but as they are to be abolished, it appears that public consultation will be abolished too.

6 It is unclear how strategic decision making will be conducted, if at all. Just as the schools system is being fragmented so that the strategic responsibilities of local authorities are being taken away, so it is with health. Devolution to the individual is the abolition of strategy.

7 Public health will be another casualty. It appears that the public health budget will be slashed from 7% of the total NHS budget to just 4%. Public health saves lives through the promotion of healthy life styles, public education and programmes like smoking cessation. It is one of the ways that we direct health services at the poor by directing services at inequalities.

8 Public statements have indicated that the NHS will not suffer the cuts that other departments are facing yet it is becoming clear that there are going to be significant budget cuts in health. PCTs are being told to cut 51% of their management and administrative costs. The effect of this is to hobble any attempt at strategic management.

9 Targets are being abandoned. Whilst there has been some unease at the rigidity of the target culture it is undeniable that imposing targets and holding everyone to account for specific time limits in accident and emergency units, seeing a consultant and the performance of operations has saved and improved the lives of millions of people.

10 Cities will be particularly hard hit. In London there are probably several hundred thousand people who are not registered with a GP and they will not be able to get access to any healthcare. Anyone who is not eligible for whatever reason to register with a GP will be denied medical and health services.

11 Since its foundation the NHS has been redistributive. It was designed, and has been functioning, to redistribute to the poor so that health inequalities are reduced. Its success has been patchy, but that explicit objective is embedded at all levels and in every service. As strategic planning is abolished and service purchasing is fragmented, the aim of reducing inequality is abandoned too.

12 With the abolition of PCTs the role of the non-executive director also disappears. There are no plans to include any NEDs on the GP consortia and so the voice of the public will disappear. In addition, NEDs provide senior links to other authorities by representing the health service on community safety boards, safeguarding boards, and may other bodies, and these links will disappear leaving health out of the loop.

February 2011