Health and Social Care Bill

Memorandum submitted by Fiona Duxbury (GP in Oxford) (HS 89)

Aspects of the Bill, such as the greater involvement of clinicians in planning and shaping NHS services, have the potential (if implemented well) to improve patient care. However, benefits that clinician-led commissioning can bring are threatened by other parts of the Bill, particularly:

Enforced competition: Forcing commissioners to tender contracts to any willing provider - including commercial organisations - could destabilise local health economies and fragment care for patients. Research indicates that healthcare is not like buying a shampoo. Choice of product worsens quality of care often and is usually more expensive. I like NICE: it ensures \"best practice\" scientific care, and helped us deliver cost-effective care. Most doctors would sign up to NICE. What we do not sign up to is \"Choice\" where NHS money is likely to be spent on the richer, worried well. Health inequalities are likely to be increased by enforced competition. The poor, sick and vulnerable, many of whom do not have access to the internet or the ability to fully understand choices, will be disadvantaged.

Price competition: The Bill will allow providers and commissioners to agree prices below the tariff set by Monitor (to be paid for different sorts of treatments), opening the door to price competition. I am concerned that such a move could allow some providers to chase the most profitable contracts, possibly using their multinational size to undercut on price, which could ultimately damage local services. Price competition has been shown to lead to a reduction in care quality.

Pace and scale of change: At a time of huge financial pressure, these major, untested reforms are, undoubtedly, a massive gamble. The deadline for all trusts to achieve foundation status, for example, is 2014. There is a real risk that forcing all hospitals to become foundation trusts before they are ready could lead to a focus on achieving financial stability rather than maintaining high quality patient care.
We GPs have a day job and are relative amateurs as regards management. I know some of my colleagues will be happy to move away from frontline service into administration and learn fast, but they will be rather expensive administrators compared to many at the PCT. They will be tempted to spend NHS money buying in expensive management consultancy firms.
I was pleased with the removal of the Strategic Health Authorities, and the drive to reduce PCT bureaucracy but that could simply and cheaply have been done by stopping the more daft Labour initiatives that had no outcomes research base for the value of the proposed intervention behind them. A slimmed down PCT focused on the essentials with clinician expertise as input advice would be a much simpler way of delivering a cost-effective NHS rather than destroying the NHS with this bill that is likely to cost £1.2 billion to implement and lots of TUPE payments to staff.
The proposed structure lacks democratic input. In Oxfordshire only we GPs have voted on the shape of things to come. There is no obligation to invole the public or hold meetings in public which the PCTs were obliged to do. So less public say with this new NHS Bill?

In Oxfordshire we are going to inherit a budget deficit. The deficit is partly the result of the tug of war between the Oxford Radcliffe Hospital Trust and the PCT. If the ORH \"over-performs\" on its contract the PCT has to pay up and whoever negotiates the hardest comes out the winner. All this juggling of paper leads to its own costs called \"transaction costs\" which are again a distraction from money going direct to patient care. The NHS Bill is about to encourage an escalation of \"transaction costs\" and meetings to negotiate prices. Actually what my patients repeatedly tell me they want (when offered choice of provider for a service through \"choose and book\") is a local hospital or provider that does the job well to agreed standards. Audit of services: yes, with expert agreement on \"best scientific practice\", ignorant choice: no.

To see how cost-effective the NHS currently is and understand how people feel about the NHS please look at this paper on comparisons between 11 different countries\' health care systems.
A selection of findings from the 2010 Commonwealth Fund International Health Policy Survey were originally published in:
C. Schoen, R. Osborn, D. Squires, M. M. Doty, R. Pierson, and
S. Applebaum, \"How Health Insurance Design Affects Access to Care and Costs, by Income, in Eleven Countries,\" Health Affairs Web First, Nov. 18, 2010.
Access to the paper can be found at:

There are no doubt some doctors motivated by money but many more of us genuinely just want to do the right thing by our patients. We will work hard in a system that has that ethos at its heart. The NHS competitive Bill will endanger that professional ethos forcing one part of the system to scheme against another instead of cooperate together.

March 2011