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Implications of the Health and Social Care Bill

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Implications of the Health and Social Care Bill

This is a copy of a letter that I am sending to members of the House of Lords prior to the Health and Social Care Bill going before them at Report stage. It discusses the part of the bill that I fear will have the most adverse effect on the country’s health – the planning and commissioning of healthcare services ceasing to be a public function.

Firstly a little bit about my professional background: I work at a senior level in a London public health department, where a significant part of my role involves managing a diabetes clinical network. My main areas of expertise are around population health and service integration and I am involved in the commissioning of local diabetes services. 

The part of the bill that is most problematic is its proposal to shift the function of commissioning health and healthcare services from the state to Clinical Commissioning Groups (CCGs), and also to what are being termed ‘Commissioning Support Organisations’ (CSOs). While the move from Primary Care Trusts (PCTs) to CCGs is fairly well known, the move to CSOs is less so, but it was this that prompted outright opposition to the Health and Social Care Bill from the BMA.

Under the system proposed by the bill, decisions about what healthcare services are commissioned for a particular area will be made by CCGs. However if this is to happen effectively there are numerous processes that need to take place that will be carried out by organisations separate from the CCGs. These include: assessing the need for a service; planning and drawing up the specification for a service; running the tendering process; monitoring the service; addressing any issues that will arise around service delivery (and there will definitely be some); evaluating the service. At a broader level services in an area will need to be integrated with one another to both improve delivery and also to ensure that they are in line with overall strategic direction. CCGs will also require ‘backroom’ support in areas such as payroll and IT.

What is being proposed in the Health and Social Care Bill is that these numerous and complex activities are no longer carried out by the state via the National Health Service, but are instead delivered by competing private sector organisations known as Commissioning Support Organisations.

Across the country regional groupings of PCT staff are currently being transformed into CSOs and numerous private sector management consultancies are developing commissioning services. The idea behind having a range of providers is that they will stimulate competition and thus drive up quality. However, having a system of health and health service planning delivered by multiple providers driven by commercial imperative and constrained by contract law will dramatically increase the risk of adverse patient and population health outcomes.

The recent affair surrounding faulty PIP breast implants highlights what can go wrong when it becomes necessary for the private sector to tackle unforeseen health issues. While some of the companies that had originally carried out the implants agreed to remove them, many did not and a number had since gone out of business. There was no question that companies would be required to remove those implants put in by their competitors. In the end it was left to the state via the NHS to remove those implants that could or would not be dealt with by the private sector.

Imagine a fairly likely scenario in which several years from now it becomes apparent that a disease that had previously been thought to be fairly well controlled is now assuming epidemic proportions. Services will need to be rapidly commissioned across the country in order to address this. However, in particular regions, some CSOs may not be able to carry out this extra activity if they are to maintain their commercial and operational viability, while for others it may simply not be in their corporate interests. As private companies there will be no obligation whatsoever for CSOs to take on this extra workload. In the case of the PIP breast implants, the state via the NHS had to step in when the private sector was unable or unwilling to deliver. Under the changes proposed by the Health and Social Care Bill, the NHS will not have the ability to do this resulting in impairment, disability and even deaths that could have been prevented under the present system.

It is important to note that once the capacity to commission healthcare services is removed as a core function of the state, the change is likely to be permanent, making us beholden to private sector organisations to commission our health services even if we were to wish this to not be the case. 

In conclusion - while the commissioning and planning of health and healthcare services may be directed by Clinical Commissioning Groups, the activity should remain a public function. Simply retain and develop the ex-PCTs which are currently grouped into regional clusters. The country that is unable to effectively plan its own healthcare is heading for a disaster.

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