Helen Salisbury: Will the latest NHS reorganisation help patients?

Another health and social care bill is on its way through parliament, changing yet again the way decisions are made in the service. Do many doctors or patients really care who sits at the top table making commissioning decisions, as long as services continue to be provided free at the point of care? Should we be concerned about this bill?

The most positive aspect of the new bill is the removal of the requirement for competitive tendering. This was brought in with the last set of reforms (the 2012 Health and Social Care Act), the aim being to improve quality and reduce prices using the mechanisms of the market. There isn’t much evidence that this has been achieved. Collaboration is now the flavour of the month, but not before private sector companies have gained significant footholds in NHS service provision. In my daily practice I now have to interact with private companies for all musculoskeletal problems, for diagnostics such as endoscopy or echocardiography, and for a large number of surgical referrals. This is all new since 2012.

The new bill could offer an opportunity to remove wasteful competition and revert to the NHS as the default provider. However, there’s nothing to suggest that this is now the general direction of travel, and there are concerns about a potential lack of transparency in the way future contracts will be awarded. This government’s recent record of handing lucrative contracts to people with connections to the Conservative Party, without an open bidding process and often resulting in very poor value for money, may serve to heighten this unease.1

Clinical commissioning groups are being merged, and their functions will now be taken over by integrated care boards (ICBs), which will include representatives of hospital trusts, local authorities, general practice, and other stakeholders.2 The inclusion of private sector providers on the shadow versions of ICBs has led many campaigners to ring alarm bells about conflicts of interest.3 If a company has a commercial stake in how services are commissioned and designed, should it have a say in those decisions? Can we be confident that a company will always prioritise providing the best possible care to patients over maximising returns to its shareholders?

It’s not clear that the middle of a pandemic is the right time to make sweeping changes, but many issues in the NHS need urgent attention. We have a huge workforce problem and a crisis in social care, widening health inequalities, and inadequate funding. Unfortunately, nothing in the bill tackles these issues. There’s also no sign of the public accountability that should be built into the NHS: public money is spent on healthcare in our interests, and we should have a right to scrutinise how decisions are reached.

There is, however, a remarkable power grab by the secretary of state for health and social care, who appears to have the right to intervene if any appointment made by—or decision taken by—an ICB is not to his or her liking. The BMA has rightly cried foul and suggested that the government should think again.4