Response to Minister Burns

Today Health Minister Simon Burns issued ten reasons why the government needs the Health and Social Care Bill. Remember, it is a bill not an act of parliament, it has not been enacted, so it is not correct to ascribe any current changes to the NHS to this bill.

Here are my responses:

1. If we want to reduce bureaucracy and management costs, then we need legislation. 

This is a bizarre statement. If the Bill was needed to reduce management costs, then there would be no reduction in the numbers of managers. However, the government takes pride in how many managers it has sacked since the election:

March 22, 2011, Department of Health:

a reduction of 2,770 managers and senior managers in the NHS between September 2009 and September 2010 – this equates to 2,416 full time equivalent (FTE) or a 5.7 per cent reduction.

At the Conservative party conference Andrew Lansley said:

"Unlike Labour, we will make sure that every penny of our investment goes right to the patients who matter, not the huge Labour bureaucracy which we inherited," he will say. "And all that is why, since the election, we now have 1,500 more doctors and 5,000 fewer managers in the NHS."

If the Bill was needed to "reduce bureaucracy and management costs" how have the government reduced the number of managers since the election  by 5,000? Surely this should be impossible since the Bill is not yet law?

The Bill does not mention management. It cannot affect management in Foundation Trusts because they are autonomous and the government has no control at all over their management. Likewise, GP practices are "independent contractors" and the government has no control over how GPs manage their practices. The "managers" that the government does control are those in Strategic Health Authorities and Primary Care Trusts (PCTs), and the Bill abolishes these. However, the Bill also creates the NHS Commissioning Board (NHS CB) and Clinical Commissioning Groups (CCGs), and it beefs up the responsibilities of Monitor, the Office for Fair Trading and the Competition Commission of all of which will need "managers". Indeed, the Bill mandates that the Competition Commission performs a review of the competitiveness of NHS providers before 2019 and every seven years after that, and since the NHS is such a large organisation, this will require the employment of thousands of "managers".

2. If we want to give doctors and nurses significantly more power than they have now to provide care for their patients, then we have to change the law.

This conjurers up an image of a bureaucrat accompanying every doctor and nurse periodically taking the clinician aside to tell them what to do. It does not happen. Indeed, many of the managers are former clinicians - doctors and nurses - who are making managerial decisions. Minister Burns says that it would be great if doctors and nurses made managerial decisions, but what would that make them? Yes, it would make them managers! If that happened after the Bill is passed, we would find that #1 ("reduction of bureaucracy and management") will kick-in and cull these managers. Then more doctors and nurses will have to make managerial decisions and ... and before we know it, there will be no clinicians left in the NHS! #1 and #2 are proof - if ever we need it - that the Bill should not be passed!

The Bill says that the three hundred new CCGs (an additional layer of management) will be making managerial decisions, but what evidence do we have that any of the managerial decisions is made by a doctor or nurse? The Bill does not says "the only people allowed to make a managerial decision must be a practising doctor or nurse".

Further, do we need the Bill to create these CCGs? There are now 266 CCGs and yet the Bill has not been passed. The Prime Minister said in PMQs on the 25 January this year:

"The point is this: there are thousands of GPs throughout the country who are not just supporting our reforms, but actually implementing our reforms. Let me give the right hon. Gentleman just one example of a supportive GP, who happens - [interruption] I think they want to hear from this one particular GP, who hails from Doncaster. When he was the acting chairman of the Doncaster GP commissioning group, he said: "Becoming one of the first national pathfinder areas is a real boost for Doncaster." I think that what is good for Doncaster is good for the rest of the country, too."

Can the Prime Minister explain how this GP managed to create this pathfinder CCG without the Bill? Minister Burns says that it is impossible, and he would have to wait until the Bill is passed.

It is not clear if CCGs will actually carry out any commissioning. Lansley has already said that one quarter of the commissioning that PCTs carry out (primary care: GPs, dentists, opticians, pharmacists, health visitors...) will be performed centrally by the unelected super-quango, the NHS CB. Further, a leaked document from the Department of Health last year said that "The largest of CCGs, and even the NHS CB itself, will not deliver best value by doing everything in house" suggesting that a proportion of the commissioning that CCGs need to do will be outsourced. The leaked document suggests that this work will be carried out by Commissioning Support Organisations (CSOs) hosted by the centralising, super-quango, the NHS Commissioning Board. These CSOs will be staffed by ex-PCT managers, so "doctors and nurses" will not be involved.


3. Most people agree that local authorities, because they’re also in charge of schools, town planning, transport and housing, should also be in charge of public health. 

The Bill does mention about making local authorities responsible for public health, but does it need legislation?

It is interesting that Minister Burns uses the term "most people", it is more likely that most people haven't a clue what public health is.

Minister Burns says:

"But we can’t do this without changing the law. Without the Bill, we can’t transfer powers or money from the NHS to local authorities"

But you can. The spending review in October 2010 transferred £1bn a year from NHS capital funds to local authorities to boost the funding of social care. Was that transfer illegal?

4. Most people agree the health and wellbeing boards are a great idea. 

There's that "most people" again. I wonder if Minister Burns has carried out a survey (if so, can we see it pleases)? If it is merely a bold assertion, then perhaps I will be permitted to reply with my own bold assertion: most people do not want this Bill.The Health and Wellbeing boards (HWB) are beefed up versions of existing Health Scrutiny Boards, and it seems that the same people will sit on the HWBs. This is still re-inventing the wheel, even if the new wheel is a big bigger.


5. We need this to Bill prevent discrimination in favour of private health companies over the NHS – it’s the first piece of legislation to do this.

If that were the case, then the technical document that accompanies the Operating Framework 2012/13 (PHF09) would be regarded as illegal. This document has the following indicator:

Patients should have the opportunity to choose a range of providers for their first outpatient appointment, including those in the Independent sector. This indicator shows a percentage of patients who have exercised choice, since it is likely that an alternative NHS provider was also offered to them. An increasing percentage of CAB bookings being made to the IS may be indicative of more choice being offered to patients.

This indicator says that the DH insists that PCTs must increase choice and it makes the assumption that an increase in choose and book (CAB, the mechanism to choose a provider for NHS care) bookings made with independent sector (IS, ie private hospitals) indicates that patients have been given choice. Minister Burns says that the private sector must not be favoured over the NHS, yet the DH is saying that they will performance manage PCTs based on increasing the number of patients using private hospitals. Why is the Department of Health producing illegal documents?

6. Most people agree that we should give more power to patients

I may get bored of repeating this, but there is that "most people" again. Minister Burns continues: "more power to patients - that they should have more choice and be much more involved in decisions about their care". We already have choice, it is the Choose And Book system mentioned above. Further, last year the government said that from April this year £1bn of NHS services will be available through Any Qualified Providers. This announcement was made without the Bill.If the Bill is necessary to extend choice, how could the government have made this announcement?


7. The Bill puts in law for the first time a duty on the NHS and local government to tackle health inequality.

This is nonsense. The Health Act 2006, clause 24 says that PCTs have such a responsibility.

8. The Bill places a duty on key organisations to integrate health and social care services.

No it doesn't. This is yet another bold assertion from Minister Burns.You can only truly integrate health and social care if you integrate the budgets and the provision. The Bill does not do this.

9. Currently, patients do not have a very strong voice in the system. 

Minister Burns says that HealthWatch will provide "a hotline to the Care Quality Commission and the NHS Commissioning Board". Well I can trump that. Through your MP you have a hotline to the Secretary of State for Health (Minister Burns' boss), but the Bill is abolishing this route.

10. The Bill changes the current arbitrary private patient cap that stifles the development of groundbreaking new treatments by the likes of Great Ormond Street and the Royal Marsden that NHS patients will benefit from.

This is nonsense. Great Ormond Street is not a Foundation Trust and so it is not covered by the current private patient cap. But more concerning is the naive belief from Minister Burns that the leprechaun gold of private patients will pay for "innovations". In fact, private patients, because they are paying, will insist that they have the treatments that have already been tried out on thousands of NHS patients and proven to be effective. What private patient will use their own money to pay for being a guinea pig? It does not make sense. Indeed, nothing Minister Burns makes sense. It is more likely that private patients will be paying for treatments developed using public funds (which is right: they have already paid their taxes, and are entitled to innovations funded by the NHS).


11. We need to pass the Bill because otherwise we will be seen to have wasted hours of Parliamentary time on a Bill no one wants

The "saving face" argument. OK so I added this one, but basically it is the only reason the government has to pass the bill: if they don't they will lose face. I agree with this one, it is the only reason for passing the Bill.