NHS shake-up: The sticking points

Image caption The House of Lords will be debating the NHS changes this week

The NHS reforms in England have been one of the most controversial aspects of government policy.

In the spring, ministers even had to halt the progress of the Health Bill underpinning the changes because of widespread opposition from MPs, doctors and unions.

A host of concessions were made following the two-month "listening exercise", including watering down the role of competition and increasing the involvement of health professionals other than GPs.

However the overhaul is still attracting criticism and with the House of Lords set to debate the bill this week, ministers are braced for more negative headlines.

But what are the remaining sticking points?


The sensitivity over this issue was perfectly illustrated last week with the coverage of the actions of one GP group in York.

The surgery had sent about 30 letters out to patients offering them the option of getting minor treatments, such as mole removals, done privately.

It was immediately seized on as an example of how the changes were threatening to destabilise the health service.

Some saw it as a conflict of interest, while others expressed concern it was the start of the weakening of the relationship between GP and patient.

The Department of Health rejected this, although officials were quick to criticise the actions of the practice.

What the case shows is that, despite ministers accepting that there needed to be a better balance between competition and cooperation when they announced their concessions, many have yet to be convinced.

Even groups which are more sympathetic to increasing the role of the private sector, like the King's Fund think-tank, have concerns about what they perceive is a lack of clarity.

Increased bureaucracy

When Health Secretary Andrew Lansley unveiled his reforms in the summer of 2010 he said it was about reducing NHS bureaucracy.

He said out would go two layers of management - 151 primary care trusts and 10 regional health authorities - to be replaced by GP consortia.

But as the government has tried to appease its critics, the complexity of the system has increased.

At the bottom of the management ladder will be clinical commissioning groups - the new name for GP consortia to reflect the fact that other health professionals will get more involved.

But in areas where they are not ready for the 2013 deadline a regional body - possibly merged primary care trusts - will stay to support them.

Clinical senates, encompassing a range of health professionals, are also being created to offer advice.

Meanwhile, the national board will have regional outposts to oversee complex care, such as cancer.

To many, it sounds an even more complicated system than the current structure.

Role of secretary of state

On first reading, it was easy to miss. But a simple change of wording has become one of the touchstone issues.

In the original plans, it was suggested that the duty of the health secretary to provide a national health service, which has been enshrined in law since the NHS was created in 1948, should be scrapped.

After an outcry ministers said this would be reintroduced, but amendments only say he or she should "provide or secure" care.

Critics say this still represents a weakening of the duty. In fact, the campaign group 38 Degrees paid for legal experts to look at the issue and concluded the health secretary was free to "wash his hands" of the NHS.

The Department of Health denies this is the case, but nonetheless the wording remains a bone of contention.

The failure regime

Hospitals have always been the public face of the health service.

But with more care being moved into the community, it is clear that there will have to be some closure of services.

By ushering in greater competition, ministers have been quite open that some hospitals could have to close.

The question is how this can be done, while protecting vital services, such as A&E.

This issue has yet to be fully explained - and even when it is many may feel uncomfortable about the prospect of NHS hospitals losing out to the private sector.

Professional opposition

When David Cameron stood up in the House of Commons on 7 September, he felt pretty confident to claim he had the backing of the health profession for the reforms.

He had, after all, helped to oversee an exhaustive consultation exercise involving more than 200 public events.

But the prime minister was quickly put in his place.

Within hours the Royal College of Nursing and Royal College of GPs were issuing statements saying they still opposed parts of the plans.

The British Medical Association, which represents over 100,000 doctors, also remains opposed, arguing the bill should be withdrawn.

The fact that there is still widespread opposition among the profession is certainly a headache for ministers.

Without warmer words from doctors and nurses it will be harder to swing wider opinion.

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