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Health and Social Care Bill: what the colleges think

The government faces mounting opposition to the Health and Social Care Bill as it enters the final stages in the Lords.

The BMA had been joined in outright opposition to the Bill by the Royal College of Nursing and the Royal College of Midwives.

Health secretary Andrew Lansley made some eleventh hour amendments on 1 February to ease its passage, which has forced the medical representatives and colleges to go away and examine the detail.

The RCGP responded first writing to the Prime Minister calling for the complete withdrawal of the Health and Social Care Bill.

Despite the number and extent of the amendments, the college remains concerned that the Bill will cause irreparable damage to patient care and jeopardise the NHS.

Three quarters of respondents to a poll carried out by the RCGP said they thought it appropriate to seek the withdrawal of the Health and Social Care Bill. The last of three surveys commissioned by RCGP Chair Dr Clare Gerada, the poll found that GPs are increasingly concerned about the Bill and the effect it poses to patient care.

But the college initially held off from calling for wholesale withdrawal, instead writing to health secretary Andrew Lansley using the survey results to reiterate its concerns and provide another opportunity for changes to be made.

The subsequent responses from Earl Howe and the Health Secretary, and the amendments presented to the House of Lords, prompted stronger action.

RCGP Chair Dr Clare Gerada said: “The government has claimed that it has made widespread concessions, our view is that the amendments have created greater confusion. We remain unconvinced that the Bill will improve the care and services we provide to our patients.

“Our position has not changed, and the concerns we expressed when this Bill was at the White Paper stage 18 months ago have still not been satisfactorily addressed. Competition, and the opening up our of health service to any qualified providers will lead not only to fragmentation of care, but also potentially to a ‘two tier’ system with access to care defined by a patient’s ability to pay.”

In contrast, the Royal College of Obstetricians and Gynaecologists (RCOG) welcomed the government’s amendments.

In particular, the RCOG is pleased by the clarification that the health secretary will retain ministerial accountability and responsibility for the NHS. The RCOG is also pleased to see further strengthening in the government’s commitment to tackling health inequalities.

On integration and accountability, Monitor, as part of its remit, will now ensure that healthcare providers co-operate with one another so that services are integrated.

The RCOG is reassured that all providers of care will be driven by a commitment to improving quality of clinical services and improving patient outcomes.

RCOG president Dr Tony Falconer said: “Throughout the passage of the Bill in both houses, the RCOG focused on areas, essential to the quality of service for women, such as reducing health inequalities and ensuring the parity of access to services. We have been reassured by the amendments and the emphasis on competition being focused exclusively for improving the quality of women’s healthcare.”

The position of other colleges, prior to amendment response:

Royal College of Radiologists

The college has “grave concerns” over several areas of the Bill:

– There should be an overriding duty on the health secretary to ensure that a high quality and integrated health service is delivered in the best interests of patients.

– There is a potential for widespread and potentially embedded health inequalities across the NHS.

– Recognising that competition has for some time played a role in the NHS, we remain alarmed that the dangers of unfettered competition as outlined in the Bill will adversely affect integrated care in both clinical oncology and clinical radiology.

– The NHS will lose its state provider status and in doing so open services to EU competition law, which would have serious implications on the provision of patient care.

Royal College of Psychiatrists

The college is not able to support the Bill. It believes that the consequences of the Bill will be entirely different from the principles which were originally set out, and do not consider that it will improve the health and care of people with mental illness. Indeed, it has strong concerns that it will have the opposite effect.

Its strongest concern is that increased competition will work against collaboration in the best interests of patients. While clinically appropriate choice is important for patients, competition must be used with caution, and only where it is clearly beneficial.

Any fragmentation of care will exacerbate their vulnerability, and work against providing the comprehensive, co-ordinated and consistent services which enable the development of supportive and trusting care relationships.

The college wants:

– parity of esteem between mental health and physical health;

a reduction rather than an increase in health inequalities;

that integrated care is safeguarded over competition;

that competition is only used in the NHS where it can be shown to clearly benefit patients;

– continuation of a system of effective postgraduate medical education and training;

meaningful involvement of service users and carers in needs assessment and commissioning processes; and

flexibility for clinicians to undertake work for the benefit of the wider NHS.

Royal College of Surgeons

The college believes that the Bill should be implemented without unnecessary delays, as otherwise procrastination, without an alternative cogent plan, will lead to further chaos and be to the detriment of patients.

It is concerned that the NHS is denying patients access to surgery as a means of saving money in the short term, when what is needed is long-term improvement like reconfiguration.

The RCS largely supports the aims of the reforms to modernise the healthcare system – cutting the bureaucracy and giving patients and their clinicians the right to decide the best treatment for individuals. It also believes that commissioning should be based around the patient, supported by the relevant clinicians and healthcare staff.

Key areas of ‘work’ include:

– Any Qualified Provider – the college argued for the idea of any ‘qualified provider’ rather than allowing any ‘willing provider’ to lessen the risk of cherry picking by the private sector.

– Clinical involvement – it called for greater clinical involvement in the NHS Commissioning Board and for more detail on the sub-national commissioning structure in the NHS i.e. clinical senates.

Research – secured a change in working from ‘a duty to incentivise research’ to ‘the Secretary of State, NHS Commissioning Board and Clinical Commissioning Groups having a duty to promote and incentivise research and innovation’.

Education and training – It has concerns about the Department of Health’s Developing the Health Care Workforce, particularly the emphasis placed on providers and Local Education and Training Boards with little role for the profession.

Royal College of Physicians

The RCP claims consistency since the publication of the white paper in July 2010 – being neither for nor against the Bill.

It recently supported the Health Select Committee’s findings saying: “The RCP agrees that meeting the £20 billion efficiency savings at the same time as dealing with the increasingly elderly population is a difficult challenge for the NHS. It is crucial that the proposed reforms help services meet this challenge, rather than distract from it. The government has failed to set out clearly how this will be achieved.

“While improving efficiency, the NHS must still at the same time invest in quality. A key priority is to provide consultant delivered care, which would both improve standards and patient experience, and save money. The health reforms must also improve the process for making decisions about service reconfiguration, for this will increase the availability of consultants, and facilitate seven day infrastructure to underpin consistent patient care. Clinicians and local communities should lead those decisions.”

Royal College of Paediatrics and Child Health

The college is not opposed to the Bill outright, but has challenged the parts of it that have the potential to be detrimental to children’s health. These are namely:

– Children with complex, multiple needs may fall through the gaps in the systems if services are not fully integrated;

– Collaboration and integration are key to delivering good quality outcomes for children;

– The college is concerned that the lack of involvement of children and young people will lead to poor service planning, and by extension, outcomes for children.

– There is too little detail on the new arrangements for postrgraduate medical education and training.

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