The Health and Social Care Act 2012 has successfully completed its passage through Parliament and is now law.
It came into effect in April 2013 but the full impact will take time to be felt. We at Get into Medicine UK want to provide a brief whistle-stop summary of its main changes, the stated intent behind them, and the areas of controversy. It is not intended to be an exhaustive and detailed summary, but it should be enough for you to grasp a basic understanding of the changes, in order to both be aware of the system you may be applying into, and to be able to intelligently discuss the legislation at interview.
A further caveat is that changes to healthcare systems are highly complex, and it is extremely difficult to prove in advance how changes to any complex system will pan out.
Pre-April 2013, the NHS was:
- State-funded from the pool of money received by the Treasurey in general taxation
- Management is organised into 10 regional Strategic Health Authorities (SHAs), with 151 Primary Care Trusts (PCTs) underneath, covering smaller regional subdivisions. PCT executive boards generally have some elected representation from local primary care providers, such as GPs.
- PCTs buy (“commission”) the services they need for the populations they cover from other branches of the NHS, like hospital trusts, GPs, mental health trusts, ambulance trusts, and so on.
- PCTs are already able to also commission services from the private sector, non-profit sector, and voluntary sector. However, due to technical aspects in the way this commissioning process is structured, it is very difficult for a non-NHS body to be able to win a contract if an existing NHS service is already providing that care.
- Based on the money they receive from their contracts with PCTs, all the above groups provide care from the patient groups they are contracted to serve.
The Act has:
- Removed the SHA and PCT layers of management. There will still be a (much slimmed-down) layer of regional strategic representation but it will no longer have commissioning powers.
- Replace their role in commissioning by about 240 Clinical Commissioning Groups (CCGs), comprised primarily of GPs but also including some other local healthcare practitioners (e.g. hospital doctors, nurses, etc). The inclusion of these latter groups into CCGs was a compromise made by the government during the passage of the Bill.
- As is already the case with PCTs, CCGs will able to also commission services from the private sector, non-profit sector, and voluntary sector. However, due to technical changes (“any qualified provider” aspects of the legislation) in the way the commissioning process will work under CCGs, it will be much more likely that these sectors can demonstrate they are able to carry out the needed care, and so win contracts away from NHS organisation if they can meet the same need at lower cost.
- GPs (and some specialist services) will not be funded by CCGs, but directly from central government.
- Based on the money they receive either centrally (in the case of GPs) or from CCGs (in the case of other organisations), these groups provide care from the patient groups they are contracted to serve.
- NHS spending will continue to be funded from general taxation. The percentage of its expenditure spent on non-NHS (private, non-profit, voluntary) sectors is likely to increase, although this is not certain. This could increase efficiency by increasing competition between qualified providers for these contracts, so making the NHS able to provide more healthcare per pound spent.
- It may also fuel the broader development a more diverse healthcare ecosystem able to better meet needs of individual patients, rather than a monolithic NHS service defined centrally.
- NHS services will be commissioned by healthcare practitioners representing smaller, more local, groups of patients. This could make commissioning more responsive to local care needs.
Areas of controversy:
- On an ideological level, some oppose any expansion of the involvement of non-NHS organisations in the delivery of NHS care, because they feel the NHS should be a public organisation where healthcare is provided by public servants (not employees of private, non-profit, or voluntary organisations). Reasons for this position vary from the political to the ethical, depending on the individual in question.
- Some object to the changes on more practical short-term grounds, suggesting any large-scale changes add a disruptive burden to the delivery of care during an already financially-difficult time. They suggest that this will act as a distraction, paradoxically increasing short-term costs and inefficiency of healthcare delivery, due to the need to managerially cope with the reorganisation.
- Others fear that a more diverse healthcare ecosystem will eventually lead to an expansion of the private sector more generally, attracting healthcare practitioners into it rather than the remaining NHS services.
- On a purely political level, some see opposing the changes as a useful way of reducing government popularity more broadly by using it as a stalking horse for other criticisms (which may be related or completely unrelated to healthcare).
Areas to think about:
- If you are a prospective applicant to medical school, it is probably unlikely that you have sufficient experience of management procurement policies and healthcare systems to be able to come to a completely rational – if such a thing can even exist – position on supporting or opposing the changes that will soon come into legal effect. Instead, focus on trying to grasp the main conceptual changes and what will remain the same. Be aware of the general arguments for and against the changes, accepting the complexity of the issue if asked about it at interview.
EDITED TO ADD: Since this article was originally published, the BBC has uploaded a decent summary, including some useful infographics, of some of the changes discussed above. You can read it by clicking here.