Attempting to untangle the NHS bill

Yesterday I blogged with a request for help understanding what is going on with the NHS Bill so I could try to work out if it is something I need to genuinely worry about, and if so, whether there is something that I should be doing about it. I like the fact that there is an NHS and I don’t want it to come under threat.

Thank you to all the people who’ve got back to me so far and offered me assistance. I now realise that this is a bigger task that I had first grasped, and feel a little less embarrassed that I don’t understand it all. That seems to be a very common problem. I’ve started to put together a Twitter list of interested people, so I can keep across the conversation a little better, and I’ll share some of the links I was sent at the bottom of this post.

Taking a step back

Before I try to get to the nitty-gritty of the bill, the debate surrounding it, and all the political waves it is causing, I think that it is a good idea to try to understand a bit more about how the NHS really works. Then with that grounding we can start to ask questions about what is going on with the NHS Bill. In the same way that you might turn the telly on to watch Eastenders, but not really understand the workings of the BBC, I visit the doctor, but have little idea of what goes on behind the scenes. So let’s start at the beginning shall we?

A (probably over-) simplified look at how the NHS works at the moment

Ha. I wrote this sub-title then drafted something that I thought made sense. I passed it by someone more expert than I, and now I’m even more confused! So, let’s just try to see what we’ve got, and if anyone else can provide me with a simpler, more accurate, public-friendly version of the current basic structure, PLEASE let me know!

The easy bit:

There’s an election, we vote, a government is formed, they choose the Health Secretary, the Health Secretary (currently Andrew Lansley) sits at the top of the Department of Health. I think we can all get our heads around that.

The next layer:

Beneath the Dept. of Health there are Strategic Health Authorities (SHAs). The English health system is enormous so the SHAs are there to break the enormity down into more manageable regions. They sit in the middle of the organisational tree, passing legislation downwards, but also collecting information from the frontline and passing it back up to the Dept of Health. Still with me?

Primary Care Trusts:

Below the SHAs are Primary Care Trusts – these were brought in by Labour, to help bring health and social care a bit closer together, which seems to make sense. But according to Professor Greener “most social care is divided into that provided by the NHS (community health services) and that provided by local authorities who have budgets, but where care is mostly privately provided (think of homes for the elderly, care agencies doing home visits)”. Primary Care Trusts (PCTs) are the ones that actually commission the services in your area. Confusingly enough, they also provide some of those services too, so are effectively commissioning themselves. PCTs are responsible for ensuring delivery of quality care at the right price.


It gets a little more complicated again at this point, because there are two types of hospital: NHS Hospital Trusts which are overseen by the PCTs and SHAs, and Foundation Trust Hospitals which have a degree of independence from the DoH and SHAs. The Foundation Trusts were meant to be the best performing, and got ‘earned autonomy’ as a result, reporting to Monitor, an independent financial regulator. Professor Greener adds “They were allegedly allowed greater freedoms for being more highly performing, but haven’t often found it – ‘freedom to do as you are told’ is how one colleague of mine describes it. Monitor will take over responsibilities for all types of trust, as well as regulating non-public provision, after the reforms so big increase in their powers”.

So what’s all this Health Bill fuss about?

Well that’s really what I’m trying to understand. I use the word “fuss” as that’s probably what outsiders are wondering, but the more I learn about this, the more this seems like a really big deal. That’s why I want to try to understand it, and that’s why I want to try to help you understand it too.

There are a few problems with this:

a) no-one seems to quite fully understand it because the bill keeps changing

b) no-one can tell exactly what will happen

c) information to help us consider the risks of the bill is being witheld (ask your MP to sign EDM2659 to get it publshed)

As far as I can tell, reading various blogs, new articles and talking directly to some NHS staff, there are a range of issues. Again, this doesn’t make it very easy for me to give a single clear cut outline of the issues, so instead I’m going to look at a few things, as simply as I can and hopefully I will get some people with more expertise to help expand on these issues one by one.

So what is the bill hoping to achieve?

Here are a few of the main things that I have seen talked about, I’m sure there are more, but this is a learning process. I’m taking it a step at a time.

1) Empower GPs to form consortia that control their own budgets and can commission services their patients need

2) Cut down on bureaucracy

3) Boost the private sector’s role in providing services, to encourage more competition and innovation

Reasons people are worried

(Disclaimer: I’m doing my very best to understand this, but if I’ve got things wrong please let me know and I will correct them. If I’ve got them wrong, it’s because there are so many different things being said, and it’s hard to sift through them and work out what’s going on.)

Empowering GPs to form consortia that control their own budgets and can commission services their patients need

The Health Bill introduces Clinical Commissioning Groups – these will be groups of GPs who are able to commission the healthcare that they need in their area.

PROS: On the face of it, this sounds like a reasonable idea – doctors know which services are most in demand because they see patients on a daily basis.

CONS: Stop for a moment and think about that, do you want your GP to spend time treating patients, or trying to work out how to secure business deals on health provision? For my money I’d much rather my GP did what he/she was trained to do, and not have to worry about anything else other than looking after their patients.

Cutting down on bureaucracy

No-one would argue against an efficient, streamlined system that gets the job done and cuts costs. We’re all weary of hearing about public services with too many managers being paid too much to shuffle paper, but what’s the reality? It’s easier to show you, with the aid of a couple of organograms courtesy of the Labour Party, since as you can tell, explaining this stuff is not easy:

NHS structure pre-2010

NHS Structure after:

Copyright Labour PartyOnce I’ve got my head around this a little more, we can go into detail, but *just look at it!*. That doesn’t look like it’s making anything simpler. Am I missing something?

Boosting the private sector’s role in providing services, to encourage more competition and innovation

I’m not sure where to start here, but one of the things that I have seen mentioned is that if companies are competing on price, rather than on quality (as I understand they currently do with fixed national unit costs) then surely corners will be cut and patients could suffer?

Also, if we’re looking at using competition to bring the price down, then can someone explain why we don’t just use the enormity of the Health Service and its purchasing power to bring prices down? I know this whole situation is complex, and so I could be missing something, but isn’t it because Tesco (for example) is such a big purchaser that it gets the best deals on products and can pass them on to its customers? Isn’t that why all the small local shops are going out of business, because they can’t negotiate on such a big scale? Why then does it make sense to have lots of itty-bitty consortia, as nice and local as they may be, instead of the might of the combined health service?


I’ve so many questions still to find answers to:

– Does anyone actually support this bill, would they like to get in touch and try to explain what I’m missing?

– If we open up the health service to competition, is that it? Can we never go back, as someone suggested to me, because it would be anti-competitive and against the law?

– If hospitals are allowed to make money by taking private patients, won’t that just lessen the number of spaces for those of us who rely on free healthcare? Will that in turn push more people to take up private healthcare? Is that the end of the health service as we know it?

– What’s with these private finance initiative (PFI) hospitals – are we really locked into contracts to pay rent and services at whatever rate the company demands?

I know that there is a lot that I haven’t even scratched the surface of, so much that I am yet to learn. That there are people who could profit from this bill, I’m working my way up to understanding how that all fits together. I feel both comforted and horrified to hear that even those in the medical profession are struggling to understand all of this.

I want to hear from you

Pick a point about the bill that worries you, or that you feel you can teach me something about. Write to me, explain it to me, help me understand. Or better, record a quick Audioboo by visiting and clicking record. You’ll get three minutes, so why not state you name, what you do/what connection you have to the NHS, the point your raising and your thoughts on it. Tag it with #nhsbill and #healthbill. I would still like to try to create some useful resource to help others understand. It’s only now that I realise that this is a can of worms.. what have I done trying to understand?!

Useful links

You can find others as favourited tweets on my @RadioKate twitter account.

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