Goodbye old NHS, hello new NHS. A brief guide.

A summary of the NHS changes

From April 1^st, the NHS has changed fundamentally, the biggest changes since its inception, as laid out in the highly contentious Health & Social Care Bill of 2012 which created a huge storm and required many changes before it could pass through parliament. Though some changes were made it still means massive and rapid upheaval and an uncertain future for the NHS at a time when budgets are having to be significantly cut and demand is rising inexorably whilst the costs increase. A perfect storm, say some.

So what exactly happened in April?

Here is a good video from the Kings Fund which makes some kind of sense of it all - possibly. 

The organisational structure of the NHS has changed. This is meant to make it more responsive to local needs. GPs, through local Commissioning Groups, will now be responsible for commissioning healthcare for their patients (see our blog on commissioning). It used to be the job of Primary Care Trusts to do this and from April 1^st they no longer exist. As you can see from the organisational diagram (courtesy of the BBC) there are more organisations and more complexity than before.

Names are still changing and the ‘National Board’, which replaces the Strategic Health Authorities, will now be known as NHS England. NHS London is our regional hub and NHS North West London, our local hub with NHS Brent & Harrow our local office. Brent Clinical Commissioning Group (CCG) is subdivided into 5 localities; we are in Kingsbury and are partially merged for operational purposes with Willesden. Well, that’s clear now!

Brent CCG is run by its  CCG Governing Body (this link may change soon with a new website – website developers have done particularly well out of the NHS changes!)

20,000 NHS staff nationally have been made redundant from NHS administration and locally many excellent people have now gone, often with very little warning – a sad way to treat long-standing loyal staff. Others have been moved to the new organisations and some of those made redundant are being snapped up by management consultancy companies and other bodies who will have a role in the new processes: there will be a lot more outsourcing.

One problem with this is that institutional memory is being lost – will the same old mistakes be made again and again? – and the long-term responsibility will be diminished – the outsource contracts are usually short-term yet the processes started have long-term implications. Designing and implementing a new service takes many months and often the benefits or problems that determine its value are only recognised during long-term evaluation. Though the PCTs had many problems at least there was some long-term stability (despite the many smaller reconfigurations made over the years).

New relationships are being formed, new organisations created, new ‘stakeholders’ and interested parties and it will take a while to see how all this works in practice.

Though these changes will have cost £1.4b, the NHS is having to plan to large savings over the next few years - £20bn to 2015, some suggest a good deal more after that (against an NHS budget in England of £120bn) . Learning how to slash the budget whilst improving services will be something of a ‘challenge’ and is seen as one of the main motivations for passing responsibility to CCGs and the doctors running them.

Will we fledgling commissioners have the necessary skills? We certainly don’t have the experience. We certainly don’t have the time (many early enthusiasts are already standing down, beaten back by the frustration of the umpteen meetings and piles of documents that the new processes inevitably create). We will all need a lot of help and many mistakes are waiting to be made as the system beds down over the next few years.

More regulations and systems will probably follow; the NHS evolved over its life to deal with the growing complexities and developments in healthcare and creating a new organisation so rapidly is throwing up all sorts of unforeseen problems and unintended consequences.

There are already concerns about conflicts of interests with many doctors involved in both providing health-care and also commissioning it. With huge transfers of money, complex contractual arrangements and greater involvement with the private sector there will be mistakes made and almost certainly scandals will be discovered. New organisations are being set up to regulate this – Monitor is the main one (originally set up to promote competition it will now be, in essence, regulating this competitive market).

In parallel are massive changes to the local NW London health provision; Shaping a Healthier Future – see our blog on that. How will it all fit together?

As patients you will not have noticed many significant changes yet but a great many are on the way. Some will be difficult for us to explain to those patients who may find their needs pushed down the priority list: the commissioning process will require a lot of patient participation and understanding by all. You can join in the discussion through our Patient Group and we’ll be opening up a discussion facility on this website. We shall try to keep you informed of the major issues.

The legislation brings us into closer working with Local Authorities – Public Health Departments (dealing with immunisation programmes, infectious disease control, healthier living etc) now come within their remit for the first time and there is a new national body- Public Health England) . Strategic decisions about commissioning will be made by local Health and Wellbeing Boards  and hopefully bring about better coordination and integration between health and social services; much needed. Information about Brent Health and Wellbeing Board can be found here.

Not only GPs but other people such as hospital doctors and nurses and local authority officers will have some involvement and responsibility for commissioning too and so there will be many interests of different shades trying to find a way through the process, especially as we start to see lobbying by special interest groups being targeted at CCGs. Balancing competing demands and budgets with politics expedients will be an important and delicate part of the process. Tough decisions will be needed and many groups and individuals will inevitably be disappointed. We’re worried about costly and time-consuming legal challenges to our commissioning decisions and feel the lawyers will be testing many aspects of the new NHS for which we commissioners bear responsibility.

We have a duty within the legislation to involve the private sector in those services we commission. The wording has been been watered down recently after a lot of concern was expressed but still the intention is to increase private and third sector involvement in NHS services, so expect, in future, to see many new players providing your health-care. And these may change from year to year. We worry that much of our time will be spent in costly tendering exercises and later in contract monitoring. 

Hopefully there will be benefits such as innovative ways of providing care more efficiently and conveniently. If it works well we have the chance to get rid of old restrictive ways of working and bring in much more responsive and suitable modernised care. We shall see; it is all a massive and largely untried experiment and if it goes wrong could be a disaster.

HealthWatch England is the new consumer champion for health and adult social care designed to give people a voice nationally and locally to get the best out of the health and social care services. It takes over from the LINKs (Local Involvment Networks). Brent is setting up a branch and the temporary details are: c/o Ann O’Neill, Brent Mencap, 379 – 381 High Road, Willesden, London NW10 2JR

The Care Quality Commission (CQC) inspects and reports GP surgeries, hospitals, dentists and care homes to ensure they are up to the national specified standards. GPs had to register for the first time this year and produce reams of documents on our operational systems and will be inspected some time in the next couple of years.

More information on the Health & Social Care Act can be found in these government fact-sheets here.  The BMA has some good information and commentary here.  An excellent blog, Abetternhs, written by a GP, pulls together a lot of commentary from various sources explaining and critiquing the reforms.