England’s new health and care bill

Abstract

The health secretary gains sweeping new powers, with unclear consequences for patients

The NHS in England is about to be reorganised (again). On 6 July, the UK government published the Health and Care Bill 2021-22,¹ which details plans for changes to NHS rules and structures in England. Parliamentarians will start debating the bill this week, and government wants the changes in place by April 2022. The bill spans 224 pages and contains measures on the NHS, social care, and public health. But its main focus is the NHS, and, broadly speaking, it is a story of two halves.

The first half is a set of changes to promote collaboration in the health system. These changes were proposed by national NHS bodies^{2 3} and try to resolve the longstanding tension between the “rules in form”—set out in the Health and Social Care Act 2012—and the “rules in use” in today’s NHS.⁴ Under these plans, every part of England will be covered by an integrated care system. These currently exist informally in 42 areas, serving populations of around one to three million. Each system will be made up of two new bodies: an integrated care board (area based NHS agencies responsible for controlling most NHS resources to improve health and care for their local population) and an integrated care partnership (looser collaborations between NHS, local government, and other agencies, responsible for developing an integrated care plan to guide local decisions). Clinical commissioning groups—currently responsible for purchasing NHS services—will be abolished and replaced by the new integrated care boards. Existing requirements to competitively tender some clinical services will be scrapped, though what will replace them is unclear.⁵

Encouraging collaboration to improve services makes sense—and goes with the grain of recent NHS policy.⁶ Reinventing the “intermediate” tier of the NHS also fits with the historical development of the health service.^{7 8} The new integrated care boards look a little like the NHS’s old strategic health authorities (scrapped under the 2012 act) and area health authorities (created under reforms in 1974).

But the potential benefits of greater collaboration—both in the NHS and between health care and wider services—are often overstated.^{9 10} And reorganising NHS agencies can distract and disrupt.^{8 11} This is particularly concerning given the enormous pressures currently facing NHS services^{12 13 14} and the size of the task to recover care disrupted by covid-19.¹⁵ The new structure also risks being complex and vague. The relationship between NHS providers and integrated care boards is unclear. Integrated care partnerships seem to play a bit part role and risk being sidelined by more powerful NHS agencies. This would undermine the bill’s aims for better integration of services beyond the NHS and limit the ability of local systems to tackle social and economic factors that shape health.

The second half of the story is a set of changes to strengthen the health secretary’s control over the daily running of the NHS in England. These changes lack rationale and warrant scrutiny. The bill gives wide ranging new powers to the health secretary. These include powers to direct NHS England (the national agency responsible for overseeing NHS planning and budgets) in relation to almost all its functions. They also include powers to intervene at any stage in service reconfigurations, such as decisions about merging or closing hospitals. NHS leaders must notify the health secretary about proposals to reconfigure services. And the health secretary will be able “retake” decisions already made by NHS leaders, as well as direct them to consider new service changes.

How these changes will benefit patients is unclear—and they might make things worse. Decisions about service changes are complex, and evidence to inform them is often limited and disputed.^{16 17} Independent judgment has been used to reduce ministerial involvement in contested decisions.¹⁸ Government should be careful what it wishes for; in the words of Rudolf Klein, “centralising power means centralising blame.”¹⁹ Accountability will always rise upwards to politicians in a tax funded health system. But these changes seem to be more about control. And the pandemic response is hardly an advert for closer political involvement in the health system. Greater central intervention might also undermine the bill’s focus on giving power to local leaders to improve population health.

Who is the author of this legislation anyway? The first half of the story is the legacy of Simon Stevens, the outgoing boss of NHS England. The second half belongs to Matt Hancock, the previous health secretary. But come the end of July 2021, neither will be in post. Reports suggest that Sajid Javid, the new health secretary, wanted to delay introducing the bill to parliament because of “significant areas of contention”—only to be over-ruled by the prime minister.²⁰ Javid has a long list of priorities as the country “learns to live” with covid-19, including tackling the backlog of unmet health needs, dealing with staff shortages, reducing vast health inequalities, and reforming England’s broken social care system.¹⁵ The bill will do little to tackle these fundamental challenges and risks distracting the NHS as it tries to recover from the biggest shock in its history.