Doctor, doctor: Give it to me straight. How serious are these NHS reforms?

Matt Chorley maps the twists and U-turns on the path of Andrew Lansley's changes to healthcare provision, and spells out what changes are on the way
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What is wrong with the NHS?

Under Labour there were record increases in NHS spending, reaching an annual budget of almost £120bn last year, up from £44bn in 1997. We now spend 8.5 per cent of GDP on the NHS, compared with just 4.5 per cent when Margaret Thatcher became prime minister in 1979. Labour hired 89,000 more nurses and 44,000 more doctors. At the same time, it introduced a raft of targets, from being seen in A&E within four hours to an 18-week target from visiting a GP to the start of treatment.



So why the need for change?

Bluntly, we are all living longer and there will be less money in thefuture. Even ardent supporters of Labour's investment accept it was not matched by the necessary level of reform. The National AuditOffice warned that hospital productivity fell in the past decade, which means we have been getting less bang for our buck. David Cameron has pledged to protect NHS spending, and funding in cash terms will rise from £102.9bn to £114.4bn by 2014/15. But critics say this will be outstripped by inflation. And, more significantly, an ageing population means more health complications. Medical advances often bring new, more expensive, drugs and treatments.



Who is in charge?

Devolution means that despite the national political furore, Andrew Lansley's domain as Health Secretary covers only England. Wales, Scotland and Northern Ireland are run separately, and differences in service levels – and, for example, charging for dentists or hospital parking – have caused cross-border rifts. In England, around 80 per cent of NHS funding is currently handed to 152 primary care trusts (PCTs), who commission – or buy – the services you first turn to when you are unwell. This includes doctors, dentist, opticians and pharmacists. The Labour government began the process of buying in services from the private sector, paid for by the NHS, with the patient paying nothing at the point of use. It focused on elective operations such as hip and knee replacements.



So what did Andrew Lansley want to do?

In the run-up to the election, few minority groups were as maligned as "faceless bureaucrats". According to both Tories and Liberal Democrats, the pen pushers were everywhere – sending troops to the front line without the right kit, enjoying council tax-funded jollies, and running the health service. Launching the Health and Social Care Bill last summer, Mr Lansley promised to put doctors back in charge, because they know best. So PCTs would be abolished by April 2013, along with the 10 strategic health authorities that oversee the planning of services to meet national priorities.



What will replace PCTs?

Under Mr Lansley's original plan, groups of GPs would form snappily titled "commissioning consortia" and would take responsibility for spending £60bn a year of NHS money. Out go the bureaucrats, leaving doctors to decide. Councils, meanwhile, would take on responsibility for health campaigns on subjects such as exercising more and quitting smoking.



So what was the problem?

The Tories had promised no top-down reorganisation of the NHSbefore the election, and while the coalition agreement said GPs would commission care, it also promiseddirectly elected individuals on the boards of PCTS. There were further concerns about plans for the health watchdog, Monitor, to encourage competition in the NHS, sparking fears of the privatisation of a national institution. Confusion surrounded what would happen to dentistry and specialist care, which will probably end up being overseen by a national commissioning board.



Why the opposition?

Almost every medical union andpatient group had complaints – from their members not being involved in decision-making to fears that private firms would "cherry-pick" easy contracts and leave the NHS struggling to deliver complex procedures. The row snowballed. The Lib Dems initially voted for the Health andSocial Care Bill in the House of Commons, but in March the party's spring conference demanded major changes.



So Mr Cameron did another U-turn?

Well, he certainly put the brakes on. The progress of the Bill through parliament was halted for a "listening exercise", overseen by the independent Future Forum, chaired by a senior GP, Steve Field, and 40 experts. They will publish their report on Monday, with the Government expected to accept all of its recommendations on Tuesday. But the Prime Minister has already promised a "clinical senate" to ensure experts oversee the running of the health service and pledged that competition will not undermine patient care.



Is competition a bad thing?

It depends who you ask. The trade unions do not like it because it threatens their members and believe all services should be provided by the state. Supporters say it is only by pitching service providers against each other that the Government can drive down costs while improving care. After the backlash, Monitor will now have a duty to promote integrated care.



More jargon – what's "integrated" care?

It means different parts of the state working together instead of in silos. So social care provided to, say, an elderly person is better co-ordinated. At present, they might be visited separately by a care nurse, a district nurse and a surgery nurse and communication between them will be almost non-existent. By joining up the dots – because an ill person just wants to get better – it is hoped money can be saved while providing better care.



What difference will Mr Lansley's plan make to patients?

If all goes according to plan, not much. You will still go to the doctor when you are ill, and they will send you for treatment to the place they consider best. You will have more say in where to be treated – possibly opting for a hospital near a relative or a specialist centre further afield. Patients will also be able to change their GP more easily, so they could register with a surgery nearer to their place of work



Who picks up the bill?

According to an impact assessment by the Government, the changes will cost £2bn by 2020, with savings generated worth almost £12bn. But critics say major changes to the health service never run smoothly and promised dividends rarely materialise. To make things even tougher, David Nicholson, the chief executive of the NHS, has demanded efficiency savings of £15bn to £20bn by 2014.



What will the Forum say?

Talk of competition will be toned down, with Monitor no longer having a duty to encourage it. Nurses and hospital doctors will now sit alongside GPs on the commissioning consortia, and there will be more public and patient accountability in the system. The plans will also go ahead only when areas are ready, not tied to the 2013 deadline. It is likely that some of the managers from PCTs will be rehired to run the day-to-day administration.



Who will make sure it works?

Accountability has been a key issue. In addition to Monitor looking at the finances, the Care Quality Commission will scrutinise care quality. Decision-making by the consortia will also be opened up to more public scrutiny after criticism that major spending commitments would be made behind closed doors.



Where does this leave Mr Lansley?

Grumpy but determined to stay and see his plan through. The Health Secretary has had a terrible few months: once hailed as the saviour of the NHS by his boss, David Cameron, he has been accused of lacking any political nouse to sell his proposals. Time and again, instead of talking about doctors knowing what's best for patients, he highlighted the role of pathfinder commissioners. Andrew Lansley will play down the significance of the changes to his Bill, while Mr Cameron says he has listened and made substantial changes, and Nick Clegg claims a Lib Dem victory on a key policy to save the NHS. Both Conservatives and Lib Dems need this policy to work because they know going into the next election with a record of harming the NHS is political suicide.

What the experts say...

Price competition would mean the quality of patient care could become of secondary importance. Commissioning should be clinically led with nurses involved at every level. We have always said that this must be done extremely carefully.

Peter Carter; General secretary, Royal College of Nursing

Quality, collaboration and integration must be at the heart of the health service and these principles – not competition – should be the focus of health service regulators. Reforms to doctors' training should be put on hold so changes can be properly implemented.

Sir Richard Thompson; President, Royal College of Physicians

The greatest damage to competition comes through "integration" which is about entrenching local monopolies. While we squabble about whether competition is good or bad, everyone else gets on with managing it to maximise benefits and minimise risks.

Nick Seddon; Reform think-tank

The primary duty of the economic regulator must be changed – from promoting competition, to protecting services for patients. Paying incentives to GP consortia needs to be rethought. There needs to be much greater flexibility in the timetable for hospital trusts to achieve foundation status.

Hamish Meldrum; Chairman of council, British Medical Association

We recognise the need to improve efficiency. However, with health professionals already being asked to find £20bn in savings, we are concerned that introducing the biggest ever restructure of the NHS at the same time will achieve the opposite of what David Cameron says he wants for the NHS.

Ann Green; Chairman, Chartered Society of Physiotherapy

If you drive the commissioning of maternity services to a totally local level, that could be too small to ensure that women have choices. In these circumstances, it is the most disadvantaged women who tend to get the smallest slice of the cake.

Cathy Warwick; General secretary, Royal College of Midwives

The NHS reforms are in a mess. Like a one-club golfer, the Government went straight for the statute book when it could have used the Health Secretary's existing powers to enact most of these reforms far more quickly with less fuss. My advice would be to shelve the Bill.

Professor Kieran Walshe; Manchester Business School

David Cameron's new Bill must abolish the grotesque and expensive market bureaucracy; must abolish Monitor and exposure to commercial law; must abandon the proposed structures devised to encourage private insurance and user charges in place of a tax-financed universal NHS.

Professor Allyson Pollock; School of Social and Political ScienceUniversity of Edinburgh

The financial challenge facing health and social care is unprecedented. Financial hard times are already here. The coalition government must support providers to continue to deliver high-quality care and become financially sustainable. The public and patients expect nothing less.

Anna Dixon; King's Fund think-tank

Finances are constrained and the NHS cannot afford to be complacent about the use of medicines. Research suggests only a fifth of patients achieve optimum benefit from medication. Pharmacists have the skills to prevent people becoming unwell.

Howard Duff; Pharmacy director, Royal Pharmaceutical Society

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