Conservative MPs have voted in favour of the Health and Care Bill for the third and final time by 294 votes to 244, meaning the Bill will now head to the House of Lords for further debate.
A total of 18 MPs rebelled at the final stage before the Lords, in support of an amendment which sought to introduce better workforce planning for health and social care in England.
However, this lack of workforce planning is just one reason the Bill has proved controversial among unions, healthcare professionals and MPs.
While supporters of the Bill believe it will undo some of the changes bought about during the reform law in 2012, campaigners fear it could accelerate NHS privatisation.
What is the purpose of the Health and Care Bill?
The new Health and Care Bill sets out key legislative proposals to reform the delivery and organisation of health services in England.
The government says the Bill supports collaboration, rather than competition, and aims to deliver better, more integrated care for patients across England.
A key change will see 106 Clinical Commissioning Groups (CCGs), which currently decide how local NHS services are provided, replaced with 42 Integrated Care Systems (ICSs).
ICSs are independent partnerships that bring together providers and commissioners of NHS services with local authorities and third sector bodies “to collectively plan health and care services to meet the needs of their local population,” as explained by the King’s Fund.
If the Bill is passed through the House of Lords, these 42 ICSs will be established as statutory bodies, meaning they would have the power to authorise legislation.
Since the NHS was founded in 1948, one central body has held this power. But under the new law, each individual ICS would be responsible for commissioning and delivering services to patients within their geographical region.
The Bill also plans to give the Health Secretary, which is currently Sajid Javid, direct power over some aspects of the health service.
Why are campaigners concerned about the Bill?
The new Health and Care Bill has been met with significant backlash since it was published earlier this year, with the British Medical Association (BMA) branding it "the wrong Bill at the wrong time."
Ahead of the Bill’s third and final reading on Tuesday (23 November), a petition opposing the legislation was signed by more than 300,000 people. Demonstrations were also staged in Westminster and Manchester, with thousands in attendance.
In a letter written to MPs, the BMA highlights its various concerns, saying the Bill “fails to address dangerous workforce shortages, risks unnecessary and destabilising outsourcing to private providers, fails to empower and engage with local clinical leadership, and gives politicians greater powers to interfere in operational NHS decision making.”
Fears of NHS privatisation
Unions, backbenchers and various organisations have criticised the new Bill for being modelled on the healthcare system in the USA, where profit is the key priority.
Unite the Union says the Bill will provide private organisations, or what the government are calling Alternative Provider Medical Services (APMS), with inroads into our NHS.
Unite’s national officer for health, Jackie Williams, said: “APMS contracts have been described by legal professionals as ‘the private sector's gateway to providing primary health care to NHS patients.’ They allow companies that are not owned or controlled by medical professionals to run GP surgeries.”
Unite are not alone in their concerns, as a recent survey conducted by a leading campaign group highlights. The survey, led by We Own It, found that seven in 10 people are concerned that the Bill will mean NHS contracts will be given to private companies without adequate scrutiny. This includes 70% of Conservative voters and 82% of Labour voters.
Sajid Javid has assured campaigners that private sector representatives will be blocked from joining these boards, but only if they “could reasonably be regarded as undermining the independence of the health service”.
But Labour and the BMA both hold that this policy doesn’t go far enough, and there are fears the health secretary will be left with the sole decision to “block” private companies.
The Bill “fails to address dangerous workforce shortages”
Healthcare organisations are also concerned that the Bill does not address the “dangerous workforce shortages” currently facing the NHS.
In the letter written to MPs, BMA North East regional council chair George Rae set out various amendments to the Bill. Among these, was a call to “improve the health secretary’s accountability to parliament for safe staffing and workforce numbers through regular and transparent reporting.”
This amendment to workforce planning was supported by more than 60 separate organisations. However, in yesterday’s (23 November) final report reading, MPs voted against it.
Anita Charlesworth, Director of Research and REAL Centre at the Health Foundation, said the rejection of the amendment is “deeply disappointing”.
She said: “Structural change is not the answer to the staffing crisis. While there is sense in merging HEE and NHSE to better coordinate workforce planning this will not address the growing gap between the demand facing health and care services and the staff available to provide care.
“Further inaction will significantly hamper the NHS and social care’s ability to recover after the pandemic and address the backlog of care. A fully funded long-term workforce strategy is long overdue.”
Dr David Wrigley, BMA council deputy chair, said it is “deeply disappointing” that the government has “squandered this opportunity to demonstrate a commitment to safe staffing in the NHS.”
He added: “There are 93,000 overall staff vacancies in the NHS, including a critical shortage of nurses, doctors, and midwives among other colleagues. Additionally, the BMA estimates that the NHS in England needs an additional 50,000 doctors to care for patients and provide safe care; the Government must understand the scale of this challenge and meet it with appropriate action.
“The Health and Care Bill as it stands falls woefully short of detail on workforce planning and this amendment, supported by many influential and expert organisations, would have held the Government to account - ensuring it regularly assessed how many doctors we need now and in the future.”
“The Westminster Government needs to recognise this and listen to those on the frontline who see the major problems we face day to day in the NHS and act now to support us in our endeavour to provide safe and effective patient care,” he concludes.
The proposals “will worsen the postcode lottery of care”
Rae is also concerned that reducing 106 CCGs to just 42 ICSs will mean commissioning bodies are much larger, and this could have a negative impact on those living in certain geographical regions.
He said the plan will see the north east and north Cumbria covered by one ICS, geographically the largest in the country. Rae questions how the interests of all communities living in such a large area can be accommodated for, taking into account their varying needs and the mixture of urban and rural areas, including some very remote communities.
A report by the Institute for Public Policy Research (IPPR) has compounded these beliefs, finding there is a north south divide in how well the emerging ICS regions are already integrated. For example, there were nine times as many delayed discharges in Norfolk and Waveney compared to Sussex and East Surrey.
Campaigners are therefore fearful that this new system will lead to stark differences in care across the country, worsening the “postcode lottery” of care that is already so evident.
Politicians will have “greater powers to interfere” in key decisions
Under the new Bill, the health secretary will have greater powers to interfere in operational NHS decision making.
Currently, changes to NHS services can be referred to government. But under the new Bill, the health secretary will have the power to intervene in minor local plans at any time.
The King’s Fund, Nuffield Trust and the Labour party have all criticised these powers, with Labour proposing an amendment to delete this clause entirely (which has, so far, been unsuccessful).
Richard Murray, Chief Executive of The King’s Fund, said that these “sweeping new powers for Ministers” will create “the risk of political expediency trumping clinical judgement in important decisions.”
The Nuffield Trust similarly warned that ministers could “feel pressure to distort decisions about services, staff and treatment to meet political goals.”
It seems even Javid himself was initially concerned about these new powers, as when he first took up his post as health secretary, he wrote to Boris Johnson asking for the Bill to be delayed due to “significant areas of contention”. But, he was overruled by the Prime Minister.
The Bill will come into effect in April 2022
The Bill will now be debated in the House of Lords where Boris Johnson is expected to face fierce opposition to the proposed reforms.
It is expected the Bill will come into effect in April 2022, but while the NHS is still battling with the backlog of patients awaiting treatment, health organisations, backbench MPs and other campaigners continue to question why the government is so insistent on pressing ahead with the reforms.
As Labour MP Justin Madders writes: “Every second the NHS spends on this top down reorganisation is a second less spent on bringing down waiting lists and improving care, better supporting the NHS workforce or modernising our hospitals.”