Regardless of any political view the lay observer may hold, it must be common ground that the Health and Social Care Act 2012 has, after a somewhat tortuous journey, taken huge steps to reinvent the landscape of healthcare provision. Comprising 309 sections and 23 schedules, the Act has implications for the entire NHS. The rationale for the change, and the effectiveness of the provisions now in force, remain a matter of debate; the Government would appear not to have made the case for change as compellingly as perhaps they would have wished.

It would be impracticable to attempt to summarise the workings of the Act within a few short paragraphs, never mind to try to reconcile the reactions and implications of the Act, particularly where key issues on the implementation of the Act remain unclear. A short account of the key points, however, may be of assistance:

  • The Act seeks to define the duties attendant on the Secretary of State, Monitor, clinical commissioning groups, NICE and other bodies within the new NHS. The extent to which those duties can be easily reconcilable is perhaps a moot point; pertinently, there would seem to be an inevitable tension within the expanded remit of Monitor both to control price and efficiency and to maintain or improve quality
  • PCTs and SHAs are in the process of being abolished. In their place, the Act establishes clinical commissioning groups to provide a nationwide network of commissioners answering to the NHS Commissioning Board. Some may say that in order to achieve effective bargaining leverage, a critical patient density and to attract suitable experienced commissioners, the new CCGs will in effect simply be old PCTs reinvented
  • The Board itself is subject to a range of duties, including those to promote innovation and quality of care, reduce inequality and promote the interests of the individual. Again, there may be a tension between the various duties, and it would also appear that showing compliance with those duties will be burdensome
  • NHS Trusts are to move towards foundation trust status, allowing greater financial flexibility in the provision of healthcare and the promotion of public health. Failure provisions are set out
  • Monitor's remit is expanded to a general duty to promote effective, economic and efficient healthcare services. It carries ongoing oversight, licensing and tariff responsibilities for both NHS and private providers and is under a positive duty to eliminate anti-competitive practices. Provisions are made to ensure that providers cannot simply cherry pick the most desirable or profitable patients or services, and to ensure reasonable and transparent consistency of pricing. Monitor and the Care Quality Commission are also required to work together in a step towards the Government's goal of a comprehensive health and social care system
  • Patient representation is sought to be enhanced through local Healthwatch organisations reporting to Monitor, the Secretary of State and other bodies

The legislation is imposing in its breadth. It seems remarkable that, despite the physical size of the Act, there remain questions as to how it will in fact work; guidance documents setting out how Monitor will exercise its functions are awaited, for example.

Andrew Lansley stated that his aim was to "...deliver power to clinicians, ... put patients at the heart of the NHS, and...reduce the costs of bureaucracy".

In a time of financial crisis, with Trusts struggling to make financial savings and with clinical and nursing morale seemingly heading towards an all time low, it can only be safely said that the costs of reorganising the NHS will be considerable. The benefits of change, and whether Mr Lansley's aims have in truth been achieved, still remain somewhat undefined.

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