- Email: [email protected]
Medical students speak out on detrimental National Health Service reforms
Correspondence
The passage of England’s Health and Social Care Bill has been highly controversial and unusually prolonged owing to extraordinary public, professional, and parliamentary concern. On Feb 8, 2012, the Bill entered the House of Lords report stage. By this date, 301 amendments had been tabled to the Bill to be moved at report stage; of these, 165 (mainly government) amendments were tabled on Feb 1. This excess of amendments in itself raises serious issues about the processes to ensure the robustness of parliamentary scrutiny. The UK Government has given several assurances to parliamentarians that it has taken heed of the concerns of the public, patients, peers, and medical and nursing professions, some of which are set out in a Comment (Feb 4, p 387).1 It has tabled further amendments to allay concerns. On Feb 6, we published a briefing2 which covers crucial amendments relevant to the fundamental structural changes contained in the Bill, specifically the transfer of powers to clinical commissioning groups (CCGs) and other commissioners in place of the current delegation of powers to primary care trusts (PCTs). In it we show that: (1) The amendment to Clause 1, which concerns the duties of the Secretary of State for Health, would not restore the duty to provide health services or to secure provision, which, in association with section 3 of the National Health Service (NHS) Act 2006, is the duty that underpins the current structure of the NHS. (2) Amendments to Clause 4, which promotes autonomy over public health, would still require the Secretary of State to accept the principle of autonomy. (3) Amendments to Clause 12, which concerns the new structures of the NHS, namely CCGs, would not require CCGs, operating on behalf of the Secretary of State, to make sure that comprehensive and equitable health www.thelancet.com Vol 379 March 17, 2012
care is available for everyone, nor to be responsible for all residents in single geographically defined areas that are contiguous, without being able to pick and choose patients.2 (4) Amendments to Clauses 24 and 25, which again concern the responsibilities of CCGs are aimed at universal coverage. However, as we show in our briefing,2 these are oblique and messy, do not go very far, and do not address the problem of service and patient coverage at source. (5) Amendments to Schedule 2, which concerns the basis of services, leave unchanged the legal basis for private companies and law and accounting firms to commission services instead of the Secretary of State. The Government’s continued insistence on its structural changes and its failure to provide an adequate account of why they are necessary confirms concerns that the policy rationale has not been fully disclosed. The Government says that its changes are “vital”.3 But this is only the case if the object is to create a system that permits alternative funding sources for services currently provided free as part of the NHS. These amendments do not affect the heart of the policy behind the Bill, which is to introduce a mixed financing system and to abolish the model of tax-financed universal health care on which the NHS is based. The Bill and current amendments fail to safeguard the core principles of universal care and the duties of the Secretary of State to uphold those principles. The duty on the Secretary of State to provide or secure provision in accordance with the founding legislation of the 1946 Act must be restored if England is to have a national health service. PR is a London-based public interest lawyer who has supported 38 Degrees on an unpaid basis. TT is a non-practising barrister and formerly Head of Legal Services, Vale of White Horse District Council. The other authors declare that they have no conflicts of interest.
*Allyson Pollock, David Price, Peter Roderick, Tim Treuherz [email protected]
Centre for Primary Care and Public Health, Queen Mary, University of London, London E1 4NS, UK (AP, DP); 101 Weavers Way, London, UK (PR); and 5 Hobson Road, Oxford, UK (TT) 1
2
3
Pollock AM, Price D, Roderick P, et al. How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England. Lancet 2012; 379: 387–89. Pollock AM, Price D, Roderick P, Treuherz T. Briefing note 14. Clauses 1, 4, 12 and Schedule 2: the duty to provide, the hands-off clause, GP commissioning, and the red lines. http://www. allysonpollock.co.uk/administrator/ components/com_article/attach/2012-0206/20120206-Pollock_HouseOfLords_HSCB_ Briefing14_C1_4_12_Sch2_06Feb12.pdf (accessed Feb 10, 2012). House of Lords Constitution Committee. 22nd report, Health and Social Care Bill: follow-up. Appendix 2, correspondence: letter from Earl Howe, Parliamentary Under Secretary of State for Quality, Department of Health, 10 October 2011. http://www. publications.parliament.uk/pa/ld201012/ ldselect/ldconst/240/24005.htm (accessed Feb 10, 2012).
Getty Images
A flawed Bill with a hidden purpose
Published Online February 15, 2012 DOI:10.1016/S01406736(12)60246-3
Medical students speak out on detrimental National Health Service reforms Medsin-UK (a group of students with more than 3000 members across the UK) is calling for the Health and Social Care Bill to be dropped. In addition to the concerns highlighted by the Royal College of General Practitioners (RCGP),1 medical students have major concerns that the reforms are potentially detrimental to medical education. Principally, we are concerned that the reforms jeopardise the future training of health-care professionals. Medical education is threatened by the fragmentation of services and an uncertainty over who will be mandated to provide education and training, especially at a postgraduate level.2 These concerns arise for two reasons. First, the move to isolate education and training in a separate bill implies that the reforms to the health-care system and education are two completely separate entities. It is a dangerous assumption that healthcare structure does not significantly affect education, since the health
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
999
Correspondence
For a full response see http:// www.yyka.gov.gr/articles/ ministry/hgesia/21-secretary
system provides the framework for a working environment. Second, fragmentation of the National Health Service (NHS) is likely to exaggerate systemic and operational differences between NHS Trusts. This means that retraining of existing staff and students will be required. Moreover, communication between different services in the NHS could become disjointed with multiple service providers. This will potentially lead to a greater chasm between different sectors of health care, creating challenges in continual learning and smooth transition for students to new services. At present, there is no information about whether private health-care providers will have a role in medical education and training. Additionally, a restructure of this size requires reorganisation of educational programmes within services, since structural procedures in current training programmes could become obsolete. Such reorganisation will make for a chaotic learning environment. Finally, the Health and Social Care Bill will catastrophically change the shape of the NHS that students expect to work in. We view the reforms as representing a shift in focus, away from the notion that everyone is entitled to health care and towards one that focuses on private profit and corporate gain. As students, we are concerned about the failure of the reforms to take into account the damage to medical education and training. Furthermore, we believe that the reforms will create an unequal health-care system, in which the poorest and most vulnerable in our society will be disadvantaged. Students are the future health-care professionals; we are the ones who will have to live and work through these destructive reforms. We declare that we have no conflicts of interest.
Alex Elliott-Green, Anya Gopfert, on behalf of Medsin-UK [email protected] Faculty of Medicine, University of Bristol, Bristol BS8 1TH, UK
1000
1
2
Royal College of General Practitioners. Health and Social Care Bill second reading briefing— House of Lords. http://www.rcgp.org.uk/pdf/ HSC%20Lords%20Briefing.pdf (accessed Feb 27, 2012). Yorkshire & Humber Health Innovation & Education Cluster Board. Response: Health Committee Inquiry into Education, Training and Workforce Planning. http://yhhiec.org.uk/ wp-content/uploads/2012/02/YHHIEC_ response_to_health_committee_inquiry_ v0.2.pdf (accessed Feb 27, 2012).
Health and Social Care Bill: RCPCH responds The Royal College of Paediatrics and Child Health (RCPCH) does indeed share many of the concerns about the Health and Social Care Bill noted in the letter by Stuart Logan and colleagues (Feb 25, p 707).1 Examples of such support can be found in the Summer 2011 RCPCH Newsletter2 and my piece in the BMJ.3 The RCPCH has more than 10 000 members in the UK and we are in the midst of seeking their views by an online survey.
Terence Stephenson [email protected] President, Royal College of Paediatrics and Child Health, London WC1X 8SH, UK 1
2
3
Logan S, on behalf of 154 signatories. Paediatricians oppose Health and Social Care Bill. Lancet 2012; 379: 707. Royal College of Paediatricians and Child Health. Summer 2011 newsletter http://www. rcpch.ac.uk/sites/default/files/Summer%20 2011%20Newsletter%20for%20web.pdf (accessed March 6, 2012). Stephenson T. Those who cannot remember the past are condemned to repeat it. BMJ 2012; 344: e1159.
conservative administration, and not on recent data under the present socialist administration. This “tragic” national health service (NHS) witnessed a 20% increase in admissions in 2010 compared with 2009.2 Furthermore, data envelopment analysis showed an increase in hospital efficiency (unpublished data), implying that the crisis has not had a short-term effect on NHS services. Regarding alleged cuts in hospital budgets, the accurate figures are 12% in 2010 compared with 2009, and 6% in 2011,3 as a positive result of improvements in financial management efficiency (eg, procurement, logistics, and accounting systems). Hence, the claim that “there were about 40% cuts in hospital budgets” is untrue. Concerning morbidity and mortality, the figures reported by Kentikelenis and colleagues could be seen only as predictions for 2011, and mortality according to the Hellenic Statistical Authority in fact remained the same. Finally, Kentikelenis and colleagues’ data on drug users, rehabilitation, and violence are under consideration. We feel optimistic that the crisis can be overcome with hard work to improve the public and private sectors of our economy, including the NHS. In any case, no hard evidence has proven that it has become a health hazard or even more so a “disaster”. A full response can be found on the Ministry of Health website. I am Secretary General of the Greek Ministry of Health and Social Solidarity.
Health and the financial crisis in Greece My scientific and institutional role obliges me to comment, from a political perspective, on Alexander Kentikelenis and colleagues’ Correspondence: “Health effects of financial crisis: omens of a Greek tragedy” (Oct 22, p 1457).1 Indeed there are problems in the Greek health system. However, Kentikelenis and colleagues’ criticism is based on 2007–09 data, under Greece’s
Nikos Polyzos [email protected] Secretary General’s Office, Ministry of Health and Social Solidarity, 10187 Athens, Greece 1
2
3
Kentikelenis A, Karanikolos M, Papanikolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011; 378: 1457–58. Polyzos N. ESY.net: presentation of the Secretary General of the Ministry of Health and Social Solidarity. Athens: Ministry of Health and Social Solidarity, 2011. Secretary General of Ministry of Health and Social Solidarity. Report results of MHSS and NHS Units 2010. Athens: Ministry of Health and Social Solidarity, 2011.
www.thelancet.com Vol 379 March 17, 2012
The passage of England’s Health and Social Care Bill has been highly controversial and unusually prolonged owing to extraordinary public, professional, and parliamentary concern. On Feb 8, 2012, the Bill entered the House of Lords report stage. By this date, 301 amendments had been tabled to the Bill to be moved at report stage; of these, 165 (mainly government) amendments were tabled on Feb 1. This excess of amendments in itself raises serious issues about the processes to ensure the robustness of parliamentary scrutiny. The UK Government has given several assurances to parliamentarians that it has taken heed of the concerns of the public, patients, peers, and medical and nursing professions, some of which are set out in a Comment (Feb 4, p 387).1 It has tabled further amendments to allay concerns. On Feb 6, we published a briefing2 which covers crucial amendments relevant to the fundamental structural changes contained in the Bill, specifically the transfer of powers to clinical commissioning groups (CCGs) and other commissioners in place of the current delegation of powers to primary care trusts (PCTs). In it we show that: (1) The amendment to Clause 1, which concerns the duties of the Secretary of State for Health, would not restore the duty to provide health services or to secure provision, which, in association with section 3 of the National Health Service (NHS) Act 2006, is the duty that underpins the current structure of the NHS. (2) Amendments to Clause 4, which promotes autonomy over public health, would still require the Secretary of State to accept the principle of autonomy. (3) Amendments to Clause 12, which concerns the new structures of the NHS, namely CCGs, would not require CCGs, operating on behalf of the Secretary of State, to make sure that comprehensive and equitable health www.thelancet.com Vol 379 March 17, 2012
care is available for everyone, nor to be responsible for all residents in single geographically defined areas that are contiguous, without being able to pick and choose patients.2 (4) Amendments to Clauses 24 and 25, which again concern the responsibilities of CCGs are aimed at universal coverage. However, as we show in our briefing,2 these are oblique and messy, do not go very far, and do not address the problem of service and patient coverage at source. (5) Amendments to Schedule 2, which concerns the basis of services, leave unchanged the legal basis for private companies and law and accounting firms to commission services instead of the Secretary of State. The Government’s continued insistence on its structural changes and its failure to provide an adequate account of why they are necessary confirms concerns that the policy rationale has not been fully disclosed. The Government says that its changes are “vital”.3 But this is only the case if the object is to create a system that permits alternative funding sources for services currently provided free as part of the NHS. These amendments do not affect the heart of the policy behind the Bill, which is to introduce a mixed financing system and to abolish the model of tax-financed universal health care on which the NHS is based. The Bill and current amendments fail to safeguard the core principles of universal care and the duties of the Secretary of State to uphold those principles. The duty on the Secretary of State to provide or secure provision in accordance with the founding legislation of the 1946 Act must be restored if England is to have a national health service. PR is a London-based public interest lawyer who has supported 38 Degrees on an unpaid basis. TT is a non-practising barrister and formerly Head of Legal Services, Vale of White Horse District Council. The other authors declare that they have no conflicts of interest.
*Allyson Pollock, David Price, Peter Roderick, Tim Treuherz [email protected]
Centre for Primary Care and Public Health, Queen Mary, University of London, London E1 4NS, UK (AP, DP); 101 Weavers Way, London, UK (PR); and 5 Hobson Road, Oxford, UK (TT) 1
2
3
Pollock AM, Price D, Roderick P, et al. How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England. Lancet 2012; 379: 387–89. Pollock AM, Price D, Roderick P, Treuherz T. Briefing note 14. Clauses 1, 4, 12 and Schedule 2: the duty to provide, the hands-off clause, GP commissioning, and the red lines. http://www. allysonpollock.co.uk/administrator/ components/com_article/attach/2012-0206/20120206-Pollock_HouseOfLords_HSCB_ Briefing14_C1_4_12_Sch2_06Feb12.pdf (accessed Feb 10, 2012). House of Lords Constitution Committee. 22nd report, Health and Social Care Bill: follow-up. Appendix 2, correspondence: letter from Earl Howe, Parliamentary Under Secretary of State for Quality, Department of Health, 10 October 2011. http://www. publications.parliament.uk/pa/ld201012/ ldselect/ldconst/240/24005.htm (accessed Feb 10, 2012).
Getty Images
A flawed Bill with a hidden purpose
Published Online February 15, 2012 DOI:10.1016/S01406736(12)60246-3
Medical students speak out on detrimental National Health Service reforms Medsin-UK (a group of students with more than 3000 members across the UK) is calling for the Health and Social Care Bill to be dropped. In addition to the concerns highlighted by the Royal College of General Practitioners (RCGP),1 medical students have major concerns that the reforms are potentially detrimental to medical education. Principally, we are concerned that the reforms jeopardise the future training of health-care professionals. Medical education is threatened by the fragmentation of services and an uncertainty over who will be mandated to provide education and training, especially at a postgraduate level.2 These concerns arise for two reasons. First, the move to isolate education and training in a separate bill implies that the reforms to the health-care system and education are two completely separate entities. It is a dangerous assumption that healthcare structure does not significantly affect education, since the health
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
999
Correspondence
For a full response see http:// www.yyka.gov.gr/articles/ ministry/hgesia/21-secretary
system provides the framework for a working environment. Second, fragmentation of the National Health Service (NHS) is likely to exaggerate systemic and operational differences between NHS Trusts. This means that retraining of existing staff and students will be required. Moreover, communication between different services in the NHS could become disjointed with multiple service providers. This will potentially lead to a greater chasm between different sectors of health care, creating challenges in continual learning and smooth transition for students to new services. At present, there is no information about whether private health-care providers will have a role in medical education and training. Additionally, a restructure of this size requires reorganisation of educational programmes within services, since structural procedures in current training programmes could become obsolete. Such reorganisation will make for a chaotic learning environment. Finally, the Health and Social Care Bill will catastrophically change the shape of the NHS that students expect to work in. We view the reforms as representing a shift in focus, away from the notion that everyone is entitled to health care and towards one that focuses on private profit and corporate gain. As students, we are concerned about the failure of the reforms to take into account the damage to medical education and training. Furthermore, we believe that the reforms will create an unequal health-care system, in which the poorest and most vulnerable in our society will be disadvantaged. Students are the future health-care professionals; we are the ones who will have to live and work through these destructive reforms. We declare that we have no conflicts of interest.
Alex Elliott-Green, Anya Gopfert, on behalf of Medsin-UK [email protected] Faculty of Medicine, University of Bristol, Bristol BS8 1TH, UK
1000
1
2
Royal College of General Practitioners. Health and Social Care Bill second reading briefing— House of Lords. http://www.rcgp.org.uk/pdf/ HSC%20Lords%20Briefing.pdf (accessed Feb 27, 2012). Yorkshire & Humber Health Innovation & Education Cluster Board. Response: Health Committee Inquiry into Education, Training and Workforce Planning. http://yhhiec.org.uk/ wp-content/uploads/2012/02/YHHIEC_ response_to_health_committee_inquiry_ v0.2.pdf (accessed Feb 27, 2012).
Health and Social Care Bill: RCPCH responds The Royal College of Paediatrics and Child Health (RCPCH) does indeed share many of the concerns about the Health and Social Care Bill noted in the letter by Stuart Logan and colleagues (Feb 25, p 707).1 Examples of such support can be found in the Summer 2011 RCPCH Newsletter2 and my piece in the BMJ.3 The RCPCH has more than 10 000 members in the UK and we are in the midst of seeking their views by an online survey.
Terence Stephenson [email protected] President, Royal College of Paediatrics and Child Health, London WC1X 8SH, UK 1
2
3
Logan S, on behalf of 154 signatories. Paediatricians oppose Health and Social Care Bill. Lancet 2012; 379: 707. Royal College of Paediatricians and Child Health. Summer 2011 newsletter http://www. rcpch.ac.uk/sites/default/files/Summer%20 2011%20Newsletter%20for%20web.pdf (accessed March 6, 2012). Stephenson T. Those who cannot remember the past are condemned to repeat it. BMJ 2012; 344: e1159.
conservative administration, and not on recent data under the present socialist administration. This “tragic” national health service (NHS) witnessed a 20% increase in admissions in 2010 compared with 2009.2 Furthermore, data envelopment analysis showed an increase in hospital efficiency (unpublished data), implying that the crisis has not had a short-term effect on NHS services. Regarding alleged cuts in hospital budgets, the accurate figures are 12% in 2010 compared with 2009, and 6% in 2011,3 as a positive result of improvements in financial management efficiency (eg, procurement, logistics, and accounting systems). Hence, the claim that “there were about 40% cuts in hospital budgets” is untrue. Concerning morbidity and mortality, the figures reported by Kentikelenis and colleagues could be seen only as predictions for 2011, and mortality according to the Hellenic Statistical Authority in fact remained the same. Finally, Kentikelenis and colleagues’ data on drug users, rehabilitation, and violence are under consideration. We feel optimistic that the crisis can be overcome with hard work to improve the public and private sectors of our economy, including the NHS. In any case, no hard evidence has proven that it has become a health hazard or even more so a “disaster”. A full response can be found on the Ministry of Health website. I am Secretary General of the Greek Ministry of Health and Social Solidarity.
Health and the financial crisis in Greece My scientific and institutional role obliges me to comment, from a political perspective, on Alexander Kentikelenis and colleagues’ Correspondence: “Health effects of financial crisis: omens of a Greek tragedy” (Oct 22, p 1457).1 Indeed there are problems in the Greek health system. However, Kentikelenis and colleagues’ criticism is based on 2007–09 data, under Greece’s
Nikos Polyzos [email protected] Secretary General’s Office, Ministry of Health and Social Solidarity, 10187 Athens, Greece 1
2
3
Kentikelenis A, Karanikolos M, Papanikolas I, Basu S, McKee M, Stuckler D. Health effects of financial crisis: omens of a Greek tragedy. Lancet 2011; 378: 1457–58. Polyzos N. ESY.net: presentation of the Secretary General of the Ministry of Health and Social Solidarity. Athens: Ministry of Health and Social Solidarity, 2011. Secretary General of Ministry of Health and Social Solidarity. Report results of MHSS and NHS Units 2010. Athens: Ministry of Health and Social Solidarity, 2011.
www.thelancet.com Vol 379 March 17, 2012