In July of this year, the Government published its Health and Care Bill, which has been progressing this month through Parliament. This new piece of health legislation aims to establish an improved integrated organisational framework of NHS services in England. The Bill replaces clinical commissioning groups that are currently responsible for planning local health services with sub-regional integrated care systems (ICSs).
As part of the community-based ambitions of the NHS Long Term Plan, the 42 new ICSs are designed to better meet the health and care needs across a regional population through enhanced coordination, collaboration, and planning between specialised organisations. Additionally, the new Bill also gives the secretary of state for health and social care, Sajid Javid, controversial new sweeping powers to intervene earlier in the decision-making of NHS England.
What are the potential tangible on the ground benefits for local mental health services and service users?
The idea behind ICSs may have benefits for service users and mental health services. Following on from more than a decade during which services have been treated legislatively as competing, marketised, and autonomous organisations. In contrast, the new ICSs are designed to bring together providers and commissioners across an area to plan services, collectively joining up hospital and community-based services. This aims to combine specialised services from physical and mental health to services in health and social care.
Currently, a significant barrier that can arise in access to adequate treatment, especially in treating co-occurring conditions such as drug or alcohol addiction and mental ill-health, is that there is seemingly little to no collaboration between different services, and many with ‘complex’ issues are left to navigate a fractured, siloed eco-system of competing organisations. Consequentially, the Bill has been hailed, such as by the King's Fund, as an essential step forwards in facilitating integration between organisations to deliver improved, seamless standards of care to the increasing number of people who require multiple services.
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In addition, the focus on integration and increased dialogue between local services has been seen as an opportunity to address established health inequalities that exist between different population groups and areas. Part of the ICSs bodies will be integrated care boards (ICBs) – bodies responsible for planning, allocating, and controlling local NHS resources – who will have a statutory duty to reduce inequalities between patients. These ICBs will be held to account by being required to publish a five-year plan and a report on how they are fulfilling their statutory duty annually.
What have been the criticisms of the Bill?
‘Doesn’t go far enough’
However, some have heavily criticised the Bill as it does not contain measures relating to the future demand and supply components necessary for an adequate, functional workforce strategy.
Writing for PolicticsHome, Professor Subodh Dave, dean of the Royal College of Psychiatrists, concluded that the Bill ‘does little more than enable the continuation of the current status quo’. He argued that considering the current established structural problems in mental health services, a greater political vision is necessary to meet those challenges.
In his op-ed, Prof Dave highlighted the ‘16,600 full-time equivalent vacancies across the mental health workforce’ and the ‘1,215 medical posts and 8,388 nursing posts unfilled'. The considerable pressure from these vacancies, he added, will only worsen due to the recent necessary reforms to the Mental Health Act (MHA), due to come into force next year. This, he wrote, is due to the combination of the workforce shortages, the Covid-19 pandemic backlog, and the increased workload demands that the MHA reforms will generate.
Prof Dave further criticised the Health and Care Bill for not providing any solutions to those structural problems in mental health services, writing that ‘the current draft of the Bill does little more than enable the continuation of the current status quo'. Although he welcomed the inclusion of a clause mandating a report into workforce planning, but he wrote this ‘doesn’t go far enough’ as it ‘fails to demonstrate whether we are training and retaining enough people to deliver services or provide clear governance and accountability for doing so.’
As a result of the workload and structural problems in the mental health sector, the Royal College of Psychiatrists and over 60 other organisations are supporting an amendment to the Health and Care Bill that would require the Government to commission an independent report every two years, examining the current and future workforce capabilities. The aim of that report would be to increase public and parliamentary scrutiny of provisions for mental health services and to ensure that they are receiving sufficient levels of Government investment in line with on the ground demands.
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‘Creeping backdoor privatisation of the NHS’
Despite the British Medical Association (BMA) welcoming the removal of competition rules and the formalisation of ICSs, the health organisation has raised significant concerns about the Bill. The BMA has said that without amendments, there is a real threat of private health providers becoming increasingly more central in the decision-making of NHS service provision.
Through the ICSs system, the Bill provides corporate healthcare providers and charities with seats on the new boards, allowing them to influence service procurement and regional strategy. Consequently, the BMA is calling for the Bill to be amended to establish the NHS as the default option for services rather than outside private healthcare organisations.
Dr David Wrigley, deputy chair of BMA council, said: “The BMA has consistently called for meaningful clinical leadership, engagement and representation at every level of Integrated Care Systems, including from primary and secondary care as well as public health doctors to ensure the right voices are heard when it comes to commissioning decisions, but this has not been adequately addressed in the legislation. The threat of private health providers having a formal seat on new decision-making boards, and wielding influence over commissioning decisions, must be ruled out.”
“The BMA has long supported collaboration and called for the removal of enforced competition through Section 75, which the Bill would achieve. The most effective way of doing that is to make the NHS the default option for NHS contracts and to only tender competitively where this is not possible. This is also vital to avoid the awarding of contracts without scrutiny to private providers at huge expense to the taxpayer, as was seen with the procurement of PPE and Test and Trace during the pandemic.”
Similarly, the union Unite has branded the Bill as ‘the wrong prescription for our NHS’, although Unite is campaigning for the whole Bill to be rejected rather than merely amended. Jacalyn Williams, Unite national officer, commented: “The Westminster government’s new Health and Care Bill is a Trojan horse for more privatisation, cronyism, austerity and a licence for politicians to run down and sell off the NHS.”