The Health & Social Care Bill is one of the largest Bills in recent times. A total of 353 pages, it touches almost every area of the NHS: from new duties on the Secretary of State to secure continuous improvements in NHS quality and outcomes through to a requirement that salaries at the Care Quality Commission now be approved by the Secretary of State.

The Bill is three times the size of the legislation that set up the NHS back in 1948. The main parts of the Bill cover:

Part 1 – the NHS in England

This contains the key elements of the Bill. It begins with new requirements to secure continuous improvement in the quality and outcomes delivered by the NHS, as well as a duty on the “need to reduce [health] inequalities”. Crucially, it establishes the NHS Commissioning Board and Commissioning Consortia as statutory bodies, making them subject to the Freedom of Information Act in line with the Government’s commitment to promote openness and transparency.

Other provisions lay down the Secretary of State’s duties in respect of public health, with an explicit authority to, “provide financial incentives to encourage individuals to adopt healthier lifestyles”; it also locates the commissioning of specialised services, such as heart transplants, with the NHS Commissioning Board. Powers to allow the creation of further Special Health Authorities as directed by the Secretary of State could see the numbers of NHS bodies actually increase rather than decrease.

Before the start of the financial year the Health Secretary will have to publish and lay before Parliament “the mandate” which specifies the objectives and requirements for the NHS Commissioning Board in the coming year; it will also include the Board’s resources. The Board will have 9 duties, significant duties are those to improve the quality of services; promote autonomy; reduce inequalities; obtain appropriate advice and promote innovation. The Board will have to publish a Business Plan and Annual Report at the start and end of each financial year.

All providers of primary care medical services are to be required to join a commissioning consortium. Commissioning consortia are to have similar duties to the NHS Commissioning Board and, in relation to commissioning functions they will be bound by the advice of the Board. Commissioning consortia will also be required to publish a Business Plan and Annual Report. Performance assessment against these plans will be carried out annually by the NHS Commissioning Board, which will have wide powers to give directions, dissolve and even take over the running of failing consortia.

However, for all the criticism following the White Paper, Liberating the NHS, the Bill gives little definition about the governance or accountability arrangements to ensure in year financial stability of consortia and the appropriate use of NHS funds.

Strategic Health Authorities and Primary Care Trusts are to be abolished.

Part 2 – Further provisions about public health

This section includes miscellaneous provisions on the abolition of the Health Protection Agency, and other bodies.

Part 3 – Economic regulation of health & social care

The creation of Monitor as a truly independent regulator is one of the NHS’ recent successes. This Bill seeks to re-cast Monitor as a full economic regulator with a duty to promote competition in the NHS and social care sectors. A new Monitor would have four main roles: licensing providers; setting NHS prices; supporting service continuity and promoting competition. It would also retain its role of regulating and authorising foundation trusts.

This section of the Bill comprises over 42 pages with a chapter of detailed technical legal construct dedicated to each of Monitor’s main functions. The provisions are for complex additions and deletions to the National Health Service Act 2006 and further analysis will be required before the exact implications become clear.

Part 4 – NHS Foundation Trusts and NHS Trusts

In direct contrast to Part 1 of the Bill where governance arrangements are lacking this section includes details for the governance and management arrangements for NHS Trusts. All NHS Trusts will be abolished from April 2014, when they are expected to have gained foundation trust status. Moreover, mergers between foundation trusts will become considerably easier and the cap on limiting private income of foundation trusts is to be lifted. There will also be a new failure regime.

Part 5 - Public involvement and local government

This section establishes Healthwatch England as the new voice of the public in the NHS. There are to be local Healthwatch organisations and powers for local authorities to establish Health and Wellbeing Boards.

These boards will take a lead on Joint Strategic Needs Assessments (including Pharmaceutical Needs assessments) and strategies, but also have the potential to be unwieldy, with statutory members including: one local authority councillor; the director of adult social services; the director of children’s services and the director of public health; a representative of the local healthwatch organisation and a representative of each relevant commissioning consortium. In addition, there are to be other such persons, or representatives of such other persons, as the local authority think appropriate.

Part 6 & 7 – Primary care services and regulation of health & social care workers

This section contains minor amendments on the general medical services contract; the payment for pharmaceutical needs assessments and entry on pharmaceutical lists. The Bill lays the responsibility for granting pharmacy contracts with the NHS Commissioning Board (using locally developed PNAs as a control of entry mechanism).Pharmaceutical lists of pharmacy contractors will also go to the Board.  In addition, the General Social Care Council is to be scrapped and functions transferred to the Health and Care Professions Council in England.

Part 8 – National Institute for Health & Clinical Excellence

The National Institute for Health & Clinical Excellence (NICE) is to be recast as a statutory body focusing on clinical quality. In exercising its functions, NICE will now have to achieve a broad balance between the benefits and costs of both health and social care services in England. There are new specific duties on preparing “quality standards” and providing advice to the Secretary of State or NHS Commissioning Board on “quality matters”.

There is a separate Department of Health consultation running on value-based pricing of medicines.

Part 9 – Information on health and social care services

This is arguably one of the most critical elements of the Bill. Without the provision of timely and accurate information on the quality of health and social care services, the impetus for competitive change will be lost.

The NHS Commissioning Board and the Secretary of State gain new powers to publish “information standards” concerned with the provision of health and social care services. The NHS Information Centre will become a corporate body with the power, under the direction of the Secretary of State to establish information systems for the collection, analysis and dissemination of data. Powers will also exist for the creation of a scheme regulating the accreditation of information service providers - there will be a competitive market in information – and for a database of “quality indicators”.

Part 10, 11 – Abolitions of public bodies; miscellaneous and final provisions

Bodies to be abolished are the Alcohol Education and Research Council; the Appointments Commission; the National Information Governance Board for Health and Social Care.

Miscellaneous provisions include various duties on bodies to co-operate with each other – namely, Monitor and the Care Quality Commission (CQC) – and a brand new requirement for the Secretary of State to approve remuneration policy at the CQC.

Costs of NHS re-organisation and expected savings

A charge against the Secretary of State has been that the costs of this re-organisation will outweigh any benefits and certainly for the next two years that will be true. The impact assessment which accompanies the Bill states that the total costs of the re-organisation will be £1.2 billion. However, the future costs of commissioning will be £1.3 billion p.a. less than existing costs and by 2014-15 the NHS will start to reap these benefits.

Crucially, the impact assessment, signed by the Secretary of State, is duty bound to highlight the key risks of GP-led Commissioning. They are listed as:

• GP Consortia not having the capacity and capability to engage with and deliver clinical commissioning;
• Potential conflicts of interest between GP consortia as providers and commissioners of patient care;
• Potential higher transaction costs as we change the number of organisations commissioning services;
• The ability of GP consortia to manage risk, and
• The ability of GP to deliver the potential financial savings outlined above.

In advance of the second reading of the Government’s Health Bill the RPS has asked politicians to raise the following issues and put forward the professions view during the second reading debate.

Powers of the Secretary of State

The RPS is supportive of the move to devolve decisions on patient services away from Whitehall and to “liberate the NHS”. We are therefore surprised that the Bill appears to ensure that the Secretary of State retains considerable powers, particularly over the NHS Commissioning Board.

We hope that MPs will consider how the NHS Commissioning Board can be empowered to act in patients’ interests as independently as possible from Government.

Commissioning consortia

Ensuring participation of healthcare professions commissioning consortia will be at the heart of the new NHS. It is essential that these consortia have access to specialist pharmacist knowledge when commissioning health services for a patient population. We recommend that each commissioning consortium establish an advisory board consisting of representatives of key healthcare professions. This Board could provide general advice and support to the consortium and be supplemented by specialist pharmacists, for example when a tender for specialist services was to be issued

Membership of health & wellbeing Boards

As one of the duties of the Boards is to “encourage integrated working”, we are concerned that their make-up should reflect broad healthcare expertise of service providers. We propose that the Bill be amended to state that representatives of other healthcare professions, including pharmacy, be included in their membership. This is particularly important when Health and Wellbeing Boards are making decisions relating to a specific healthcare profession such as pharmacy.

Monitor and financial scrutiny

The Bill gives Monitor the power to do anything it needs to in order to exercise its functions including the power to examine the finances of any NHS provider. There are more than 13,000 pharmacies throughout the UK which, while commissioned to provide a range of NHS services, are independent businesses. The RPS questions the need for Monitor to review an individual pharmacy’s financial records when income is not exclusively from NHS sources.

Public health budgets

The Government has announced that the public health budget is to be ring-fenced and managed by Public Health England. However, we are concerned that with local authority budgets under unprecedented pressure, funds will be diverted away from core public health services to housing or social care projects. Steps should be taken to ensure that the provision of sexual health, smoking cessation, weight loss and other core public health services is not negatively affected, as these services, many of which are provided by pharmacists, prevent the development of ill health and patient harm and avert financial costs later on.

Patient information and choice

Within a reformed NHS, it is hoped that greater access to data and information will drive patient choice and the quality of services. It is therefore essential that this information - standardised across the country - is available to patients in advance of the new system of commissioning being established.

Ensuring a level playing field

The Bill seeks to create an expansion of competition and choice in healthcare provision. It is vital that this market is balanced and that providers compete on a level playing field. This means implementing standardised budgeting so that no providers, NHS or non NHS, are advantaged in tendering processes. These tendered services must be subject to strategic planning.

Any Willing Provider

The RPS is pleased to support the introduction of the ‘Any Willing Provider’ model but providers operating in this model must be in close communication for the benefit of patient care. Access to the summary and other care records by all providers, such as pharmacists, will benefit the NHS and most importantly support high quality and safe patient services.

This is not an exhaustive list and the RPS will continue to influence the bill to the benefit of pharmacists as the Bill progresses through Parliament.

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