8 Feb 2012

The NHS bill – what has changed?

With the government’s controversial NHS bill debated in the Lords, Channel 4 News looks at the changes made to the legislation since it was first unveiled.

The NHS and Social Care Bill has become an albatross around the government’s neck, with criticism of Health Secretary Andrew Lansley reaching a stage where a Downing Street source is alleged to have said he should be “taken out and shot”.

The issue was raised by Labour leader Ed Miliband in the Commons on Wednesday, prompting Prime Minister David Cameron to say that Mr Lansley’s career prospects were “a lot better than his”.

Since its white paper was first published in July 2010, changes have been made to the government’s plans. Following criticism from the Conservatives’ Liberal Democrat coaltion partners, there was a pause in the NHS bill’s passage through parliament in 2011 to allow for further consultation.

Professor Steve Field, a working GP, was asked to liaise with doctors, nurses and other NHS professionals and come up with proposals to improve the bill. The government accepted the recommendations of the NHS Future Forum, chaired by Prof Field, and drew up a host of amendments, which will now be considered by peers.

But this has not pacified the Royal College of GPs, Faculty of Public Health, British Medical Association, Royal College of Nursing and Royal College of Midwives, which all oppose the bill outright.

Nor has it placated the Royal College of Physicians, which has called an extraordinary general meeting on 27 February and may decide to boycott the reforms.

GP commissioners

The centrepiece of the bill is a proposal to give family doctors control over most of the NHS budget. The plan was for them to form GP consortia to buy care on their patients’ behalf – from NHS hospitals, the private sector, charities or social enterprises.

Prof Field and his colleagues took on board criticism from within the health service that nurses and hospital doctors should also be involved in commissioning patient care.

This was accepted by the government, which has drawn up plans for so-called clinical commissioning groups, made up of nurses, hospital doctors and GPs.


The government is keen to encourage competition in the health service, and it was originally anticipated that the existing regulator Monitor would carry out this role.

Monitor would be given powers to prevent anti-competitive behaviour and would be able to apply sanctions to enforce competition law.

After fears were raised about the commercialisation of the NHS, the government accepted that Monitor’s primary duty should become the protection and promotion of patients’ interests.

It has been made clear that competition will be based on quality, not price. Originally, competition was going to be opened up to “any willing provider”; this has been changed to “any qualified provider”.

The structural changes … could damage NHS performance and harm patient care. Chris Ham, King’s Fund

Foundation trusts

The government wants all NHS trusts to become foundation trusts, giving them more financial and managerial freedom.

Originally, the government proposed that all trusts should achieve foundation status by April 2014. It has now relaxed this deadline, although most trusts will be expected to meet it.

Foundation hospitals will be able to raise up to 49 per cent of their income from private patients, although this is only likely to affect a small number of specialist institutions. The Royal College of Nursing is seeking assurances that NHS patients will not be disadvantaged, and the King’s Fund health think tank wants the government to consider amending its bill to make it a statutory requirement for hopsitals to report to parliament on their public/private income split.


A major part of the government’s plans is the abolition of layers of management – strategic health authorities (SHAs) and primary care trusts. The pace of this reform has been slowed down, with the scrapping of SHAs delayed until 2013.

A National Commissioning Board, independent of ministers, will also be established. But this has prompted two leading lights who support reform – Dr Charles Alessi and Dr Michael Dixon – to complain that instead of reducing bureaucracy, GPs will now find themselves under the control of a new management body.

Health secretary

Mr Lansley’s ambition was to refashion his own role, with the health secretary’s duty to provide health services replaced by a duty to promote them instead. The NHS Future Forum said it should be made clear that the health secretary is ultimately accountable for the NHS. The government has agreed.


In response to criticism from the NHS Future Forum that the NHS will become fragmented, Mr Lansley assured the Commons health select committee that integation around patients’ needs was key to his reforms.


These reforms are taking place at a time the NHS is under more financial pressure than it has been for many years.

During the Labour years, spending increased dramatically, and the coalition government has promised to increase the NHS budget in real terms every year. But the health service has also been told to make £20bn of effiency savings by 2015.

NHS faces fresh opposition. Read Health and Social Care Correspondent Victoria Macdonald


Unlike the Royal College of GPs and the Faculty of Public Health, the King’s Fund does not believe the bill should be withdrawn, but it is worried patient care could suffer.

Chief executive Chris Ham told Channel 4 News: “The amendments made following the NHS Future Forum’s report and in the House of Lords have improved the Bill. So, for example, it now sets out a more nuanced approach to competition and includes a new emphasis on promoting integrated care.

“At the same time, we remain concerned that the structural changes it sets out and the associated cuts in management posts could damage NHS performance and harm patient care. The sheer number of changes being made to the health system also risk creating confusion and additional bureaucracy.”