Health and Social Care Act 2012
The Health and Social Care Act 2012 (c 7) is an act of the Parliament of the United Kingdom. It provided for the most extensive reorganisation of the structure of the National Health Service in England to date.[1] It removed responsibility for the health of citizens from the Secretary of State for Health, which the post had carried since the inception of the NHS in 1948. It abolished primary care trusts (PCTs) and strategic health authorities (SHAs) and transferred between £60 billion and £80 billion of "commissioning", or healthcare funds, from the abolished PCTs to several hundred clinical commissioning groups, partly run by the general practitioners (GPs) in England. A new executive agency of the Department of Health, Public Health England, was established under the act on 1 April 2013.[2]
Long title
An Act to establish and make provision about a National Health Service Commissioning Board and clinical commissioning groups and to make other provision about the National Health Service in England; to make provision about public health in the United Kingdom; to make provision about regulating health and adult social care services; to make provision about public involvement in health and social care matters, scrutiny of health matters by local authorities and cooperation between local authorities and commissioners of health care services; to make provision about regulating health and social care workers; to establish and make provision about a National Institute for Health and Care Excellence; to establish and make provision about a Health and Social Care Information Centre and to make other provision about information relating to health or social care matters; to abolish certain public bodies involved in health or social care; to make other provision about health care; and for connected purposes.
7
Section 46, 56 (1) and (3), 57, 58, 60, 150 (2) and paragraph 1 of Schedule 13, Section 214 (1) Section 222 (1), Sections 230(1) - (4), and (6) and paragraph 53 and 59 of Schedule 15, Part 7, Section 231 (1), (3) And Part 2 of Schedule 20, Section 300, 301, Part 12, extend to England, Wales, Scotland and Northern Ireland, Sections 128-133 extend to England and Wales and Scotland only
27 March 2012
The proposals were primarily the result of policies of the then Secretary of State for Health, Andrew Lansley. Writing in the BMJ, Clive Peedell (co-chairman of the NHS Consultants Association and a consultant clinical oncologist) compared the policies with academic analyses of privatisation and found "evidence that privatisation is an inevitable consequence of many of the policies contained in the Health and Social Care Bill".[3] Lansley said that claims that the government was attempting to privatise the NHS were "ludicrous scaremongering".[4]
The proposals contained in the act were some of the coalition government's most controversial. Although mentioned in the Conservative Party's manifesto in 2010,[5] they were not contained in the Conservative–Liberal Democrat coalition agreement,[1] which mentioned the NHS only to commit the coalition to a real-term funding increase every year.[6] Within two months of the election a white paper was published, outlining what The Daily Telegraph called the "biggest revolution in the NHS since its foundation".[7] The bill was introduced in the House of Commons on 19 January 2011.[8][9] In April 2011 the government announced a "listening exercise", halting the Bill's legislative progress until after the May local elections; the "listening exercise" finished by the end of that month. The Bill received Royal Assent on 27 March 2012. Many of the structures established by this Act of Parliament were dismantled by the Health and Care Act 2022.
Contents[edit]
Parts 1 and 2 Health service in England[edit]
Section 9 establishes the National Health Service Commissioning Board, later known as NHS England. The Secretary of State is to publish, annually, a document known as the mandate which specifies the objectives which the Board should seek to achieve. National Health Service (Mandate Requirements) Regulations are published each year to give legal force to the mandate.
Section 10 establishes Clinical Commissioning Groups which are to arrange the provision of health services in each local area.
Section 11 makes the protection of public health a duty of the Secretary of State, and section 12 makes local authorities responsible for improving the health of the people in their areas. Among the effects of this, local authorities regained the commissioning of some community services such as those for sexual health and substance misuse.[31]
Section 30 requires each local authority to appoint a director of public health, and gives the Secretary of State certain powers over that person's appointment.
Public reactions[edit]
General[edit]
On 19 January 2012 two major unions of healthcare professionals that had previously tried to work with the government on the bill, the Royal College of Nursing and the Royal College of Midwives, decided instead to join with the British Medical Association in "outright opposition" to the bill.[32] On 3 February 2012 the Royal College of General Practitioners also called on the Prime Minister to withdraw the bill.[33]
The Confederation of British Industry supported the bill, declaring that "Allowing the best provider to deliver healthcare services, whether they are a private company or a charity, will spur innovation and choice."[34]
In May 2011, a number of doctors from GP consortia wrote a letter to the Daily Telegraph in which they expressed their support for the bill, calling its plans "a natural conclusion of the GP commissioning role that began with fundholding in the 1990s and, more recently, of the previous government's agenda of GP polysystems and practice-based commissioning".[35] On 14 May 2011, The Guardian published an article reporting that the GP appointed to head the NHS "listening exercise" has unilaterally condemned the bill.[36] The article said that Steve Field had "dismissed" the plans "as unworkable" and that these statements were "provisional conclusions that could fatally undermine the plans". The Royal College of General Practitioners (RCGP) also denounced the bill.[37]
The Royal College of Physicians and Royal College of Surgeons[34] welcomed in principle the idea of medical professionals determining the direction of NHS services, but questioned the Bill's implementation of the principle, particularly in regard to the approach of making GP consortia the primary commissioning deciders, and also in regard to requiring competition. The British Medical Association said similarly.[34] Neither of these organisations supported the bill.
In February 2011 David Bennett, newly appointed Chair of Monitor, said the NHS could become like other privatised utilities, so that Monitor would potentially be a regulator like Ofcom, Ofgem and Ofwat: "We, in the UK, have done this in other sectors before. We did it in gas, we did it in power, we did it in telecoms […] We've done it in rail, we've done it in water, so there's actually 20 years of experience in taking monopolistic, monolithic markets and providers and exposing them to economic regulation."[38] The House of Commons Select Committee on Health condemned the comparison as not "accurate or helpful."[39]
GPs as commissioners[edit]
The bill intended to make general practitioners the direct overseers of NHS funds, rather than having those funds channelled through neighbourhood- and region-based primary care trusts, as was previously done.[40]
There were concerns about fragmentation of the NHS and a loss of coordination and planning. The Royal College of General Practitioners said it was "concerned that some of the types of choice outlined in the government's proposals run a risk of destabilising the NHS and causing long-term harm to patient outcomes, particularly in cases of children with disabilities, those with multiple comorbidities and the frail and elderly."[34] The Royal College of Physicians said that "Whilst we welcome the broad provision in the bill to seek professional expertise, the RCP is concerned that the bill does not require that specialists are at the heart of the commissioning process."[34] The Royal College of Psychiatrists said it "would be dismayed if psychiatrists were not closely involved with local consortia of GPs in the development of mental health services."[34] The Royal College of Surgeons said that "the legislation leaves the question of regional level commissioning unanswered with no intermediary structure put in place."[34] And there were concerns about management expertise, particularly by looking at the US. The BMJ wrote that
In January 2015, Chris Ham and others from the King's Fund produced a review of the government's health reforms. Their conclusions as far as the act was concerned were that:
In November 2017, Jeremy Hunt in an interview with the Health Service Journal said "The idea of lots of competing foundation trusts and payment by results works well when you have in your mind that most of the work the NHS does will be single episode elective care, but when you're dealing with complex patients who are going in and out of the system a lot those structures prove not to be fit for purpose."[65]
Nick Timmins, writing in 2018, concluded that the legislation, in its own terms, had failed. Choice and competition were not, as envisaged, the driving principles of the NHS. In fact the development of integrated care systems was unpicking the "purchaser/provider" split that had been the dominant theme of NHS management since 1991. The organisations set up by the act, Monitor and the NHS Trust Development Authority had effectively been merged. And there was nothing to suggest that "political micro-management" and "excessive bureaucratic and political control" had disappeared. However, he said the act had given the NHS an independent voice, and that according to Jeremy Hunt "the independence of NHS England is the bit that has worked best".[66] David Benbow argued in 2020 that the legislation did not extend patient choice as envisaged (as this policy subsequently took a backseat) but that it did lead to an increasing amount of the NHS budget being diverted to private providers.[67]
The publication of the NHS Long Term Plan in January 2019 marked the official abandonment of the policy of competition in the English NHS. Integrated care systems would be created across England by 2021, and in 2022 Clinical Commissioning Groups were abolished and NHS Improvement absorbed into NHS England, though all this was intended to happen without repealing the legislation.[68] In February 2019, NHS England produced a document outlining changes it wanted to see in legislation. One of the central proposals was to remove the obligation to put services out to competitive tender if local commissioners considered a service would be best provided from within the NHS.[69]