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Undermining the NHS

The hidden reality behind David


Cameron’s health reforms
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Behind the Rhetoric
David Cameron said he was committed to the NHS. Ever keen to say what people wanted to hear
he promised to protect it – against top-down reorganisation, and from cuts. But the reality is very
different.

When you peel away the rhetoric, the hidden truth is that David Cameron and his Tory-led
Government, supported all the way by Nick Clegg and the Liberal Democrats, are taking the NHS
backwards. They are subjecting it to unnecessary, ideological reforms which will take power away
from patients and which threaten standards of care.

David Cameron promised to “stop the top-down reorganisations of the NHS that have got in the
way of patient care”. Less than two months into government he broke that promise, approving
Andrew Lansley’s plan for the NHS – the hidden reality of which is a wholesale top-down
reorganisation of the NHS, including the handing over of commissioning budgets to new GP
consortia and the abolition of existing commissioning structures.

This Health and Social Care Bill will bring about a massive bureaucratic re-organisation which
won’t improve patient care.

That would be bad enough. But it gets worse. David Cameron’s reorganisation isn’t just a waste of
money, and an unnecessary distraction to the NHS. It is a bad Bill, built on bad assumptions and
dangerous ideology.

David Cameron wants to keep hidden the truth of his Bill: It makes the NHS increasingly subject to
UK and EU competition law, putting NHS services and commissioners at risk of legal challenge. It
puts NHS services at risk of going bust and closing in the face of private sector competition. It
weakens local accountability over service changes, meaning valued local services could be closed
without warning.

No wonder the public, patients, NHS staff and health experts are so worried about the plans. Even
the Liberal Democrats, after happily signing the plans off in Cabinet and voting for them at
Second Reading, are starting to have second thoughts. But the so-called “listening exercise” the
Government has promised is no more than a sham – the reality is the policy is carrying on as if
nothing had happened, and Andrew Lansley is himself refusing to address the Royal College of
Nursing’s annual conference.

Labour will keep challenging the Tory-led Government’s dangerous plans. It’s becoming
increasingly clear: You can’t trust David Cameron with the NHS.

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The Hidden Reality of David Cameron’s Bill
You can’t trust David Cameron with the NHS. The Health and Social Care Bill includes
plans to make the NHS increasingly subject to UK and EU competition law, putting
NHS services at risk of legal challenge from private sector competitors. It contains no
protection to stop NHS services going bust in the face of private competition, and
includes new proposals to allow services to be shut down without local consultation. It
even gives GPs new powers to charge for services.

1. No protection from insolvency for NHS hospitals – NHS hospitals could go bust,
leaving patients without the services they have relied on.
• The Health and Social Care Bill will apply commercial insolvency law to NHS Foundation Trusts.
The Bill details that this is to create a “level playing field” which is “in the best interests of
[Foundation Trusts’] creditors” – not necessarily in the best interests of the patient.1

• Under the reforms, there are no provisions to protect NHS services which may be threatened
by competition from the private sector.2 There is no clear mechanism to stop NHS hospitals
closing.3

2. EU competition law and fining hospitals – NHS hospitals could be fined up to 10%
of their turnover by the new economic regulator
• According to a recent Parliamentary Answer, the Government plans to make EU competition
rules "increasingly" applicable to the NHS.4

• Another recent Parliamentary Answer showed that the Government still doesn’t know
”whether and to what extent European Union state aid law will have an impact” in the NHS
following its NHS reforms.5 This means that it is unclear whether and on what grounds private
sector competitors of the NHS could subject NHS services to legal challenge.

• According to the Explanatory Notes for the Health and Social Care Bill, the design of the new
NHS economic regulator, Monitor, is modelled on “precedents from the utilities, rail and
telecoms industries, tailoring them to the particular circumstances of the health sector."6

• Clause 60 of the Health and Social Care Bill gives Monitor concurrent powers with the Office
of Fair Trading under the Competition Act 1998.7 The Office of Fair Trading has a wide range
of powers to investigate businesses suspected of breaching competition law and can take
enforcement action, for example ordering that offending agreements or conduct be stopped,
and fining businesses up to 10% of their worldwide turnover.8 Similarly, under the Bill Monitor
will be given powers to fine NHS Trusts up to 10% of turnover for breaches of competition
law.9

3. Weakening local accountability over NHS closures and reconfigurations – Local NHS
services could be closed down without any consultation
• David Cameron said at Prime Minister’s Questions in February that the Government are putting
in arrangements to make sure that local people are listened to when decisions are being made
about local NHS closures and reconfigurations.10

• But the Government plans to weaken public accountability for the continuity of services that
have not been “designated”. Currently, any major service changes have to be consulted on and

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decisions referred to the Secretary of State. But following the reforms, “providers will have
greater freedom to adapt… without recourse to formal public consultation”.11 This would allow
local services to be closed down with no public involvement, with no notice, and with no power
to refer the decision to the Secretary of State.

• An NHS Service can be “designated” if the loss of that service could be deemed to have a
significant adverse impact on the health of a population if that service was no longer
provided.12 Health Minister Simon Burns has indicated that A&E services in London may not be
“designated” services, meaning they could be closed without consultation under the
Government’s plans.13

4. Putting private patients first – NHS patients could suffer as hospitals prioritise
those who can afford to pay
• Currently, Foundation Trusts can generate a limited percentage of their income from private
patients. But the Health and Social Care Bill will remove the cap on private income, meaning
that Foundation Trusts can generate as much income as they like from private patients.14

• The Department of Health’s own impact assessment states that a risk of removing the cap is
that hospitals could divert more of their resources to treating private patients, meaning that
private patients could be prioritised above NHS patients leading to a growth in waiting lists.15

• The Royal College of Nursing says that there is no guarantee that private income will not be
taken at the expense of NHS patients.16

5. New GP powers to charge for services


• It is currently the duty of the Secretary of State to decide which services should be provided
by the NHS.17 But the Bill takes away this duty from the Secretary of State, and hands it over
to GP consortia.18

• At present, the power to determine charging is given to the Secretary of State. The existing
legislation says that the Secretary of State may “make such charge as he considers
appropriate for anything he does in the exercise of any such power and to calculate any such
charge on any basis that he considers to be the appropriate commercial basis”.19 Clause 22 of
this Government’s Health and Social Care Bill gives this power to GP consortia.20

• David Cameron, Nick Clegg and Andrew Lansley have offered no explanation of why these
changes are needed or what they might mean for patients.

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David Cameron’s Shambles on the NHS
You can’t trust David Cameron with the NHS. Despite his high-profile pledge to stop
top-down reorganisations, he pushed ahead rapidly with a plan for massive structural
change to the NHS. As opposition from patients, NHS staff and the public grew, he
announced a “listening exercise” in which the Tory-led Government would “pause,
listen, reflect and improve” the plans – but in fact the policy is proceeding and, far from
listening, Andrew Lansley has refused an invitation to address the Royal College of
Nursing conference.

Broken promises
• David Cameron and Nick Clegg promised in the Coalition Agreement to “stop the top-down
reorganisations that have got in the way of patient care”.21 David Cameron said that “there will
be no more of those pointless reorganisations that aim for change but instead bring chaos”.22

• But they approved Andrew Lansley’s plan for a wholesale top-down reorganisation of the
NHS, including the handing over of commissioning budgets to new GP consortia, the abolition
of existing commissioning structures, and the application of UK and EU competition law to the
NHS.

Top-down reorganisation
• Andrew Lansley’s proposals were rushed out within weeks of the Coalition Agreement being
drawn up. The White Paper Liberating the NHS was published on 12 July, just two months after
the Government took office, with a three-month consultation period across the summer. The
Health and Social Care Bill was published in January, only three months after the consultation
closed. With 281 clauses, the Bill is more than three times longer than the Bill which set up the
NHS in 1948.

• Sir David Nicholson, Chief Executive of the NHS, said that the scale of the change being
imposed on the NHS was so big that “you can actually see [it] from space”.23 Robert Creighton,
Chief Executive of Ealing PCT, warned that it “could be a bloody awful train crash”.24 Peter
Carter, General Secretary of the Royal College of Nursing, says the Bill “could well turn out to
be the biggest disaster in the history of our public services”.25

Opposition grows
• Opposition to the proposals from the public and from expert organisations has grown, with
concerns raised by the Health Select Committee,26 the British Medical Association, unions and
professional organisations representing NHS staff, including the British Medical Association,
the RCN, the Royal College of Midwives and Unison,27 the King’s Fund28 and Conservative MP
and former GP Dr Sarah Wollaston.29 Even Lord Tebbit, once described as “my political hero” by
Andrew Lansley,30 expressed serious concerns.31

• At Prime Minister’s Questions on 16 March, David Cameron was unable to answer Ed Miliband’s
questions about the implications of making the NHS subject to EU competition law.32 Asked
later about the same issue, Culture Secretary Jeremy Hunt said, “that’s an area which I think we
need to ask Andrew Lansley about”.33

“Pause”?
• In April, Andrew Lansley announced a “pause” in the reorganisation – but was still unable to say
how, if at all, the policy would change.34 He said that the plan to abolish Primary Care Trusts
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would not be stopped.35 A leaked memo said that a number of “red lines” must be maintained,
including the creation of GP consortia and the new commissioning board, and the abolition of
PCTs by 2013.36

• Despite engaging in a “listening exercise”, Andrew Lansley has refused to address the Royal
College of Nursing conference, choosing instead to hold a Q&A session with just 50 nurses.
Nurses have tabled an emergency motion of no confidence in his ability to direct the
reforms.37

Liberal Democrats add to the confusion


• The Liberal Democrats have strongly backed the Government’s NHS plans. Nick Clegg signed
the foreword to the White Paper in July.38 No Liberal Democrat MP voted against the Health
and Social Care Bill at Second Reading.39 Liberal Democrat Health Minister Paul Burstow has
resisted all attempts by Labour to amend the Bill in Committee.

• The Liberal Democrats passed a motion at their Spring Conference in March calling for
wholesale changes to be made to the Health and Social Care Bill.40 Baroness Shirley Williams
described the reforms as “stealth privatisation” and said that they amounted to a plan to
dismantle “one of the most efficient public services of any in Europe”.41 But following the vote,
Downing Street said "This is not about significant changes to the policy but about reassuring
people with minor changes to the language of the bill as it goes through the House".42

• After the announcement of a “pause” in the policy, Nick Clegg told Parliament that there would
be “substantive changes”.43 But Health Minister Simon Burns said it would be “inappropriate” to
say what changes the Government would make.44

• Norman Lamb, chief political adviser to Nick Clegg, said on Sunday that “there is no evidence”
about how the new GP consortia will work, and that “to do it in one fell swoop would be very
risky”.45 He said that this could be a resignation issue for him.46 Nick Clegg said, “I couldn’t
agree more with Norman, I couldn’t agree more with Norman”,47 but was unable to say what
changes he supported to the legislation, saying “the devil lies in the detail”.48

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Labour: The Party of the NHS
• The National Health Service is the Labour Party’s greatest achievement. We created it, we
saved it, we value it and we will always support it.

• In 1997 the NHS was suffering from years of neglect and underfunding. With sustained
investment and reform, Labour turned it into a high-quality service for patients, at the heart of
which is a core value: care provided on the basis of need, not of ability to pay.

• Under the Tories, the NHS was neglected:

• Between 1979 and 1997, inpatient waiting lists went up by over 400,000.
• In 1997, 284,000 patients were waiting for over six months for their operations. In
1995, the Tories introduced a waiting time target of 18 months – and they failed to
meet it.
• In 1997, just 63% of people with suspected cancer were seen by a specialist within
two weeks of referral.
• In 1997, half the NHS estate was older than the NHS itself, with buildings dating from
before 1948.

• Labour brought enormous improvements to the NHS between 1997 and 2010, including:

• 89,000 more nurses and 44,000 more doctors in the NHS, helping to drive up
standards and drive down waits.
• Before 1997 it was not uncommon for patients to wait over 18 months for an
operation – by 2010 Labour guaranteed that nobody need wait more than 18 weeks
• Waiting lists fell by over 500,000 with waiting times at their lowest level since records
began.
• In 1997, 284 000 patients waited more than 6 months for an operation. By 2010 the
figure was almost zero.
• 3 million more operations carried out each year than in 1997.
• The premature mortality rate for cancer the lowest ever recorded, saving nearly 9,000
lives in 2006 compared to 1996.
• Premature mortality from cardiovascular diseases dropped by more than 40 per cent
since 1996, saving nearly 34,000 lives a year.
• The NHS delivered the largest hospital building programme in its history, with 118 new
hospital schemes opened and a further 18 under construction.
• Labour created new services to provide patients with greater convenience including
around 100 new walk-in centres and over 750 one-stop primary care centres.
• By 2010, over three quarters of GP practices offered extended opening hours for at
least one evening or weekend session a week.
• All prescriptions are now free for people being treated for cancer or the effects of
cancer, and teenage girls are offered a vaccination against cervical cancer.
• Labour delivered a guarantee of seeing a cancer specialist within two weeks if your GP
suspects you may have cancer, and guaranteed that whatever your condition, you
would not have to wait more than 18 weeks from GP referral to the start of hospital
treatment – and most waits were much shorter than this.

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Notes

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“This would assist in ensuring a level playing field between foundation trusts and other providers, and the
procedures could facilitate the rescue of a failed foundation trust (for example, through administration or a voluntary
arrangement with creditors) or enable the affairs of a trust to be wound up in the best interests of its creditors (for
example, through voluntary or compulsory liquidation). Introducing an effective failure regime would allow for orderly
market exit. It would also mean that trust directors would be under similar obligations to company directors since
offences that may be prosecuted under the insolvency legislation would be applied through regulations and
disqualification proceedings could be taken against directors who were held responsible for misconduct. “
Health and Social Care Bill, Explanatory Notes, para 737

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Eddie Mair So if there is no ideal balance, and nothing in the legislation to protect the NHS in terms of
this balance and if the mantra is to serve the patient and the patient has choice and
control, what happens if ultimately patients always choose private because they find they
like the quality and GPs like it because the price is right?
Andrew Lansley Well I mean, we have a level playing field and we have competition and there will be a range
of providers and who are the appropriate providers will change over time. As I say, what I’m
going to do is to make sure that there is a level playing field and actually there are
foundation trusts…
Eddie Mair And then [inaudible] the NHS can take its chances?
Andrew Lansley No no, it’s not a free-for-all because it’s all you know, clearly there is a continuity of
services to patients and we will.. and the legislation is very clear about the NHS continuing
to provide services to patients and the quality continuously improving. But what we do
need to do is to make sure that we have innovation and the benefits of competition do
bring innovation and drive up quality and we’re determined that’s going to happen.
BBC R4 PM, 19 January 2011

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Eddie Mair:: But under your plan is there any mechanism to stop the demise of say all NHS hospitals?
Andrew Lansley: Well I don’t know [laughs].
Eddie Mair: Perhaps that’s funny?
Andrew Lansley: Well it’s not funny it’s just absurd and…
Eddie Mair: That would be the logical conclusion [inaudible], you have nothing to put a top…
Andrew Lansley: No it’s not the logical conclusion and there is no evidence to support that proposition
indeed the evidence is completely to the contrary.
Eddie Mair:: Well there’s no evidence, this hasn’t been done before.
Radio 4 PM, 19 January 2011

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Tom Blenkinsop: To ask the Secretary of State for Health what recent assessment he has made of the likely effect
of (a) UK and (b) EU competition rules on the operation of GP consortia. [44028]
Mr Simon Burns: The Health and Social Care Bill itself does not extend the applicability of current United Kingdom or
European Union competition law to the health sector of England.
However, as national health service providers develop and begin to compete actively with other NHS providers and
private and voluntary providers, UK and EU competition laws will increasingly become applicable.
Hansard, 7 March 2011, column 896W

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Mr Barron: To ask the Secretary of State for Health what consideration he has given to the application of state aid
in the NHS following the re-establishment of Monitor as an economic regulator. [50942]
Mr Simon Burns: We are currently assessing whether and to what extent European Union state aid law will have an
impact in the national health service, including what the position will be with respect to a health system that will
remain funded by the taxpayer and providing universal coverage, free at the point of need.
Hansard, 5 April 2011, Column 836W

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"This Bill turns Monitor into an economic regulator for all NHS-funded health services. As an economic regulator,
Monitor’s overarching duty would be to protect and promote the interests of people who use health care services, by
promoting competition where appropriate and through regulation where necessary. It would have three core
functions: promoting competition where appropriate; setting or regulating prices; and supporting the continuity of
services. To support its functions, Monitor would have the power to licence providers of NHS-funded care. These

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clauses draw upon precedents from the utilities, rail and telecoms industries, tailoring them to the particular
circumstances of the health sector."
Health and Social Care Bill, Explanatory Notes, para 491

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(1)The functions reoffered to in subsection (2) are concurrent functions of Monitor and the Office of Fair Trading
Health and Social Care Bill, Clause 60, p. 40

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“Businesses that break the law can be fined up to 10% of their worldwide turnover and third parties (including
injured competitors, customers and consumer groups) can bring damages claims against them. In addition, individuals
found to be involved in cartels can be fined and imprisoned for up to five years and directors of companies that
breach the prohibitions can be disqualified for up to 15 years.”
Office of Fair Trading, http://www.oft.gov.uk/about-the-oft/legal-powers/legal/competition-act-1998/

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Clause 95 - Discretionary requirements
(1) Monitor may impose one or more discretionary requirements on a person…
(2) In this Chapter, “discretionary requirements” means –
(3) A requirement to pay a monetary penalty to Monitor of such amount as Monitor may determine (referred to in
this Chapter as “variable monetary penalty”….
(4) A variable monetary penalty must not exceed 10% of the turnover in England of the person on whom it is
imposed, such amount to be calculated in the prescribed manner.
Health and Social Care Bill, Clause 95, p. 89

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Daniel Kawczynski (Shrewsbury and Atcham) (Con): The local NHS trust in Shropshire is proposing major
reconfiguration changes to services throughout the county, including maternity and paediatric services. Those are
causing significant concerns for local Shrewsbury doctors, GPs and patient groups. Can the Prime Minister give an
assurance that those concerns will be taken on board and acted upon before any changes are made? My hon. Friend
the Member for Montgomeryshire (Glyn Davies), whose constituents also use the Royal Shrewsbury hospital, shares
my views.
The Prime Minister: I can certainly given that assurance, because my right hon. Friend the Health Secretary has put in
place much stronger arrangements for making sure that local people are listened to when these discussions are
taking place. No changes will be allowed unless they focus on improving patient outcomes, unless they consider
patient choice and unless they have the support of the GP commissioners, and remember that in the future health
system it will be the decisions of GPs and people that will drive the provision of health services, not top-down
decisions made by Ministers in Whitehall.
Hansard, 2 Feb 2011, column 856

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“In future, there will be a clearer distinction between: those services which are designated as subject to additional
licence conditions and which Monitor will ensure continue to be provided, even if the provider fails; and those services
where providers have greater freedom to adapt in line with changing demands, for example through patient choice,
without recourse to formal public consultation.”
Liberating the NHS: Legislative framework and next steps, December 2010, p. 109

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“Subsection (2) provides that a commissioner may only apply for a service to be designated if a consultation of the
relevant persons has been carried out and if the criterion in subsection (3) has been met. That criterion is that or that
this would be likely to cause a failure to prevent or ameliorate such adverse impact. The relevant persons a
commissioner would be required to consult are specified in subsections (9), (10) and (11) . Relevant persons differ
depending on who the commissioner is and include any person who the commissioner considers appropriate, which
might include potential providers of NHS services.”
Health and Social Care Bill, Explanatory Notes, para 587

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“Shadow health minister Liz Kendall asked Mr Burns whether his definition of designated services meant that
accident and emergency services in London would qualify.
“He said: ‘A designated service will be one to ensure that across the country there are appropriate services to meet
the needs of the people. There are a number of A&E services in London, so there would not be a need to designate
them… If I was talking about Cornwall, A&E would be designated there.’
“When questioned, Mr Burns clarified that he was not saying this will happen. ‘I was using it as an illustration to make
a point, it was not a prediction,’ he said.”

10
HSJ, 3 March 2011, http://www.hsj.co.uk/news/acute-care/burns-london-aes-may-not-be-
designated/5026490.article

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“abolishing the arbitrary cap on the amount of income foundation trusts may earn from other sources to reinvest in
their services and allowing a broader scope, for example to provide health and care services;“
Equity and excellence: Liberating the NHS, July 12 2010, p. 36

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“If the latter, there is a risk that private patients may be prioritised above NHS patients resulting in a growth in
waiting lists and waiting times for NHS patients. This is the eventuality that the PPI cap was originally introduced to
prevent.”
Health and Social Care Bill, Impact Assessment, 19 January 2011, p. 61

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“As the RCN’s response to the NHS White Paper stated, the RCN cannot support the removal of the private income
cap, as proposed by Clause 150, until healthcare providers can demonstrate that private income is not taken at the
expense of NHS patients.
“The RCN believes that the current arrangements for the cap should remain in place and does not believe that there
has been sufficient analysis to justify the proposed change in this area. The RCN does not support any change in
policy around the private income cap until assurances can be made that NHS patients access to care services will not
impacted. As a result the RCN believes that Clause 150, should be removed from the Bill. “
Royal College of Nursing, Memorandum submitted by the Royal College of Nursing (HS 27)

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Secretary of State's duty as to provision of certain services
(1)The Secretary of State must provide throughout England, to such extent as he considers necessary to meet all
reasonable requirements—
(a)hospital accommodation,
(b)other accommodation for the purpose of any service provided under this Act,
(c)medical, dental, ophthalmic, nursing and ambulance services,
(d)such other services or facilities for the care of pregnant women, women who are breastfeeding and young children
as he considers are appropriate as part of the health service,
(e)such other services or facilities for the prevention of illness, the care of persons suffering from illness and the
after-care of persons who have suffered from illness as he considers are appropriate as part of the health service,
(f)such other services or facilities as are required for the diagnosis and treatment of illness.
(2)For the purposes of the duty in subsection (1), services provided under—
(a)section 83(2) (primary medical services), section 99(2) (primary dental services) or section 115(4) (primary
ophthalmic services), or
(b)a general medical services contract, a general dental services contract or a general ophthalmic services contract,
must be regarded as provided by the Secretary of State.
(3)This section does not affect Chapter 1 of Part 7 (pharmaceutical services).
National Health Service Act 2006, clause 3

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9 Duties of consortia as to commissioning certain health services
(1) Section 3 of the National Health Service Act 2006 is amended as follows.
(2) In subsection (1)—
(a) for the words from the beginning to “reasonable requirements” substitute “A commissioning consortium must
arrange for the provision of the following to such extent as it considers necessary to meet the reasonable
requirements of the persons for whom it has responsibility”, and (b) in each of paragraphs (d) and (e) for the words “as
he considers” substitute “as the consortium considers”.
Health and Social Care Bill 2011, Clause 9, p. 5

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7 Extension of powers of Secretary of State for financing the Health Service.
(1)In order to make more income available for improving the health service (as defined in the M1National Health
Service Act 1977 or the M2National Health Service (Scotland) Act 1978), the Secretary of State shall have the
powers specified in subsection (2) below; but for the avoidance of doubt it is hereby declared that nothing in this
section authorises him or any body to which he gives directions under subsection (3) below to disregard any
enactment or rule of law or to override any person’s contractual or proprietary rights.
(2)The powers mentioned in subsection (1) above are powers [F1(exercisable outside as well as within Great
Britain)]—

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(a)to acquire, produce, manufacture and supply goods;
(b)to acquire land by agreement and manage and deal with land;
(c)to supply accommodation to any person;
(d)to supply services to any person and to provide new services;
(e)to provide instruction for any person;
(f)to develop and exploit ideas and exploit intellectual property;
(g)to do anything whatsoever which appears to him to be calculated to facilitate, or to be conducive or incidental to,
the exercise of any power conferred by this subsection; and
(h)to make such charge as he considers appropriate for anything that he does in the exercise of any such power and
to calculate any such charge on any basis that he considers to be the appropriate commercial basis.
Health and Medicines Act 1988, clause 7

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14S Raising additional income
(1) A commissioning consortium has power to do anything specified in section 7(2)(a), (b) and (e) to (h) of the Health
and Medicines Act 1988 (provision of goods etc.) for the purpose of making additional income available for improving
the health service.
(2) A commissioning consortium may exercise a power conferred by subsection (1) only to the extent that its exercise
does not to any significant extent interfere with the performance by the consortium of its functions.
Health and Social Care Bill 2011, Clause 22, p. 32

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Coalition Agreement, p. 24

22
"There will be no more of those pointless re-organisations that aim for change but instead bring chaos."
David Cameron, speech to the Royal College of Nursing, 11 May 2009

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“In December 2010 he adopted the same approach when he told NHS finance officers that he had consulted
change management experts from around the world: and no one could come up with a scale of change like the one
we are embarking on at the moment. Someone said to me ‘it is the only change management system you can actually
see from space’ — it is that large”
House of Commons Health Committee, Commissioning, Third Report of Session 2010–11Volume I, Volume I: Report,
17

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"This could be a bloody awful train crash. It could collapse. All of us are looking inwards […]
"I’ve got to completely clean out the team and make a whole series of new appointments. I spent 13 hours yesterday
interviewing yesterday, I’m spending another six hours today, eight hours tomorrow. In all that time, I am not spending
a moment thinking about patient care or money. It will be very difficult to keep everybody focused in the task in hand.
"This must be working together, but we are at risk of blowing it. Sometimes I feel I’m only doing what I’m doing
because of a sense of public duty. In two years’ time, I will probably be out of a job.
"The Government is saying that everything I have done for the past eight years has been bad or should be destroyed.
Where’s the sense of that?"
Robert Creighton, Chief Executive of Ealing PCT, quoted in House of Commons Health Committee, Commissioning,
Third Report of Session 2010–11 Volume I, Volume I: Report, p. 23

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"The Health and Social Care Bill 'could well turn out to be the biggest disaster in the history of our public services –
if organisations like the RCN are not listened to, and listened to now,' Mr Carter warned."
Nursing Times, 11 April 2011, http://www.nursingtimes.net/nursing-practice/clinical-specialisms/management/carter-
warns-reforms-could-be-biggest-disaster-in-history-of-nhs/5028486.article

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“There was a significant policy shift between the Coalition Programme, published on 20 May 2010, and the White
Paper, published on 12 July 2010. The Coalition Programme anticipated an evolution of existing institutions; the
White Paper announced significant institutional upheaval. The Committee does not believe that this change of policy
has yet been sufficiently explained given the costs and uncertainties generated by the process. The Committee
broadly shares the Government’s policy objectives so it therefore welcomes the fact that these are substantially
unchanged. It does not believe however that the approach adopted by the Government represents the most efficient
way of delivering those objectives. The failure to plan for the transition is a particular concern in the current financial
context. The Nicholson Challenge was already a high-risk strategy and the White Paper increased the level of risk
considerably without setting out a credible plan for mitigating that risk.”

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House of Commons Health Committee, Commissioning, Third Report of Session 2010–11 Volume I, Volume I: Report,
p. 3

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Sir,
Radical reform of the NHS in England is expected to come a major step closer this week, with publication of the
Health and Social Care Bill. As unions and professional organisations representing the 1.3 million staff who make up
the NHS, we are extremely concerned that the Government is not heeding the warnings about key elements of the
proposals. We recognise the need to provide NHS services more cost-effectively, but we believe this can and must be
achieved without taking unnecessary risks and damaging care.
One of the major concerns is the role that the NHS’s economic regulator, Monitor, will be given to ensure that any
willing providers, including NHS and voluntary organisations, and commercial companies, are able to compete to
provide all NHS services. In addition, the 2011-12 operating framework for the NHS, published last month, revealed
that providers will be able to offer services to commissioners at less than the published mandatory tariff price.
There is clear evidence that price competition in healthcare is damaging. Research by economists at Imperial College
shows that, following the introduction of competition in the NHS in the 1990s, under a system that allowed hospitals
to negotiate prices, there was a fall in clinical quality. With scarce resources there is a serious danger that the focus
will be on cost, not quality.
Enforced competition will also make it harder for NHS staff to work collaboratively in multidisciplinary teams, across
organisational boundaries, to create the integrated care pathways that patients want and need, and that will help to
make services more efficient.
Furthermore the sheer scale of the ambitious and costly reform programme, and the pace of change, while at the
same time being expected to make £20 billion of savings, is extremely risky and potentially disastrous.
Dr Peter Carter, Royal College of Nursing
Dr Hamish Meldrum, British Medical Association
Karen Jennings, Unison
Karen Reay, Unite
Professor Cathy Warwick, Royal College of Midwives
Phil Gray, Chartered Society of Physiotherapy
Letter to the Times, 17 January 2011,
http://www.rcn.org.uk/newsevents/news/article/uk/rcn_and_other_unions_express_concern_about_nhs_reform

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"The publication of the Health and Social Care Bill signals the biggest shake-up of the NHS since its inception.
"The last decade has seen significant progress in the performance of the NHS. While ministers are right to stress the
need for reform to make it truly world class, these gains are at risk from the combination of the funding squeeze and
the speed and scale of the reforms as currently planned."
Chris Ham, Chief Executive, Kings Fund, Press Release, 19 January 2011,
http://www.kingsfund.org.uk/press/press_releases/the_kings_fund_32.html

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“An organisation responsible for over £100billion needs people who seriously understand accountancy and, trust
me, GPs do not.
“Bearing in mind that the NHS Commissioning Board in London will be responsible for commissioning every GP
practice, pharmacy and dental surgery, it is clear that they will need some regional presence. I cannot see that it
makes sense to foot the bill for redundancies for the entire middle layer of NHS management only to be re-employing
many of them within a couple of years. Commissioning consortia will be overwhelmed trying to adapt to their new
roles. Someone needs to get a grip or we will continue to haemorrhage the best staff as a result of intolerable
uncertainty and pointless morale-sapping denigration. It all risks going 'belly up' rather than 'bottom up'.
“It is not Greeks that could destroy the NHS, but if Monitor, the new economic regulator, is filled with competition
economists with a zeal for imposing competition at every opportunity, then the NHS could be changed beyond
recognition.
“It is no use ‘liberating’ the NHS from top down political control only to shackle it to an unelected economic regulator.
We have moved from a position of widespread support from patient groups and the professions for the health
reforms to one of outright hostility.”
Dr Sarah Wollaston MP, Daily Telegraph, 19 March 2011, http://www.telegraph.co.uk/health/8392564/Why-David-
Camerons-plans-for-the-NHS-are-dangerous.html

30
“My political hero is Norman Tebbit”
Andrew Lansley, The House magazine, 15 November 1999

13
31
"I have known the Secretary of State, Andrew Lansley, for 30 years. In his day he was a very able civil servant, and
it seems to me that if anyone could unravel and reform the tangled bureaucracy which holds up the devoted
professionals of the NHS, it ought to be someone with his experience."
“What worries me about the reforms however is the difficulty of organising fair competition between the state-
owned hospitals and those in the private sector.”
Daily Mirror, 4 April 2011, http://www.mirror.co.uk/news/top-stories/2011/04/04/norman-tebbit-don-t-let-david-
cameron-destroy-our-nhs-115875-23036253/

32
Hansard, 16 March 2011, columns 292-294

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Andrew Neil: Why is a Eurosceptic government like yours bringing the NHS under EU competition law?
Jeremy Hunt: Well I … that’s an area which I think we need to ask Andrew Lansley about. I know that one of the
things that even Andrew Lansley’s critics would not dispute is his tremendous control and command
of the detail of his subject and I am absolutely sure that what he is trying to do, which is incidentally
very much in the direction of travel of the last Labour government, is to make sure that we can
harness some of the skills in the independent, charitable and private sector. But we obviously need
to do that in a way that allows the core NHS to carry on its functions.
BBC Daily Politics, 16 March 2011

34
“Our desire is to move forward with the support of doctors, nurses and others who work in the NHS and make a
difference to the lives of so many of us, day in and day out. However, we recognise that the speed of progress has
brought with it some substantive concerns, expressed in various quarters. Some of those concerns are misplaced or
based on misrepresentations, but we recognise that some of them are genuine. We want to continue to listen to,
engage with and learn from experts, patients and front-line staff within the NHS and beyond and to respond
accordingly. I can therefore tell the House that we propose to take the opportunity of a natural break in the passage
of the Bill to pause, listen and engage with all those who want the NHS to succeed, and subsequently to bring
forward amendments to improve the plans further in the normal way.”
Andrew Lansley, Hansard, 4 April 2011, column 767

35
Andrew Lansley: We are basing commissioning in the legislation and in the overall reforms on the basis of
clinically-led commissioning, doctors and nurses leading commissioning. Primary Care Trusts, the
intention is to continue to abolish Primary Care Trusts and the reason is very straight forward…
Eddie Mair: And people can’t stop that?
Andrew Lansley: No, we’re intending to go ahead with legislation…
BBC R4 PM, 6 April 2011

36
"A two-month 'listening exercise' in which medical professionals will be asked to contribute to a review of changes
to the NHS has been thrown into doubt by a confidential memo highlighting a series of government red lines that
must be maintained.
"As David Cameron and Nick Clegg joined the health secretary, Andrew Lansley, on Wednesday to launch the exercise
at a hospital in Surrey, the memo by NHS chief executive David Nicholson indicated there may be little room for
manoeuvre in reworking the health and social care bill.
"The memo drew a red line beneath the fundamental planks of the bill that are not for changing: GP consortiums, an
independent commissioning board to oversee them, every hospital to become a foundation trust, and Healthwatch
and primary care trusts to be abolished by 2013.
"The memo said there would be delays in setting up Monitor, a regulatory body for bringing competition in the NHS, to
which many object, which will slip to July 2012, and the abolition of strategic health authorities will also be delayed to
the same date."
Guardian, 6 April 2011, http://www.guardian.co.uk/society/2011/apr/06/nhs-listening-exercise-thrown-doubt

37
"The Health Secretary is facing a vote of no confidence after nurses accused him of not having the 'guts' to speak
to thousands of them.
"Andrew Lansley has been heavily criticised for declining an offer to deliver a speech at the Royal College of Nursing
(RCN) conference in Liverpool.
"Instead, he has decided to hold a 45-minute Q&A with just 50 nurses as part of the Government's 'listening exercise'
on the controversial NHS reforms.

14
"Angry nurses have demanded to know why he will not deliver a speech during his visit tomorrow, and are to vote on
an emergency motion of no confidence in his ability to direct the reforms."
PA, 12 April 2011

38
Department of Health, "Equity and Excellence: Liberating the NHS", July 2010, p. 1

39
http://www.publicwhip.org.uk/division.php?date=2011-01-31&number=185&display=allvotes

40
“The government's plans for a health service shakeup face a radical overhaul after the Liberal Democrat leadership
was forced to bow to the strength of a grassroots rebellion fuelled by fear of privatisation and an undue emphasis on
competition.
“The Lib Dems voted almost unanimously at the party's spring conference in Sheffield to give councillors a central role
in GP commissioning and in scrutinising foundation trusts. They called for a ban on all cherry-picking by private
companies offering treatment services.”
Guardian, 13 March 2011, http://www.guardian.co.uk/politics/2011/mar/13/nhs-reforms-overhaul-liberal-democrats

41
“It was, she realised, a plan to dismantle what she calls ‘one of the most efficient public services of any in Europe’.
She sums up Lansley's agenda as ‘stealth privatisation’. There were other aspects that would transform the NHS
beyond recognition, tucked away, such as allowing ‘any willing provider’ to supply services. ‘The NHS was always seen
as the preferred provider. That is swept away,’ she says.”
The Guardian, 12 March 2011, http://www.guardian.co.uk/politics/2011/mar/12/shirley-williams-nick-clegg-nhs

42
"Downing Street said: 'This is not about significant changes to the policy but about reassuring people with minor
changes to the language of the bill as it goes through the House.'"
Guardian, 13 March 2011, http://www.guardian.co.uk/politics/2011/mar/13/nhs-reforms-overhaul-liberal-democrats

43
"As the Secretary of State for Health said very clearly yesterday, where there are legitimate concerns, for instance
about the governance of a GP consortium or the role of the private sector, we will seek to address them. That will
then lead to substantive changes through amendments at the end of the process, in about two months' time."
Nick Clegg, Hansard, 5 April 2011, column 883

44
"But Simon Burns, the Health Minister and Mr Lansley's deputy, refused to accept there would be substantive
changes, saying there were 'misconceptions' and 'misrepresentations' about the reforms. 'It would be inappropriate of
me at the beginning of an independent process... to start saying categorically what we are definitely going to do,' he
told BBC Radio 4's World at One programme."
Independent, 7 April 2011

45
Norman Lamb: The financial risk is that at the moment the plan is to transfer responsibility to GP consortia, new
organisations, there is no evidence about how these organisations will work but they are supposed
to be up and running by April 2013, there is a process to ensure that they have to meet a standard
before they are given full approval, but my preference, my strong preference is to look at what we
are doing in the education reforms, in education, schools can opt for academy status, surely we
should be doing the sort of evolutionary approach in health as we are doing in schools.
Jon Sopel: So to be clear you think Andrew Lansley, you’ve just said it, is going ahead on this on the basis of no
evidence? … that is what you just said, no evidence that there will be benefits.
Norman Lamb: I said that the principle at the core of this of giving GPs more power and responsibility is absolutely
right but when you introduce any new structures of course there is no evidence so the sensible
thing to do after this period for reflection is to test it to see how it works and it would gather a
momentum of its own, if it works as we hope it would then others would follow suit… but to do it in
one fell swoop would be very risky…
Jon Sopel: And keep the Primary Care Trusts in the transitional period?
Norman Lamb: Well we have now got these clusters of Primary Care Trusts, they’ve been brought together I think
they have to stay because I think performance management of GPs is going to be really critical
during this period and incidentally for those areas that don’t opt in to this, it is not an opt out of
reform, there would still be a progressive devolution of responsibility to GPs, there are different

15
ways of skinning the cat here, lets stick to the principle which is really good, but lets not destroy it
by getting the process wrong.
BBC Politics Show, 10 April 2011

46
Norman Lamb: Well I just think it is essential that we all work to ensure that we get a package that people can
support, that my party the Liberal Democrats can support…
Jon Sopel: Sorry to interrupt you Mr Lamb, of course I understand that point completely but you have to
consider the possibility what if you don’t
Norman Lamb: Well this package is not going to work unless we can get people on board and that includes the
addressing the concerns that I have raised.
Jon Sopel: So presumably when you spoke to Nick Clegg you raised the possibility that this could be a
resignation issue?
Norman Lamb: Look, I’ve said that if it is impossible for me to carry on in my position I will step down, I don’t want to
cause embarrassment, but I feel very strongly about this issue and I think that it is in the
government’s interest to get it right in the way that I suggest.
Jon Sopel: But that could happen?
Norman Lamb: It could
BBC Politics Show, 10 April 2011

47
"The detail of exactly how you make those principles work in practice are of course things that we want to get
right. And I couldn’t agree more with Norman, I couldn’t agree more with Norman, we have to get this right. The NHS is
too precious, it is too precious to me, it is too precious to everybody else who relies on it in the country to not get the
principle translated properly into practice."
Nick Clegg, BBC R4 Today, 11 April 2011

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"Well there is no point having a pause unless you are prepared to make substantive changes at the end of it where
those substantive changes are necessary. I totally of course agree with Norman, we talk about this on an almost daily
basis, that the status quo needs to change, we need to change the current system, that everybody agrees that it is
right to put more financial responsibility in that hands of GPs who know patients best. But how you do that is…
therein lies... the devil lies in the detail… Now Norman’s got very strong views about a particular aspect of it, other
people have got very particular views about other aspects of it, I think it… yes it is unusual that a government is
saying look we are going to have a pause and listen and reflect and then change things where necessary, but it is... I
think it is a good thing that we are listening."
Nick Clegg, BBC R4 Today, 11 April 2011

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