The Health and Care Bill, voted on in Parliament this week, has prompted months of debate.
NHS bosses, MPs, medics and carers alike have all been weighing in on what the new legislation, which narrowly passed in the House of Commons, will mean for health and social care across the country.
The bill’s supporters, including Health Secretary Sajid Javid, claim the legislation will reduce competition within the NHS, and will go some way to end the "the crisis in social care and the lottery of how we all pay for it" by introducing a controversial cost cap.
But its detractors say that the bill allows for “privatisation” of the NHS, and will leave poorer people worse off when it comes to paying for their social care.
The Manchester Evening News asked a spectrum of regional leaders about the Health and Care Bill, and fact checked the claims on both sides of the debate.
What is the Health and Care Bill? A few key points to know...
The proposals, should they pass through the House of Lords, will bring an end to Clinical Commissioning Groups (CCGs). At the moment, there are 106 CCGs across England responsible for planning many of the NHS services which their local populations need.
The CCGs are in charge of the main budget which pays for the likes of planned hospital care, urgent and emergency care, mental health and learning disability services, most community health services and many GP services.
Under the new legislation, CCGs would be replaced by Integrated Care Systems (ICSs).
These ICSs will be made up of two parts: Integrated Care Boards (ICBs) to do all of the planning and paying for the more immediate needs of people seeking health and care; and Integrated Care Partnerships which will bring together different organisations, like councils and charities, to solve longer term health and social care issues facing people.
The bill will also end the automatic requirement to put all health contracts out to tender, and give the Health Secretary direct power over some aspects of health services and the NHS in England.
The new legislation, supported and requested by NHS leadership, is expected to unpick changes brought in by the Conservative government in 2012.
That 2012 Health and Social Care Act heralded a move towards ‘competition’ between areas of the health and social care system, leading to a period of tendering where private services provided more NHS services.
The new bill looks to decrease that competition, but does not necessarily reduce the role of private providers which have long been involved in the NHS within health care services , according to independent health think tank, The King’s Fund.
There has also been concern about the potential for private providers to hold seats on ICBs, which will be allowed to choose their own members under the new legislation - causing those against the bill to call this an opportunity for ‘cronyism’.
The Nuffield Trust, another independent health think tank, argues that the changes to the tendering process will not result in the ICSs “handing contracts to their chums”, but says “it will become easier not to open contracts up to the market”.
“Overall, it is unlikely that the changes in the Bill will result in a substantial change in the private sector’s involvement in delivering NHS services,” added The King’s Trust.
The British Medical Association, however, have warned that the alterations would “allow contracts to be awarded to private providers without proper scrutiny or transparency”.
Social care has also been a point of contention during the debate. Boris Johnson managed to squeeze his care cap amendment into the bill, despite significant backlash from his own party.
The aim of the cap, which would come into force in October 2023, would mean no one in the country would pay more than £86,000 towards their own care costs with an aim of helping parents pass on more money to their children.
But there are fears that poorer people could end up paying more than those who are more affluent.
What do important figures in Greater Manchester think?
The Manchester Evening News asked a spectrum of regional leaders about the Health and Care Bill.
Next year, Manchester City Council boss Sir Richard Leese will be leaving his role in politics to chair Greater Manchester's Integrated Care Board.
“It will now be a statutory duty for local authorities and the NHS to cooperate around population health, health inequalities and integration of care," he told the M.E.N.
"The budgets will remain where they are, local authorities will retain budgets for social care and public health, t he rest is NHS - b ut the duty to collaborate is very powerful to start with.
“We’ll have structures through the ICP to enable all the stakeholders that need to be involved with population health to plan a strategy together.
“All of the NHS budgets will be brought into one place as a starting point, so we’ll start off with a single health budget. That will then go out to trusts, primary care networks and community health organisations, but it does mean Greater Manchester will have control of our health budget in Greater Manchester.
“That’s a pretty powerful tool we haven’t got at the moment.”
‘Why are we doing this now?’
One major concern echoed by a number of people is the timing of the widespread restructuring of the NHS.
For months, medics and politicians have been crying out for help as GP surgeries and hospitals have become overwhelmed with patients, kicking off what is expected to be a highly pressurised winter.
As NHS and social care staff admit that this could be the ‘worst winter of their careers’, frightened by their inability to give the care they would like in the face of unprecedented demand, questions about potentially expensive reforms at a time when the service is still catching up are flooding in.
Dr Helen Wall, a GP partner and the clinical director of commissioning for Bolton CCG, told the Manchester Evening News that she is concerned about staff welfare through such a change.
“The big thing for us at the moment is that we just don't know,” explained Dr Wall.
“It's a period of great transition and change. Obviously, the difficulty is that many people in our workforce are already extremely exhausted and not in a great place mentally or with morale.
"The NHS goes through these kinds of changes every 10 years or so. We're used to it, but it is an unsettling and uncertain time. It's difficult to say whether it'll be good or bad because there isn't enough detail yet as to how this is going to play out locally.”
Manchester City Council’s Executive Member for Health and Care, Coun Joanna Midgley, agreed saying: “We are coming to the end of a pandemic, this is not the time to be taking on a major health organisation or for talented staff to be taking time to reorganise the system.
“Our time might be better spent doing other things. Change is difficult.”
Will the legislation relieve the current pressures?
The Kings Fund has raised fears that the bill is too 'weak' to tackle chronic staff shortages, saying the legislation will force the Health Secretary to report 'at least every five years' on workforce needs, which isn’t often enough.
Sir Richard Leese says that a five year review is among the least of the National Health Service's worries when it comes to staffing.
"It gives us an opportunity," he says. "It's down to us in Greater Manchester to make use of the new legislation. We will put structures in place that enable us to join up services, especially at a neighbourhood level.
"We will improve, as we have done around the vaccination programme, the data we collect and how we analyse it so we are far better informed about where and how inequalities are operating both in populations and within the provision of services.
“On concerns that poorer places will be disadvantaged in comparison with more affluent parts of the city-region - one thing we will be doing is making sure we’ve got the data so that if that does happen, we know it’s happening and we can do something about it.
“This is work that’s already underway.
“At a neighbourhood level, we will get services working together so it’s an integrated system.
“At least 80 per cent of improving population health isn’t about provision - it’s about housing, jobs, education, exercise, diet. If you want to improve population health, we have to make sure that we’ve got the right data and we can target where there are issues.
"I don't know whether the regularity of the workforce review is the issue. The bigger issue is retention rates and that we're not training enough people.
“There is a pressing issue about what we’re going to do now to significantly increase the number of people in training.
“Medical schools are regularly turning away qualified candidates because they haven’t got enough places.
“We need to look at career development, support given to people in work from development to support for people dealing with stress, different ways of training such as apprenticeships."
Is the NHS being privatised by the bill?
Despite the assurances of independent think tanks, concerns remain over the role and influence the private sector will have in the new arrangement.
Labour councillor Joanne Midgley said: “As politicians, we’re of the view that public sector organisations are the best providers of healthcare, there is no place for the private sector on Integrated Care Boards.
“We do not support private organisations within tendering.”
The inclusion of private sector groups will ‘further health inequalities within deprived communities’, fears the councillor, inequalities which have already been made worse by Covid-19 and ‘10 years of terrible austerity’.
But Sir Richard said: “I don’t think there is anything within the legislation that would lead to the conclusion [that it’s privatisation]. Actually, reduction in competition is the opposite of that.
“It’s always worth bearing in mind that most of primary health care is wholly private anyway, dentists, GPs, opticians are all businesses. They contract with the NHS, obviously, but they are independent businesses.
“When the system gets overloaded, as it has done during Covid, we contract with some of the independent sector hospitals to fill the gaps. I don’t think that is likely to change.
“I don’t think anything in the legislation is fundamentally different from what we do now.”
The King’s Fund has said: “Critics of the current bill fear that private sector involvement in delivering clinical services will increase due to changes to procurement rules, the ability for private providers to hold seats on integrated care boards (ICBs) and potential conflict of interests in the awarding of contracts.
“The changes to how clinical services are procured sit within a wider package of reforms that aims to place collaboration, rather than competition, at the heart of how health care services are organised.
“Yet there are concerns that these changes, particularly where new services are being commissioned or services are being substantially changed, would allow contracts to be awarded to new providers without sufficient scrutiny, opening the door to private providers.
“In practice, though, the changes are framed by a duty on commissioners to act in the best interests of patients, taxpayers and their local populations, and will be informed by a new NHS provider selection regime, which is being developed by NHS England to support commissioning organisations and will include safeguards such as transparency expectations.
“A greater risk of the changes to competitive tendering is that existing contracts are regularly rolled over to the incumbent provider, with little opportunity for alternative providers to come forward.”
Helen Buckingham, of the Nuffield Trust, agreed, saying “there will be quite a few other people around that table too - NHS leaders, local authority leaders and independent non-executives. Meetings will be held in public and decisions must be transparent.”
Social care costs
The most significant criticism around the care cap, which dictates that no one will have to spend more than £86,000 on their own care, is that means-tested support payments from their council they might receive won't count towards reaching the cap.
This means people would need to find a lot of money on their own before seeing any benefit, and poorer people on means-tested help could end up paying as much as richer people if care goes on long enough.
The Prime Minister has told reporters: "[We're restricting] the amount that you can possibly pay to a fixed limit, when the state comes in and helps you - that's never been done before.
"This is a government that is levelling up across the whole country with the biggest investment in railway infrastructure for a century, and fixing a problem that has bedevilled governments for decades and addressing health and social care."
But, speaking on the Andrew Marr show, money expert Martin Lewis explained what the cost cap could mean for people needing social care, saying: "Everyone had assumed they were going to follow Andrew Dilnot’s proposals because that was the language they talked about.
“Within the Dilnot proposals, there are two protections for people on social care. One is a cap: £86,000. You won’t have to pay more money than that.
“The other is the means test where the state will fund some of your social care and in his proposals the two interacted. What’s happened is that the government said they’re not going to interact.
"It was thought that if you got means-tested support and the state paid for some of your social care, that would go towards your price cap along with any private funds you put in.
"But now, it won’t. If you’re very wealthy you wouldn’t have got any means-tested support but those on lower incomes and with less wealth, the means-tested support doesn’t matter."
The author of the definitive report on social care reform, Sir Andrew Dilnot, told MPs last week that the government’s proposals would leave 60 per cent of older people needing social care worse-off than under his proposals.
He also said it would “hit people in regions of the country with lower house prices, so there is a north-south axis to this."
Yasmin Qureshi, MP for Bolton South East said: “I will never vote for a bill which forces working people to sell their home to care for their loved ones in their old or ill state. This is a fundamentally wrong and immoral policy.”
“How can it be fair that those in the south who have benefited from arbitrary house price growth can have a larger slice of the cake than those of us in Bolton? It is another example of the Government holding those in the North with contempt.”
Despite his government’s proposal of the social care reforms, Bury South MP Christian Wakeford voted against them. The Tory MP swiped a traditionally Labour seat during the last general election.
After the Prime Minister inserted the social care point into the legislation, Mr Wakeford warned “we’re changing the goalposts halfway through the match”.
He told Times Radio: “One of the main messages for introducing this levy was 'you won't need to sell your house for care'.
“To get to that point where unfortunately you might need to, and arguably our least well-off, it's not something I'm particularly comfortable with."
As for Sir Richard, the discussion around social care will not end any time soon.
“That is something that is clearly going to be revisited in the committee stage of this legislation, I don’t think that discussion is over by any means," he said.
“What really worries me about the discussion around social care is that it’s entirely dominated by residential care for older people.
“That is not where the biggest expenditure or biggest growth in expenditure is for local authorities. There’s no discussion about support for people with severe learning or physical disabilities or people with mental health concerns.
“In terms of demand on social care, care for severe learning disabilities can be very expensive. People are living longer and require care all the time.
“A lot of social care is provided by relatively low paid people where there’s no career path and that impacts on the quality of care. There are some big questions to be resolved there.
"The whole of health and care in Greater Manchester has that as the number one priority. Something that has come out of Covid-19 is a really strong understanding in every part of the system is how it all joins together.
"The chief executive of Manchester Foundation Trust will talk as much about the need for proper structures for social care as he would about the need for more resources for elective care."
Manchester is already a step ahead
In more positive news, many of the health chiefs and medics within Greater Manchester have welcomed the bill as a step towards better collaboration, which promises to improve NHS services for patients.
More working together means fewer patients falling through the net, wiser spending, and a more unified fight against chronic health and care problems that plague residents across the region.
“What we effectively have been trying to do in Greater Manchester for the last five years on a voluntary basis, we can now do on a statutory basis. And everywhere else has got to do it as well," explains Sir Richard.
“It gives us a better set of tools to do what we’ve been trying to do in terms of integrating care and improving overall population health.
“The legislation gets rid of the competition requirements that came in during the last round of reform in 2012.
“Legally, health trusts are supposed to compete and everything has to go out to tender. Under the new legislation, they will be required to collaborate together.
“Things will not have to automatically go out to tender and that’s a positive thing.
“Other positives are the emphasis on population health and tackling health inequalities; and the role of the NHS as a national institution within the wider economy.
“It’s wholly consistent with what we’ve been trying to do in Greater Manchester since 2016.”
Coun Midgley added that priority is “providing the best possible care and health outcomes for the people in this city”, saying: “Integration in Manchester is ahead of the curve because we have been integrating our health and care for years now.”
‘We can only hope that the changes don’t put our deprived communities at a disadvantage’
Doctors on the frontline, serving patients in the communities struggling the most, hope that the sweeping restructure still involves local knowledge.
"We know there is going to be a Greater Manchester ICB, but what we're not clear on is how much of the decision-making will be done on a locality basis,” says Dr Wall.
"In Bolton, we currently have really good working relationships across the CCGs and the hospital trusts, the NHS Federation, the council, the voluntary sector. We're keen to keep those relationships and the people that know our town in those positions, fighting for our more marginalised communities.
"We're not sure whether that's going to be able to happen. When you centralise things, there's always a risk that you do create more health inequalities because clinicians in Bolton know where our deprived communities are, they know what challenges those communities face. No more have we ever been privy to that than through Covid and the vaccine programme.
"We have learned those lessons. We're not perfect, we make mistakes and sometimes people still can't access services. But it is worrying if that all goes to Greater Manchester, and we lose that local knowledge, how will these changes pan out?
"But all we can hope for is that we're going to be able to keep that place-based intervention, that's what I think will give us the best chance of managing our health inequalities.
"Every area will have a different view. In Bolton, we have very good engagement with practices within our borough system, I don't think that's been replicated everywhere.
"There is a definite wish for this to continue , but then again people don't like change. People will try to keep the status quo unless things are really challenging, and they are."
In its explanation of the bill, The King’s Trust adds: “While the reforms in the bill will result in changes to how the NHS in England is organised to support integration, these measures have been requested by the NHS, building on existing work to integrate care and are deliberately flexible to allow for different approaches according to local circumstances.
“In contrast to many previous attempts at NHS reform, the bill does not try to dictate from the top, instead recognising the need for local discretion.”
And Sir Richard says that on his watch, local knowledge will always be involved, adding: "I’m not concerned about that because we’re determined in Greater Manchester that we will have a bottom-up approach.
“The intention is that in each of the 10 council areas, there will be a locality board. Those boards will bring together health and local authorities.
“What we have in the Manchester locality board, which is largely already in place, we have the chief executive of the council, the chief executive of Manchester Foundation Trust, the chief executive of Greater Manchester Mental Health Trust, the chief executive of our local care organisation, the leader of the council, and the executive member of health from the council, and elected GPs.
“We will almost certainly be adding a voluntary sector voice.
“There will be local arrangements in place. GPs will be absolutely central to that.
"We’ll start with neighbourhoods then go to local authority level, then the Greater Manchester level."
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