Child health professionals air their opposition to NHS reforms

A growing list of professional bodies are calling for the withdrawal of the Health and Social Care Bill. Here, four prominent organisations set out their concerns about the bill and what they believe needs to change

The Health and Social Care Bill has courted controversy since its inception. Criticism from healthcare professionals has remained forceful even after attempts to amend the legislation and, as the government presses on with its attempt to push the controversial bill through parliament, opposition appears
to be growing.

Prime Minister David Cameron organised a Downing Street summit last month to talk to health leaders about implementing the changes in the bill, but the meeting turned into a debate about the problems with the legislation.

Concerns are rife among child health professionals; 154 members of the Royal College of Paediatrics and Child Health have signed a letter calling for the bill to be withdrawn. The proposals herald the largest shake-up of the NHS in its 64-year history.

Here, professional bodies representing paediatricians, midwives, psychiatrists and speech therapists set out their concerns about the proposals as they currently stand.

•     The Health and Social Care Bill will see the abolition of primary care trusts and strategic health authorities from April 2013.
•     Instead, clinical commissioning groups, led by GPs, will be in charge of planning healthcare for patients in communities.
•     The NHS Commissioning Board will distribute cash to these commissioning groups and oversee commissioning for certain services, such as primary care.
•     Councils will be responsible for public health and will manage local health and wellbeing boards, charged with developing joint health and wellbeing strategies.
•     HealthWatch will be the independent consumer champion – locally and nationally – to promote better outcomes in health for children and adults.
•     “Any willing provider” will be allowed to provide NHS-funded services to improve patient choice.
•     Foundation hospitals will be allowed to raise up to 49 per cent of their income through private patients.
•     The healthcare regulator Monitor will regulate providers of NHS services so they meet the best interests of patients.

ROYAL COLLEGE OF PAEDIATRICS AND CHILD HEALTH
Professor Terence Stephenson, president

The membership of the Royal College of Paediatrics and Child Health last month voted to call for the withdrawal of the Health and Social Care Bill just three days after I had been part of a delegation attending the health summit at Number 10.

The RCPCH never supported the bill, but we had until now embarked on a strategy of “critical engagement”. From the outset we warned that it could lead to the fragmentation of services. For children with chronic, complex, and disabling diseases who need to be treated by a large number of doctors and nurses, it’s better they get that all from one service rather than multiple services. The bill appeared to make that less possible.  

We were also concerned that the bill’s principle of “no decision about me, without me” did not sufficiently extend to children and young people. This could lead to poor service planning and poor outcomes for children.

None of that means that we are anti-reform; the opposite is true. We have been involved in an enormous amount of work to support the reconfiguration of paediatric services throughout the UK.

For paediatrics, we feel it will be difficult to staff and maintain 220 separate 24-hour emergency services around the UK without redesigning how and where ill children are cared for. The defence of tradition does not guarantee success and, as a college, we have always tried to concentrate on outcomes, not processes or structures.

Yet despite revisions to the bill in recent months, there has been a visible hardening of opinion among our membership, with a growing sense that proceeding with the bill will ultimately damage children’s health.
Some of the concerns include the 49 per cent private patient cap, confusion over the role of the Secretary of State, and the government’s refusal to release the risk assessment of the bill. It is those concerns that led to a strong majority of our voting members demanding the bill be withdrawn outright.

The question now is, what next? While the debate may be becoming more polarised and more intense, there are clearly areas where healthcare professionals agree – such as the principle of clinically-led commissioning. There is also widespread support for a greater focus on public health and outcomes, not targets.

We believe that all healthcare professionals now need to be brought together to thrash out how the areas of agreement can be put into practice. Consensus on reform is possible, even if consensus on this bill is not.

THE ROYAL COLLEGE OF MIDWIVES
Sean O’Sullivan, head of policy

The Royal College of Midwives wasn’t invited to the recent Downing Street summit on the Health and Social Care Bill. The exclusion came as no surprise, since we have always had grave doubts about the bill and last month called for its withdrawal. We were, however, disappointed that government is turning a deaf ear to those organisations representing the overwhelming majority of NHS staff.

The government says that those who oppose the bill are against reforms to the NHS. Not so. The RCM is in favour of reform, but just not these reforms. We agree with the government when it says it wants patients to have a greater say in how their care is delivered; that there needs to be further integration of health and social care; and that local government should be given a more prominent public health role.

But these aspirations can be realised without this legislation – if anything, the bill will hamper reform because it is dismantling the very organisations that are driving change.

The bill is also a major distraction from the real challenges facing the NHS; specifically, to achieve unprecedented efficiency targets – £20bn over four years – with a frozen budget and growing demand on services. The House of Commons Health Committee recently warned that the reorganisation process, set in train by the bill, is creating disruption that is hindering the ability of the NHS to reform services and release savings.

Our fundamental objection is that the bill will lead to a more market-orientated and competitive NHS. This runs counter to the ethos of collaboration that is essential if women and families are to receive safe,
responsive and high-quality care. Given the costs, risks and potential litigation associated with labour and childbirth, private providers are likely to cherry-pick those aspects of maternity care they are willing to provide, leading to more fragmented services.

The bill also proposes that NHS foundation trusts can earn up to 49 per cent of their income from private patient care. Our fear is that parents prepared to pay a bit extra would be guaranteed a standard of care
denied to NHS service users – for example, guaranteed one-to-one care during labour.

There is still time to change course. We remain committed to working with the government to deliver real improvements to services. However, if the government continues to set its face against the overwhelming majority of clinicians, we will look to MPs and peers to consign the bill to history.

THE ROYAL COLLEGE OF PSYCHIATRISTS
Professor Sue Bailey, consultant child and adolescent psychiatrist and president

In recent weeks, the medical royal colleges have borne a striking resemblance to a set of dominoes – as one after the other has come crashing down in opposition to the controversial Health and Social Care Bill.

Our college cannot support the bill as it stands. Over the past six months, we’ve surveyed members several times. The last survey, carried out at the end of January, shows their increasing concern. More than 80 per cent of psychiatrists who responded said they considered the bill to be fundamentally flawed, and 85 per cent believe it will have a negative impact on the health and social care system.

We’ve received many comments from child and adolescent psychiatrists, who are worried the bill will pose a particular threat to children, young people and their families. One described child and adolescent psychiatry as the “Cinderella service of Cinderella services” – a low-budget specialty with challenges that are likely to be poorly understood by the new commissioners of services.

Another feared the bill may use competition in a way that will drive down standards and disadvantage certain groups of patients, such as those with complex diseases or children with chronic conditions. Another voiced their fear that it could result in child psychiatrists “burning out and leaving” the profession.

We know there are already fragmented pathways for many young people as they make the transition from child and adolescent mental health services (CAMHS) to adult services. The bill, as it stands, could lead to further fragmentation of care.

Increased competition will work against collaboration in the best interests of patients with mental health problems. While clinically appropriate choice is important for patients, competition must be used with caution.

While we cannot support the bill as it stands, we are continuing to engage with government in the hope we can bring about further changes to the proposed legislation.

We are also taking a firm lead on commissioning, because it’s clear that whoever commissions mental health services in future will need expert advice from clinicians, patients and carers. Last month, the Joint Commissioning Panel on Mental Health, which we co-chair with the Royal College of General Practitioners, published four good practice guides for commissioners – including one on young people making the transition from CAMHS to adult services. More guides, including one specifically on CAMHS, will be published later in the year.

ROYAL COLLEGE OF SPEECH AND LANGUAGE THERAPISTS
Kamini Gadhok, chief executive

The Royal College of Speech and Language Therapists was among the 12 allied health professional bodies that wrote to the Prime Minister earlier this month. We told him we could not support the Health and Social Care Bill in its current form.

We did not take this step lightly. We have worked hard to improve the bill and will continue to do so, but, as a professional body, we cannot support legislation that could harm our service users.

Children’s speech and language therapy is an important service that is always at risk of falling between the cracks. The NHS commissions it but, if it is required by a child’s statement of special educational needs, the local authority must ensure it is provided. Many therapists are employed by the NHS but work in schools or early years settings. That is why speech and language therapists care so passionately about the integration of services. It is why we cannot support a competitive approach to service delivery, which would make integration more difficult to achieve.

Children with complex health needs are particularly vulnerable to any fragmentation of services. They depend on a broad range of services and are easily placed at risk by failures of co-ordination.

Effective – and integrated – commissioning of children’s health services requires a detailed understanding of children’s mental and emotional needs, child protection issues, the particular needs of disabled children and the role of wider children’s services. It remains to be seen whether GPs will have sufficient breadth of experience to bring such an understanding to bear.

The best way to ensure that local health services are commissioned effectively is to involve a full range of health professionals – not just doctors and nurses. We are therefore disappointed that, despite our best efforts, the bill still gives no place to allied health professionals on the governing bodies of clinical commissioning groups.

We welcome the recent establishment of a Children and Young People’s Health Outcomes Forum to develop a new strategy for improving care. We are keen to develop the opportunities for better co-ordination provided by the new health and wellbeing boards.

But we want the government to go further. We want it to address the fundamental threat to integration posed by the emphasis on competition. We hope it will respond to the weight of professional opinion on this issue.