GPs 'Need a More Central Role in Health & Care Bill'

Becky McCall

July 19, 2021

General practice needs to engage with England's Health and Care Bill, according to the head of the Royal College of General Practitioners (RCGPs), speaking at a webinar discussion on the planned legislation and its implications for general practice last Thursday, hosted by the London-based Health Foundation charity.

Professor Martin Marshall, GP and chair of the RCGP, expressed his mixed feelings about the Bill that is currently being debated in Parliament. "Never has there been a better time to address the fragmentation between hospitals and community silos," but cautioned that, "if general practice doesn’t engage with this, then it won’t work."

However, he recognised that the vast majority of GPs are in "survival mode", and stressed: "They have their heads down; they see the problems with fragmentation, but knowing what to do and whether this policy initiative will make a difference is really hard to assess. Yet, at a time of stress, a service is often more receptive and ready to engage with change."
 

'Knackered'

Last week, as the Health and Care Bill went through its second reading the House of Commons, many health bodies including the British Medical Association (BMA) argued that the timing is wrong, given the persistent pandemic; that the Bill fails to address chronic workforce shortages, and that it places too much power in the hands of the Government’s Health Secretary. 

From an NHS perspective, the Bill effectively aims to resolve tensions between the formal rules created by the Health and Social Care Act of 2012 and some of the ways the NHS has been working in recent years and wants to continue doing so in the future, explained Dr Rebecca Fisher, GP and senior policy fellow at the Health Foundation, chairing the webinar. 

"As a GP, we’re so busy doing the day job right now, half of staff are off self-isolating and we’re knackered, so it is hard to engage with this sort of system level change, and it’s harder still to know if we need to engage with it, what’s it about and should we care?", she said. "But like it or not, this is happening, and the Bill should become law by April 2022."
 

Nuts and Bolts of the Bill

In short, the changes to the NHS within the Bill have two key strands: collaboration and centralisation, the former being less controversial than the latter. 

The collaboration and integration part of the Bill is to formally establish integrated care systems (ICSs) into the NHS by statute. ICSs coordinate services across an area to meet health and social care needs. In June, an ICS Design Framework was set out. 

Integrated Care Boards (ICBs) will oversee all NHS functions in an ICS area and these will adopt the duties currently held by Clinical Commissioning Groups (CCGs), explained Dr Fisher. "The day these boards are formed, so the CCGs will be abolished."

The centralisation part of the Bill – also known as powers of direction - relates to a continued merging of NHS England and NHS Improvement but also, more controversially, a political centralisation of power back to Whitehall. "This means a broad increase in the power of the Secretary of State for Health, who will have power to intervene at any point at a local level; service reorganisation to transfer functions to and from arms-length bodies, and even to abolish an arms-length body," Dr Fisher pointed out. 
 

More Democratic Model Run by Local Government 

Despite welcoming the efforts towards less fragmentation, Prof Marshall reserved some scepticism. "In the last 20 years I’ve seen at least nine policy initiatives to reduce fragmentation in the NHS… suggesting none of them are working very well. Is this going to work any better?" 

Perhaps the time is right for a major overhaul, he said. Prof Marshall came up with an unexpected proposal. "Let’s be radical and go for the Swedish model; let’s get the NHS run by local government," he suggested. "Why not? It would absolutely change the nature of what we do in so many different ways – a democratically accountable health service, that would really bring us patient voice."

He added that if this Bill really stands for proper integration, then it would be wise to use the resources available – that is the community support and engagement groups that exist in local government. "With a few exceptions, the NHS is really bad at patient involvement, but actually local government is really, really good."

Referring to his experience as a GP in East London, he highlighted some exemplary partnerships between the NHS and the London boroughs. "These have opened my eyes to the work that can be done when you have a democratic voice, which we don’t have in the NHS for the public." 

Farzana Hussain is a GP of nearly 20 years standing in Newham, East London, and clinical director of the Newham Central 1 Primary Care network. She said the COVID-19 vaccination strategy in her area epitomised the value to be reaped through well-conducted patient partnerships.  

Over recent months, "Around 100 COVID champions emerged. They weren’t paid, used their own time, and helped make a difference to help the community get COVID vaccinated. It was powerful."

Dr Hussain explained that they needed to learn from patient representation both during the pandemic and otherwise. "Right now, we’ve been meeting with head teachers who are helping us understand what’s happening with knife crime in Newham. They tell us things we would never know. We need to draw on other assets and our communities are a rich form of that.

"I ask, how will this Bill make things better on the ground, for patients?"

She would like to see more detail on how the Bill will affect the neighbourhood or primary care network (PCN) level of care. "Real change will happen at the PCN level with GPs sitting with their communities. We need PCNs to have a lot more power rather than just be part of the partnership. Right now, it is still command and control from ICS down to PCN. I’d like to see this more horizontal."
 

Local Leadership

Dr Rob Webster, GP and lead chief executive officer, West Yorkshire and Harrogate ICS, reinforced that local leadership remained paramount. "I don’t want legislation defining what a neighbourhood model should look like because it won’t be right. We can’t dictate from the centre how a neighbourhood model should work in Newham, in Chapeltown or North Kirklees," he said, pointing to the need to be "sceptical but not cynical".

Echoing Prof Marshall’s point about overcoming fragmentation, Dr Webster explained the way he felt the Bill could drive a strategy for change. Despite the perception that the ICS will be in charge, "the ICS will not be in charge. At best it will facilitate working where people themselves do as much as possible".

The Bill should now move to a third reading in the autumn, with plans for the Bill to pass and new statutory structures to start functioning in April 2022.

NHS reform: what do the proposals mean for general practice? Hosted by The Health Foundation, London, on July 15, 2021.

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