1.Abolition of NHS England
Doctors in Unite were opposed to the creation of NHS England, believing that responsibility for the NHS should lie with the Secretary of State and not be outsourced to an arms-length body. Initially we welcomed its abolition until we realised that there were no plans to protect the important functions it fulfils, including healthcare public health, dental public health, NHS response to climate change, education and training, workforce planning, with loss of clinical expertise, severe short-term disruption and potential political interference in healthcare. There will be significant job losses without clear evidence of where these duties will be allocated and if the DHSC has enough capacity to absorb all these functions. Whilst there may be scope for savings in some areas, including some areas where duplication exists with DHSC, the large savings targets spread across the whole organisation will be very damaging.
Unite the Union strongly condemns the government’s plans to abolish NHS England (NHSE), warning that the associated mass job cuts are unfunded and threaten patient safety. The union is demanding an immediate freeze on redundancies, adequate impact assessments, and genuine consultation with healthcare workers. Service standards and patient safety must be maintained.
Instead of abolishing NHS England we suggest that all the clauses of the Bill which relate to the abolition of NHS England be abandoned and replaced by a single clause, repealing the entire contents of schedule A1 of the National Health Service Act 2006 and replacing them with a statement that the Secretary of State shall manage and direct NHS England, being accountable to Parliament for doing so. and making such arrangements as shall seem appropriate for the delegation of that function.
This will bring the NHS back under the direct responsibility of the Secretary of State without a damaging and complex reorganisation.
2. Reorganisations Generally
Far too much strategic time and effort is wasted on NHS reorganisations. Whilst we believe that the NHS does need to be reshaped we think this can be done organically as particular needs are identified. Economies of scale can be achieved, where they exist, by organisations co-operating together. There is no reason, for example, why a number of small NHS bodies cannot share an HR department. And economies from decentralisation can be achieved by focusing appropriate functions at the appropriate level without requiring wholescale restructuring. We suggest adding into the National Health Service Act, 2006, a clause requiring all reorganisations of NHS management to be carried out by such gradual organic methods and be evidence based, showing improvements in services and health outcomes and staff terms and conditions.
3. Public Health
We are concerned there is no reference to public health in the Bill. Public health was clearly not a priority for the recently departed Secretary of State.
Public health is as important an element of health policy as health care since
- Life expectancy is declining and people are dying too early
- Inequalities in healthy life expectancy are not accounted for in current social care age-based funding formulae as poor people need care earlier
- Productivity is lost due to people being unable to work
- The NHS is collapsing under pressure of obesity, diabetes and heart disease
- The climate emergency threatens the health of us all
Public health was part of the NHS until 2013 (although only until 1974 in the case of environmental health) when the Lansley Act in England distinguished between “the NHS” and the “statutory health service” (the NHS plus public health) which George Osborne used as an excuse to cut public health funding. This redefinition should be reversed.
We need:
- Good quality public health services, screening for ill health, and making it easier to choose healthier lifestyles. This requires
- public health grant to increase in line with NHS funding growth from 2013 and further increase so all councils equal the best funded decile
- a greater commitment to preventive spending within the NHS
- better funding of other health-relevant local government services, especially including youth services, leisure and community facilities
- Community development to help communities improve health in their area
- Neighbourhood public health leads linked to primary care
- Effective regulation – Cuts in environmental health, the Environment Agency and HSE have seriously damaged the effectiveness of public health regulation
- Addressing commercial determinants of health, with a just transition
- Public health specialists must have a primary duty to populations, not organisations, and give advice in the public domain contributing freely to public debate, so the public trusts public health advice as independent.
- Health in all policies. Health needs to have the same cross-government status as the Treasury.
- All public bodies should have duties towards health and climate change
- All public agencies must receive advice from public health specialists
- The Minister for Public Health in DHSC (and its devolved equivalents) must be a high-level appointment with a role across Government, supported by a team of public health lead Ministers in each Department
- A comprehensive publicly-provided occupational health service as part of the statutory health service
- A national health promotion agency and local health promotion teams
We support the comments by the BMA Public Health Medicine Committee (with which we have joint working arrangements) relating to the duties of the Secretary of State.
We have also drafted the following clause to protect the multi-agency role of the DPH and suggest it be added to the Bill. Please note that the words enclosed in brackets {} and marled with an * are included only for compatibility with another clause we suggest on definition of the NHS and would not be needed otherwise.
There shall be inserted into s30 of the Health & Social Care Act 2012 after the material specified therein for insertion into the National Health Service Act 2006 the following addition to the insertion
73D The Director of Public Heath shall
- be an officer of the local authority and shall have responsibility for its public health functions
- be an NHS consultant in public health responsible for giving independent professional public health advice and for promoting public debate on health matters
- be a corporation sole and NHS body for working with others to initiate measures to improve the health of the people
(d) be an officer of the Crown responsible for such functions as the Secretary of State may specify
(e) as an officer of the Crown have power to draw the attention of the Chief Medical Officer and the Attorney General to events within the area of the local authority creating circumstances in which it might be appropriate to bring proceedings in the name of the Crown for public health purposes
(f) be an officer of the National Health Service responsible for promoting the provision of services which are outcome-focused, are provided following a proper needs assessment and pay attention to the promotion of health and the prevention of illness
(g) as an officer of the NHS, have power either personally (in the case of a body which primarily serves the population of the local authority which appointed the DPH) or through joint arrangements with other Directors of Public Health (in the case of a body which primarily serves the population of several local authorities) or through a collective arrangement established by the Chief Medical Officer (in the case of a body with a national remit) to appoint, or approve arrangements for the body to appoint, a consultant in public health to serve on the governing body of any NHS body {other than an NHS body which is a local authority}*, any NHS Foundation Trust, any of the bodies established under this Act or any of the bodies established under the Health & Social Care Act 2012 or any other legislation relating to the governance of the NHS.. For the avoidance of doubt the consultant so appointed may be, but need not be, the Director of Public Health personally
(h) as an officer of the NHS and of the local authority, have power either personally (in the case of a body which primarily serves all or part of the population of the local authority which appointed the DPH) or through joint arrangements with other Directors of Public Health (in the case of a body such as a joint board or combined authority which primarily serves the population of several local authorities) to appoint a consultant in public health to attend any local authority meeting and to advise the meeting whilst it is in session on matters affecting the health of the people. For the avoidance of doubt the consultant so appointed may be, but need not be, the Director of Public Health personally and a different consultant may be appointed for different meetings
(i) be contractually required, subject to law, to carry out the functions in subsections b, c, e, f, g and h herewith as an independent health professional treating a population as a patient and pursuing the improvement of its health and to be contractually entitled not to be subject to any detriment by the local authority or by the Crown for so doing.
We have also drafted the following clause to eliminate the terminological distinction between the statutory comprehensive health service and the NHS and to return to the old nomenclature in which the statutory comprehensive health service was called “the NHS”.
(1) In s1 of the National Health Service Act 2006 as amended by s1 of the Health & Social Care Act 2012 after the words “comprehensive health service” shall be inserted the words “to be called the National Health Service (which may be referred to as ‘the NHS’)”
(2) Throughout the Health & Social Care Act 2012 and the National Health Service Act 2006 all references to the health service shall be replaced by references to “the NHS”, and all references to “the NHS” or “the National Health Service” (except those added by this clause) shall be replaced by “NHS Healthcare” (except that the term “NHS body” shall not be changed)
(3) A new paragraph shall be added to s66 of the Health & Social Care Act 2012 to supplement s66(4): “S66(4A) Those parts of the NHS which s66(4) excludes from the definition of NHS Healthcare shall be referred to as NHS Public Health”
(4) Local authorities insofar as they carry out the function of NHS Public Health, other bodies established to carry out the functions of NHS Public Health, and local authorities insofar as they carry out the function of environmental health authorities shall be added to the definition of “NHS body”.
Doctors in Unite 