Was the Health and Social Care Act as bad as we thought?
The Health and Social Care Act 2012 set out the single biggest collection of reforms that the NHS had seen since its creation in 1948.
Focusing on patient-centred care, the legislation looked to improve quality and outcomes whilst reducing inequalities through clinically-led commissioning, but it was highly controversial and critics were quick to lambast it as a disaster.
With commentators scrutinising the act for a supposed erosion of the NHS’s core value - free universal provision at the point of delivery - nearly a decade later we ask: was it really as bad as we thought?
“It cost billions of pounds and there were significant criticisms of its aims and impact, but the promotion and digitisation of healthcare is a legacy that has fundamentally shifted the NHS’s approach.”
The biggest piece of legislation of its time
When the UK Government introduced the principles of the Health and Social Care Act in a 2010 white paper, its key aim was to modernise the NHS to meet rising demands, increased treatment costs and to decentralise health spending to specially-formed Clinical Commissioning Groups (CCGs). A crucial objective was to build sustainability for the future.
This was a substantial piece of legislation and it was bound to run into issues, not only because it worked towards the “transferring of public assets and revenue streams to public sector workers”, but also because it was set to save billions per year in clunky administrative costs and shake-up healthcare management as we knew it.
What didn’t work?
Significant overspend
In theory, the move towards clinically-led commissioning sounded positive - putting funding straight into the hands of those providing the services to use it how they best saw fit. This would mean that, for example, instead of going through a lengthy procurement process, CCGs could commission services directly for their communities with limited red tape.
However, not only did the proportion of CCGs reporting a budget deficit jump from 15% to 29% between 2016 and 2017, some reported deficits of up to £60m - totalling over £100,000 in excess spending per day. This was perhaps expected in part as non-specialists were now in charge of running the business side of healthcare, but had real impact on healthcare provision and decisions about what to fund or cut to balance the books.
Worsening health inequality
One of the Health and Social Care Act’s key aims was to reduce health inequalities across the entirety of England, primarily through the involvement of local authorities, who now had increased public health functions. This meant CCGs could respond to their specific geographical health concerns, for example to work on interventions to mitigate higher levels of child obesity rates and lung cancer prevalence in poorer areas of England.
However, best practice did not ensue across all 223 trusts. CCGs were responsible for the full financial risk, and research undertaken in 2016 showed that health inequalities were persisting with patchy success on the part of CCGs to reduce it. In fact, in September 2021, Health Secretary Sajid Javid admitted that the COVID-19 pandemic had laid bare underlying health inequalities in England, which is suffering from “the disease of disparity”.
What did work?
Local consultation
In some ways, being able to target location-specific health needs by giving funding to those with the most on-the-ground insight was positive for many communities, and CCGs have been successful in some localities.
Hull CCG, for example, canvassed local people about their healthcare with a view to incorporating suggestions into their service offering. The CCG also appointed “patient ambassadors” who worked directly in the community and fed back patient voices on local interventions as time went on. This led to patient and community-centered service redesign and informed planning for new services.
The starting blocks for NHS Digital
NHS Digital - formerly the Health and Social Care Information Centre - was constructed on the back of the Health and Social Care Act 2012, and its establishment saw an overhaul in development and operation of digital technology and data services across the NHS in England. The rationale was that by having the right IT services in place, patients would get better care, and data could be used to further improve healthcare outcomes.
NHS Digital has been instrumental in creating technological infrastructure to keep the health service running and link systems together, publishing standards like the Data Security and Protection Toolkit, and using health and care data to improve understanding of health problems and support medical research.
Foundations for integrated care
The Health and Social Care Act also created the foundations for the 2021 Health and Care Bill, which will see the mandatory introduction of Integrated Care Systems (ICSs) across England. These Bill proposes a knitting together of local government, individual NHS trusts, and social care providers with the aim of created an integrated care framework that favours shared responsibility of health and care providers following years of patchwork care in the community. If voted through by parliament, ICSs could be mandated as early as 2022.
How successful was it on balance?
The Health and Social Care Act 2012 restructured the NHS. It cost billions of pounds and there were significant criticisms of its aims and impact, but the promotion and digitisation of healthcare is a legacy that has fundamentally shifted the NHS’s approach.
There were some leaps of progress catalysed by the act, but there is still a long way to go in ensuring best practice and minimum standards for making digital truly work for the NHS. Undoubtedly, the NHS is improving in both its approach and delivery of healthcare, becoming a more modern service, fit for the needs of a more diverse population with complex needs, but only time will tell whether the foundations built by 2012’s Health and Social Care Act are strong enough to support what comes next or will require multiple overhauls as time goes on.
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