The NHS Long Term Plan legislative proposals

Our response to the Health and Social Care Select Committee inquiry

18 April 2019

The Health Foundation responded to the Health and Social Care Select Committee inquiry into legislative proposals in response to the NHS Long Term Plan. 

A summary of our key points are as follows:

  • The Health Foundation welcomed the NHS Long Term Plan as an ambitious vision to improve NHS care. The Plan emphasises the need for collaboration within the NHS to improve care and manage resources. NHS England and NHS Improvement’s proposals for legislative changes in Implementing the NHS long term plan: proposals for possible changes to legislation aim to align the rules for the NHS in England with the ambitions for improving care described in the plan.
  • The proposals could make it simpler for mergers involving foundation trusts to take place - including at the direction of NHS Improvement. What is not clear is whether more mergers in the NHS would necessarily be beneficial to patients and the system. Evidence on the impact of NHS hospital mergers on costs and quality is mixed. The proposals are not clear on how these benefits would be robustly assessed in future.
  • The proposals related to competitive tendering could provide greater clarity for NHS commissioners seeking to plan and coordinate local services. A new ‘best value’ test is proposed to guide commissioners in deciding whether to award contracts directly to NHS providers or to competitively tender. It is not yet clear how such a test would work. The risk is that one set of complex and confusing rules is replaced with another.
  • The proposed changes on competitive tendering also need to be considered in relation to wider competition law and in the context of EU rules. These proposals may not be possible without making wider policy changes such as bringing foundation trusts back under direct government control.
  • A number of proposals aim to support the development of more integrated care. This is welcome, but integrating NHS organisations and creating new contracts is not the same as integrating services. Other approaches related to leadership, culture and management are likely to be just as, if not more, important for supporting the development of new, integrated models of care than technical changes to contracts and organisations within the NHS.
  • The proposals to support greater collective decision-making between local NHS organisations would formally diminish the strength of the purchaser-provider split, which has existed since 1991. Yet these changes may make little practical difference, and risk creating another workaround to the existing fragmented and complex organisational arrangements at a local level. How sustainability and transformation partnerships and integrated care systems will be held accountable remain unclear.
  • There is a strong case for aligning the work of NHS national bodies – though the rationale for new powers for the Secretary of State to transfer and delegate functions between national bodies without primary legislation is unclear.
  • Taken together, the proposals add up to several shifts in the direction of the NHS, including from competition to collaboration, increased centralisation of power from local to national bodies, and consolidation of NHS organisational arrangements. They also raise important questions related to accountability, patient choice and the mechanisms for driving improvements in performance across NHS services.
  • National NHS leaders should more clearly articulate the rationale for these changes, and the logic for how services will improve as a result. Aside from the detail of each proposal, NHS leaders must ask themselves whether changes to NHS legislation – however logical from a technical perspective – will bring additional costs, upheaval, and unintended consequences, such as directing resources away from front-line care.

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