The NHS in 2013: a reorg, Sir David Nicholson & CCGs – for £5.69 a day

On 5 July 2013, the NHS will reach Britain’s current male pension age of 65. But far from retiring, the health service will be undergoing surgery – at least in England, although there are also changes afoot in Scotland and Wales. Here are some pointers for the NHS in 2013.

1) The massive reorganisation of the NHS in England will not amount to privatisation. The changes, masterminded (but not masterly sold) by former health secretary Andrew Lansley, will not end the principle of healthcare free at the point of delivery – except where it isn’t free already, such as prescriptions, optical and dental care. On the evidence so far, they also look unlikely to greatly increase private sector involvement in the NHS. There is plenty one can criticise in the Lansley plans – see points 2, 3 & 4 – but those who focus on the p-word are missing the full picture.

2) As of 1 April 2013, the English NHS will essentially be run by the hugely powerful NHS Commissioning Board. Sir David Nicholson, the one-time communist and health service lifer who is currently NHS chief executive for the Department of Health, will become chief executive of the board, controlling a 2013/14 budget of £95.6bn – the lion’s share of all NHS spending. (By way of comparison, the UK-wide defence budget for the next financial year, both revenue and capital spending, is £34bn.) Under the Health and Social Care Act, Sir David’s new job is basically to run the English health service, rather than the health secretary – although this will not let Jeremy Hunt off the hook when something goes wrong.

3) Also as of 1 April, 211 clinical commissioning groups (at the last count) will take over from primary care trusts – and most people will not initially notice. So far, the CCGs do not look very different to the PCTs, and in many parts of the country they will cover the same areas. However, they will have more managerial input from clinicians: of the first 34 approved (by Sir David’s NHS Commissioning Board, see point 2) nearly half list a doctor as their accountable officer. It will be interesting to see how much difference this makes.

4) Early on in his career in the 1980s, Sir David Nicholson worked on the ‘care in the community’ policy of closing asylums. What happened to mental health hospitals has, very gradually, also been happening to acute care – but there are justifications to go further in cutting hospital capacity. NHS leaders say that a quarter of hospital patients, particularly the elderly, could be better treated elsewhere – their own homes, care homes or community hospitals – and telehealth/telecare is providing better ways to support this. At the same time, greater medical specialisation increases the case for fewer, better acute units.

The Nicholson challenge – that man again – is for NHS trusts to cut costs by 20% by 2015 (to provide a boost capacity, rather than save cash, with the health service budget flat in real terms). Most of the savings so far have been achieved by finding efficiencies, but these are unlikely to be enough on their own. If the target is going to be met, it will mean closing hospital units, including A&Es. Such plans will be immensely unpopular with the local public, but the fact that the Labour-run Welsh Government is planning to do exactly this in south Wales demonstrates its logic. 2013 will either see Westminster backing similar closures, particularly in London, or fudging them. I think it may well back them… and put up Sir David Nicholson to explain them. (Perhaps that’s why it’s called the Nicholson challenge.)

5) This may seem contrary to point 4, but new hospitals will be back on the agenda. The chancellor George Osborne has announced a new version of PFI, PF2, but Scotland is ahead of England with its new Non-Profit Distributing (NPD) funding model for major projects, including a series of new NHS buildings. Last month, NHS Lothian advertised the first of these: a £150m contract to rebuild Edinburgh’s Royal Hospital for Sick Children (aka the Edinburgh Sick Kids Hospital), which will combine with the city’s clinical neurosciences and child and adolescent mental health units. Work will start in 2014, and the new facilities will open in 2017. (The reason point 5 doesn’t cancel out point 4 is because new hospitals tend to have fewer beds than those they replace – but take the edge off protests over closures.)

6)  A safe-ish prediction, because it comes from the Budget: the NHS in England in 2013/14 will cost £111.3bn in revenue and capital, or £305m every day. To look at it another way: the cost of (mostly) free at the point of delivery healthcare for every Englishman and woman is £2,078 each a year – or just £5.69 a day.

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