Proposals for a dramatic overhaul of the way the National Health Service is run were laid before parliament yesterday, but fears over the pace and scale of the changes outlined in the Health and Social Care Bill are gathering force.

The coalition government has now introduced parliament to draft legislation that would steer a massive shift in NHS operations in a bid to increase the efficiency of services, boost patient care, and save around £12 billion by 2020.

The controversial Health and Social Care Bill outlines plans to hand control of as much as 80% of the NHS budget to GPs working in commissioning consortia to plan and purchase services for patients. 

In another radical move, all Primary Care Trusts and Strategic Health Authorities are up for the chop, and a newly formed independent NHS Commissioning Board will be charged with overseeing spending instead, in a bid to slash bureaucracy and management costs and bring decisions closer to the frontline instead.

Proposals laid out in the Bill also include increasing accountability for patients and the public through the creation of HealthWatch and local health and wellbeing boards within local councils; freeing the NHS from political micro-management by supporting all trusts to become foundation trusts and establishing independent regulation; improving public health by creating Public Health England; and increasing competition to boost patient care.

Defending its plans, the government said they would improve the NHS in a number of ways, such as letting clinicians and not managers lead the way on service provision, changing the focus on outcomes so that they are more meaningful to patients, and allowing patient a greater degree of control in their care under the motto "no decision about me without me".

Billions of savings

It is claimed the measures will also save the NHS more £5 billion by 2014/15 and then £1.7 billion every year thereafter, which, the government points out, could cover the cost of  over 40,000 extra nurses, 17,000 extra doctors or over 11,000 extra senior doctors every year. The changes would pay for themselves by 2012/13, and the subsequent savings would give the NHS "a stable financial basis for the future", it added.

"Modernising the NHS is a necessity, not an option," stressed Health Secretary Andrew Lansley commenting on the Bill, and he said the proposals will "strengthen the NHS for the future and make the changes that are needed for vital modernisation to put more patients and NHS staff in control".

But response to the plans has been very mixed. Describing the reforms as "courageous and right", Michael Dixon, Chairman of the NHS Alliance, said his organisation "welcomes the principles behind the reforms which will put GPs and patients in the driving seat when it comes to raising the quality and efficiencies of services", and that "it is refreshing to see a reform programme that will create a better balance between local and national requirements".

Monitor, which, if the plans are approved by MPs, will become the economic regulator for health and adult social care, has also welcomed the Bill, in particular proposals to move to a more devolved system for the NHS, the introduction or more competition to boost productivity, and increasing the freedom of foundation trusts.

The Royal College of General Practitioners was somewhat more cautious in its support. Broadly welcoming the proposals, RCGP Chair Clare Gerada said "it makes sense for health professionals - both GPs and our specialist and social care colleagues - to be involved in the planning of services and in the allocation of contracts for these services [and] for doctors to work with managers to help implement, monitor and review these contracts and to encourage the development of new services as needs arise".

But she also voiced concern about how the plans will be implemented. “Depending on how the reforms are implemented, we must guard against fragmentation and unnecessary duplication within a health service that is run by a wide array of competing public, private and voluntary sector providers, that delivers less choice and fewer services, reduces integration between primary and secondary care and increases bureaucratic costs", Gerada warned.

The NHS Confederation also supports the objectives behind the legislation but warns "there are huge risks and major uncertainties associated with it". According to the group's chief executive, a key issue in the bill is accountability. "With central government loosening day-to-day control, we need to be sure who is going to get a grip when things go wrong," he stressed.

Others are even less enamoured with the government's vision. “Ploughing ahead with these changes as they stand, at such speed, at a time of huge financial pressures, and when NHS staff and experts have so many concerns, is a massive gamble," said Hamish Meldrum, Chairman of Council at the British Medical Association.

Bill critics

While supporting the greater involvement of clinicians in shaping NHS services, "the benefits that clinician-led commissioning can bring are threatened by other parts of the Bill, Meldrum said, warning that "the legislation will allow competition to be forced on commissioners, even when they believe the best and most appropriate services can be provided by local hospitals".

Eversheds noted that "given the existing clinical commitments of GPs, many consider it likely that few GPs will have time to be too involved in the commissioning functions, much of which will be carried out by specialists recruited from the PCTs or the private sector", and it said increased competition will allow the private sector "to step in to cherry pick and provide those services which they can do more cost effectively than the NHS". 

Writing for independent think tank Civitas, Sir David Varney, Gordon Brown's former head of public service transformation, noted that the White Paper behind the Bill fails to focus on the potential risks of the planned reforms create and how they might be addressed. "When all risks are placed together, I am left with the feeling that for the White Paper to deliver as promised would constitute something of a modern miracle," he noted.

And UNISON has described the Health Bill as a "disaster of Titanic proportions", and has called on the government to "heed warnings from healthcare professionals, MPs, staff, patients, charities, think-tanks and unions that the massive upheaval will destabilise the NHS".