It is difficult to gauge what effects the Health and Social Care Act will have, and potential gains are mostly unreliable

• Don Redding
• Guardian Professional, Tuesday 3 April 2012 09.00 BST

It is difficult to predict what effect the new Health and Social Care Act will have on patients, service users and carers. The bill was like a giant treatment decision, with the benefits uncertain and the risks considerable.

National Voices, a coalition of health and social care charities, has found it impossible, during the last year, to gauge accurately how the act’s provisions would affect direct patient care and treatment. Hence there could be no simple “for or against” position on the bill – but there was a lot of pushing to improve it.

Among members of National Voices, the strongest concerns have been that: localisation will exacerbate inequalities and social exclusion; gains from successful national strategies and frameworks will be at risk; and the needs of patients with less common conditions will not be identified and responded to by GP commissioners with low awareness.

Perhaps the biggest worry, though, is whether in a localised system, new national action can be planned to ramp up areas of poor or patchy care, like mental health, neurological or diabetes care and treatment, or to provide better deals for children and for older people with long-term conditions.

Patient groups looking to secure improved quality through the new system find it complex and confusing and are now unsure where and when they can influence provision; and where the biggest risks lie. For this reason it would be valuable for patients, service users and carers to see the Department of Health’s risk register, so as to consider what role they can play in risk mitigation.

Because the act rewires structures and concentrates on commissioning, it does little that directly addresses the provision of care. Where it does touch patients closest, there are potential gains for our care and treatment, though none of these are reliable.

For example, specialised services, sometimes neglected by primary care trusts, now consolidate under the NHS commissioning board, which will have to demonstrate excellence. But we must wait to see whether care for patients with less common conditions joins up the local and the specialised.

The influence of Nice guidelines and standards is potentially stronger; but balanced by discretion for local commissioners to ration treatments.

There is logic to GPs holding budgets for the registered patient population; but are they any better equipped than PCTs to deliver ambitious redesigns that get care to the right place at the right time?

During the bill’s passage, the government listened to campaigns by National Voices and its allies, and greatly improved the act’s provisions.

The top request of our members was for integration of healthcare and social care. This was made a duty of all the new organisations, but could still be in jeopardy.

A good start was made when the chief executive of the NHS commissioning board endorsed National Voices’ patient-centred principles for integrated care. We hope to see the social care white paper reflect similar principles. But we know we will have to continue fighting for these approaches to offset the tendency to fragmentation.

When we pressed the government for clearer action on the vision of “no decision about us, without us”, it responded by instituting proper governance of clinical commissioning groups, including lay members to champion patient interests, and strengthened NHS transparency and accountability, for example by insisting all NHS boards meet publicly.

On the other hand, the arrangements for HealthWatch, locally and nationally, fall far short of creating the “powerful and effective new consumer voice” that was promised.

One of the least-noticed but potentially most powerful changes, after further campaigning by National Voices and the Health Foundation, was to clarify the duty of commissioners to ensure that individually patients are involved in decisions about their care and treatment.

If the now mandatory guidance from the commissioning board reflects the strong evidence base for patient education, support to self-management, participation in treatment decisions and personalised care planning, and if this is followed by commissioners leveraging a different culture of care from their providers, it is here that the greatest gains for patients could be achieved.

Commissioners need to understand that this granular engagement results in better patient experience, better results, and better use of healthcare resources, and is therefore a foundation stone for achieving other duties towards quality improvement.

Don Redding is director of policy for National Voices

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