NHS reforms: who's for and who's against?

The government's plans to reshape the NHS in England have provoked opposition among a variety of health organisations and unions.

An NHS sign in LondonYui Mok, PA Archive

The proposals, contained within the health and social welfare bill that is currently being debated in parliament, would see greater involvement by the private and voluntary sector in the NHS.

It would also encourage more competition between hospitals and introduce clinically-led commissioning - groups of local GPs deciding their own budgets and resources.

David Cameron hosted a "NHS summit" at Downing Street on 20 February to promote the legislation, but was criticised for only inviting people representing groups who were known to be supporting the bill.

Here's a guide to which professional health organisations are supporting or opposing the proposals, plus those who have yet to declare a view for or against.

Against the bill

  • The Royal College of GPs

This is the largest professional body of GPs in the UK. It has 44,000 members, and is responsible for promoting clinical excellence in primary care.

On 3 February it announced it was calling for David Cameron to withdraw the health bill. The college's chair, Dr Clare Gerada, said: "We have taken every opportunity to negotiate changes for the good of our patients and for the continued stability of the NHS, yet while the government has claimed that it has made widespread concessions, our view is that the amendments have created greater confusion. We remain unconvinced that the bill will improve the care and services we provide to our patients. Competition, and the opening up our of health service to any qualified providers will lead not only to fragmentation of care, but also potentially to a 'two tier' system with access to care defined by a patient's ability to pay."

The college issued a statement expressing its disappointment not to have been asked to the summit on 20 February. Dr Gerada also resorted to asking on Twitter whether any doctors had been invited.

  • The Royal College of Radiologists

This college has around 8,900 members and fellows worldwide, and represents the disciplines of clinical oncology and radiology. All members are registered medical or dental practitioners.

The college reaffirmed its opposition to the bill on 27 January. It stated it had "grave concerns" over several areas of the legislation, and stated the need for there to be: "...an overriding duty on the secretary of state to ensure that a high quality and integrated health service is delivered in the best interest of patients. There is a potential for widespread and potentially embedded health inequalities across the NHS." It also warned that: "The NHS will lose its state provider status and in doing so open services to EU competition law, which would have serious implicatiosn on the provision of patient care."

  • The Faculty of Public Health

This is the standard-setting body for public health in the UK, and boasts more than 3,000 specialist public health members.

On 8 February its president, Professor Lindsey Davies, called for the bill to be dropped. He stated: "Based on our members' expert views, it has become increasingly clear that the bill will lead to a disorganised NHS with increased health inequalities, more bureaucracy and wasted public funds. The bill will increase health inequalities because there is the real danger that vulnerable groups like homeless people will not be included when health services are being planned. Clinical commissioning groups and service providers will be able to pick and choose what procedures they perform and which services they put in place."

  • The Royal College of Midwives

This is the UK's only trade union led by midwives for midwives and those that support them. The vast majority of the midwifery profession are members.

On 17 February Louise Silverton, deputy general secretary of the college, urged for the bill to be scrapped, saying: "The Royal College of Midwives remains opposed to the government's health bill and believes the best thing for the NHS, for the people who use it and for the government would be for the bill to be dropped, with immediate effect. If it goes ahead, there is a very real danger that NHS will simply become a franchise with services being provided by a plethora of private companies with an eye on the bottom line and their shareholders."

  • The Royal College of Nursing

This college represents nurses and nursing, and seeks to promote excellence in practice and shape health policies.

In its most recent press statement on the bill, the college stated: "We still feel the reforms are creating such turmoil that they must be stopped. In particular, the amendments do not fully address the key areas of competition, nurse involvement, the private income cap and health inequalities. The bill continues to damage the NHS as we know it and combined with the need to save £20 billion in England by 2014, we fear that the health service is facing an extremely difficult future."

Dr Peter Carter, the head of the Royal College of Nursing had this to say on not being asked to attend David Cameron's NHS summit: "We don't know why we haven't been invited but we, like others, find it extraordinary because at the end of the day, it is nurses, doctors, physios, GPs that actually keep the health service going."

  • The British Medical Association

This is an independent trade union representing doctors in all branches of medicine across the UK. It boasts over two-thirds of practising UK doctors as members.

The chairman, Dr Hamish Meldrum, expressed the BMA's opposition to the bill on 3 February: "Whilst GPs and other clinicians support the concept of clinically-led commissioning, they do not believe that this expensive upheaval of the health service is needed to achieve that. If the prime minister really wants to put clinicians in control he should listen to what they are saying - louder and louder each day - and put this increasingly confused legislation out of its misery."

  • Unite

Britain's biggest trade union has 1.5 million members in every type of workplace.

Len McCluskey, general secretary of Unite, said on 20 February: "David Cameron is haemorrhaging trust over the health bill with public disquiet growing each day the government fights to keep the risk register secret. People have a right to know what damage these so called reforms will do to their NHS. The government's secrecy begs the question of who comes first; the people who pay for and use the NHS, or corporate consultants like McKinsey who drafted the bill and stand to make money from Cameron's privatisation plan? David Cameron and Andrew Lansley need to come clean, get in step with public opinion and drop this unnecessary and damaging bill."

  • Unison

This is the UK's biggest public sector trade union with more than 1.3 million members, of which nearly half a million are health workers.

On not being invited to David Cameron's NHS summit, Sara Gorton, Unison senior national officer for health, said:

"Health workers should have their voices heard when major changes to the health service are being discussed. Clearly, Unison has not been invited because David Cameron and Andrew Lansley do not want to hear what we've got to say. But they need to face up to the truth that the bill is damaging for patients and for the NHS. Excluding our voices will not shut us up. Unison will continue to call for this flawed and dangerous bill to be dropped, and for the government to come clean about the risks it poses to patients and to the cost of NHS care."

  • The Royal College of Psychiatrists

This is the professional and educational body for psychiatrists in the United Kingdom, and helps set standards and promote excellence in psychiatry and mental healthcare.

In its latest statement on its opposition to the bill, dated 1 February, the college stated it believed that "...the bill is fundamentally flawed and will not improve the health and care of people with mental illness. The college is therefore not able to support the bill as it currently stands."

The college's president, Professor Sue Bailey, was quoted as saying: "We believe that it is wrong for the government to continue without making the significant changes that we and other medical professionals have been calling for over many months. These include ensuring competition is only used in the NHS where it can be shown to clearly benefit patients; that integrated care is safeguarded over competition; a reduction rather than an increase in health inequalities; and flexibility for clinicians to undertake work for the benefit of the wider NHS."

  • The Chartered Society of Physiotherapy

This is the trade union body for the UK's chartered physiotherapists, physiotherapy assistants and students.

On 3 February the chair of the society's council, Dr Helena Johnson, said: "Together with many other health professionals, we have tried to engage constructively and make sensible suggestions throughout the bill's passage through parliament. But time and time again, the views of patients and health professionals have been ignored. The government seems determined to press ahead with these reforms. The bill threatens the very future of the health service and will significantly damage the quality of patient care."

  • The Royal College of Paediatrics and Child Health

This college is the latest to come out against to the bill. In a survey of members, 79% of respondents voted for the college to call for the "outright withdrawal" of the bill rather than continue to push for amendments.

The college's president, Professor Terence Stephenson, said on 23 February: "At the NHS summit which I attended earlier this week, the prime minister made it clear that the government will press ahead with the bill. Yet pushing the bill through is creating disaffection amongst the very people - the clinicians - who will be delivering these changes on the ground when the reality is that there are areas of reform where the healthcare profession are in agreement, most obviously the principle of clinically led commissioning and improving how services are delivered.

"All those representing healthcare professionals need to be brought together to thrash out how these areas of consensus can be effectively put into practice."

Organisations with concerns but yet to declare for or against

  • The Royal College of Pathologists

This college aims to advance the science and practice of pathology. It has over 10,000 members working in hospital laboratories, universities and industry worldwide.

Its president, Archie Prentice, recently wrote to members to say its governing council had decided to not ask for a complete withdrawal of the bill. But rather than asking for "...a survey of views on the narrow issue of straight opposition to the whole bill," it ought to continue to work to make more changes to the legislation: "[We feel] that this bill will be passed and that there is still time to get further amendments accepted."

  • The Royal College of Ophthalmologists

This college promotes excellence in the practice of ophthalmology for the benefit of patients and the public, and sets the examinations and the curriculum for medical graduates who wish to be eye surgeons.

In a statement dated 8 February, the college president Professor Harminder S Dua stated: "This bill promises to put patients at the centre of an NHS led by healthcare professionals and we welcome this approach. However, there are many serious concerns that need to be addressed if the bill is to deliver what it promises. The key areas for concern and risk are: unhealthy and unfair competition; conflicts of interest of key stakeholders; compromised education and training of future generations of doctors; fragmentation of care; a shift from patient-centred to organ-centred care; inequalities in health care."

The professor added that: "Whether the bill should be passed or abandoned is a political decision for the government. As a college we assure the public and the government that we will continue to work to ensure that the best interests of our patients are served, whatever the circumstances."

  • The Faculty of Occupational Medicine

This is the body which sets standards and certifies occupational medicine training in the UK.

In a statement dated 15 February the faculty said it: "...continues to voice concerns about [the bill] and to work with the Academy of Medical Royal Colleges to seek changes as the bill goes through the Report stage in the House of Lords. The President, Dr Olivia Carlton, has been engaged with meetings of the Academy and with other professional groups. The key concerns which the Academy continues to highlight to government are the threat to integrated patient care, the importance of the Secretary of State's responsibility to provide health care for all and the need to maintain education and training as part of a comprehensive health service."

Organisations broadly in favour but with some reservations

  • NHS Confederation

This is an organisation that seeks to speak on behalf of all organisations that commission and provide NHS services.

In a recent statement, the NHS Confederation said its members: "...support the government's objectives.
Empowering patients is clearly the right thing to do. We see real potential benefits in involving clinicians more closely in decisions about both the design of care and management of resources. We also see benefits in extending the range of providers in order to drive quality, efficiency and innovation... However, after analysing the proposed new system, the NHS Confederation has identified some significant risks, worrying uncertainties and unexploited opportunities."

  • The Foundation Trust Network

This organisation exists to promote NHS foundation trusts and to support those applying for FT status.

It attended David Cameron's NHS summit, and afterwards issued a statement saying: "FTN members support those parts of the bill that will mean better services and outcome for patients... but warned the prime minister at today's meeting that unless public providers of NHS services have the flexibility they need to manage risks inherent in a system in flux, they will be 'sitting ducks' for failure."

Sue Slipman, chief executive of the FTN said:

"The worst outcome for patients would be if the service is left in 'no man's land' with current arrangements crumbling, and without workable new arrangements in place. The burden of risk during a period of transition will fall on providers that are already grappling with higher than expected savings targets. So, we call for speedy implementation of the changes. FTN members have a continuing and unwavering commitment to do everything they can to make the new arrangements work for patients and service users."

  • The Royal College of Physicians

This college is a professional body of doctors dating back to 1518.

Its president, Sir Richard Thompson, issued a statement after attending the NHS summit: "Our position remains the same as the day the initial white paper was published. The RCP is neither for the bill, nor against the bill. From the outset we have lobbied hard, with some key successes, on the issues where we felt change was necessary, and shall continue to work with all politicians and stakeholders to ensure that the legislation is the best it possibly can be to improve healthcare for patients." Fellows of the college will debate the bill on 27 February.

  • The Royal College of Anaesthetists

This college is the professional body responsible for ensuring the quality of patient care through the maintenance of standards in anaesthesia, critical care and pain medicine.

It attended David Cameron's NHS summit, noting that: "The bill is complicated and has parts we can approve and parts we have concerns about.

"The college believes that unfettered competition is likely to harm the provision of comprehensive integrated care, affect clinically indicated changes to service provision, widen health inequalities and may impact adversely on the education and training of tomorrows doctors. The proposed changes are likely to be costly and will distract the NHS from meeting the proposed quality improvements for patients."

  • The Royal College of Obstetricians and Gynaecologists

This college encourages the study and advancement of the science and practice of obstetrics and gynaecology.

It is holding a special general meeting on 9 March to decide whether to call for the withdrawal of the bill. In an open letter to members dated 14 February, the president Dr Tony Falconer and the chief executive Ian Wylie noted that: "Many responses [from members] have supported the position of "critical engagement" [with the bill]; a significant number have asked that council now distances the college from this legislation by calling for the bill's withdrawal.

"This college still has significant concerns about parts of the biill but by not calling for its complete withdrawal, we have been able to continue to meet to discuss our concerns with ministers and with the help of our supporters in the House of Lords, we have tabled amendments in the House of Lords, where changes to this legislation continue to be accepted by the government. Were we to call for the bill to be abandoned, your college could play no further part in improving legislation, as is now the case for those who have come out against the bill."

  • The Royal College of Surgeons

This college is committed to enabling surgeons to achieve and maintain the highest standards of surgical practice and patient care.

It issued a statement after attending the NHS summit: "The college is not a political organisation but we believe that it is in the best interest of patients to critically engage in debate on the bill as there are still significant areas of concern within the profession. We felt we could best represent the views of our members by attending the meeting and briefing the prime minister directly about these issues."

Professor Norman Williams, the president of the Royal College of Surgeons, added: "The Royal College of Surgeons outlined its concerns about the bill during a meeting with the prime minister. We reiterated that the priority must be improving outcomes for patients by modernising the healthcare system, cutting bureaucracy and giving patients and their clinicians the right to decide."

A special general meeting is taking place on 8 March for all members to debate the bill.

In favour of the bill

  • National Association of Primary Care

This is a non-political organisation supporting those involved in primary care within the NHS. It is a leading voice supporting greater clinical commissioning (GPs setting their own budgets), which is a key element of the government's health bill.

Dr Charles Alessi, the organisation's chairman, attended the NHS summit in Downing Street. "The mood of the meeting was extremely positive and both David Cameron and Andrew Lansley were very upbeat in their reassurances that clinical commissioning would become a reality in the near future," he said afterwards. "It was also very encouraging to learn of the improvements already taking place through clinical commissioning, including the drop in the number of emergency admissions to hospital in the last year. This is particularly encouraging, given the political environment, in which they have taken place over that period, and this is just the tip of the iceberg, in terms of what is both possible and necessary."

  • NHS Alliance

This is another independent organisation that supports and promotes clinically-led commissioning.

Its chair, Dr Michael Dixon, has spoken of his fear that the finished bill won't go far enough in encouraging competition and GP-led commissioning in the NHS.

"To be frank, I was close to depression before Christmas because it seemed like there was no way out of the past," he said. "Even if the legislation went through, we would be back to square one. There is a very real danger that [the new] clinical commissioning groups will be wrongfooted and all the forces that have managed to keep clinical commissioning out for the last 15 years will succeed."

  • Association of Chief Executives of Voluntary Organisations

This is an organisation that helps to support, connect and represent voluntary bodies across the UK. It has nearly 2,000 members.

Its chief executive Stephen Bubb is a keen supporter of the bill, in particular of extending competition in the NHS in order to drive up standards and reduce costs.

Last year he said: "Charities and social enterprises play a hugely important role in delivering high-quality, efficient NHS services, and a policy of enabling whoever is best-placed to deliver could see them do more, to the immense benefit of NHS patients and taxpayers. We need to seize that opportunity, and leave debates about privatisation where they belong - in the last century."