2020 was the most difficult year in the NHS’s history. 2021—so far—is hardly better. But 2022 already looks more familiar: the NHS appears set for another major reorganisation.
Last week, a draft government white paper on planned NHS legislation—complete with helpful notes such as “[ADD FURTHER DETAIL LATER]”—was leaked online. The timing will feel odd to many, but the idea of reform hasn’t come out of nowhere. The leaked white paper follows a series of requests by national NHS leaders in England for changes to NHS structures and legislation—first in 2019, before the pandemic hit, then again in late 2020. The government’s full white paper on reform is due to be published imminently.
So why do government and national NHS leaders think changes to legislation are needed? Broadly speaking, there are two things going on here. One is a set of technical policy changes wanted by NHS leaders to encourage collaboration in the health system. The other is political changes proposed by government to increase ministerial control of the NHS. Both reflect familiar debates about how the NHS should be run—and both would dismantle major planks of Andrew Lansley’s controversial Health and Social Care Act 2012. It’s worth taking each in turn.
First—the more technical changes. For NHS leaders, the rationale is that legislation is needed to make it easier for NHS organisations to work together to improve local services. Although David Cameron had promised an already reform-weary health service an end to top-down reorganisation, Lansley’s 2012 Act—the last round of major NHS reform—sought to strengthen competition in the health system, and created a complex and fragmented NHS structure. The bill had a painful passage through parliament, compromising the blue-print, but nonetheless produced such big changes that—in the words of one former health service boss—you could “see them from space.”
Lansley’s reforms, however, didn’t turn out as he had hoped. As funding was squeezed, NHS leaders embraced collaboration over competition and created their own informal structures—which in current guise are called integrated care systems (ICSs)—to join up local services. But these partnerships have no formal powers, and collaboration can still be impeded by the competition rules in the 2012 Act.
That’s why NHS leaders want to reverse key elements of the 2012 Act—including removing requirements to competitively tender some NHS services, scrapping clinical commissioning groups, and formally establishing new area-based bodies to make decisions on local priorities and spending (which, for keen observers of NHS history, will look a little like the old strategic health authorities—or even the older area health authorities created in one of the early rounds of NHS reforms, way back in 1974).
Encouraging collaboration to improve services makes sense—and there is a need for legal changes to tidy the administrative mess left by Lansley’s Act. But the benefits of integrating services are perennially overstated. There are also risks. Merging and creating new agencies can cause major disruption. And however logical each round of organisational changes may seem, the cycle of NHS reform can drain staff energy and confidence. The proposals are also not clear on how ICSs will work in practice—just how much power will they have over hospitals, for instance?—and the role of local government in the new system proposed is poorly defined.
So what about the more political changes? Here the rationale for reform is less clear. The 2012 Act sought to reduce political interference in the day-to-day running of the NHS. Ministerial involvement didn’t disappear, of course—Jeremy Hunt, for instance, held Monday morning meetings on the detail of NHS performance—but NHS England, led by Simon Stevens, became the de-facto Headquarters for NHS strategy. And it seemed to work: the NHS gained a clear vision and enough independence to make the case for extra funding; and long-serving health secretary Jeremy Hunt claimed he never felt he “lacked a power to give direction” to the NHS when he needed to under the 2012 Act.
Matt Hancock must feel less powerful than his predecessor. The leaked white paper marks a shift back towards ministerial command and control of the NHS in England. The draft white paper includes a range of powers to strengthen the Secretary of State’s grip on the health care system—including powers to direct NHS England, rejig national NHS bodies, and intervene earlier in the “reconfiguration” of services.
The draft document seems to claim that the pandemic has illustrated the need for these changes. But evidence that stronger ministerial control would have boosted the NHS’s pandemic performance is hard to find. Do they really believe it? Another motivation may be to establish a narrative, ahead of any Covid-19 public inquiry, that arm’s-length bodies—not government—are to blame for England’s pandemic performance. Whatever the logic, the government should articulate much more clearly what concrete benefits we can expect from the changes. It should also explain why much needed reforms to adult social care in England appear to be being ducked yet again.
The challenges facing the NHS and its patients over the rest of the parliament are enormous. In the short term, hospitals remain under major pressure and primary care is racing to vaccinate the population against Covid-19. When these pressures ease, the NHS must address the vast backlog of unmet health care needs, fix chronic workforce shortages, and tackle health inequalities that the pandemic has only worsened. Will a reorganisation really help to meet these challenges? Let’s hope so. But evidence from past reforms is not promising. And the risk is that major reorganisation destabilises services and diverts time and resources away from what matters.
