The government's record on NHS reform: our verdict

As we head towards the general election, the government’s record on the NHS will come under intense scrutiny. The Fund’s assessment will be delivered in two parts: in March we will publish an analysis of how the NHS has performed since 2010, while today we launch a review of the government’s record on reform.

Our review of NHS reform argues that this has been a parliament of two halves. The first half was dominated by Andrew Lansley’s plans to extend competition and choice and to devolve decisions to GPs and frontline staff. The second half has seen the focus shift to patient safety and the quality of care as Jeremy Hunt responded to the Francis Inquiry report into Mid Staffordshire NHS Foundation Trust.

Debate on Lansley’s plans generated strong feelings on all sides, with critics claiming that the Health and Social Care Act 2012 would not only extend competition but also lead to much greater privatisation of provision. In fact, our assessment shows that the private provision of care to NHS patients has changed little with over 90 per cent of services still delivered by NHS providers.

Far more important have been the massive organisational changes resulting from the Act. These changes have created a system of considerable complexity and confused accountabilities. Reforms that were intended to simplify and streamline the organisation of the NHS have had the opposite effect and have resulted in a vacuum in system leadership at a local as well as national level.

The organisational changes contained in the Act have been both damaging and distracting. Damage is evident in the serious fragmentation of commissioning, the bewildering complexity of regulation (to use the words of the Berwick review into patient safety), and the loss of continuity as leaders have been replaced and organisations have been restructured. Distraction has resulted from a requirement to undertake fundamental restructuring when there ought to have been a focus on improving patient care and delivering greater efficiency at a time of constrained budgets.

Since his appointment in September 2012, Jeremy Hunt has turned away from the technocratic changes contained in Lansley’s Act by placing patient safety and quality of care at the heart of the NHS agenda. He has also worked with Norman Lamb to give greater emphasis to integrated care. Competition and choice have gone on the back burner to be replaced by regulation and transparent reporting of information as the means by which ministers have sought to improve performance. These developments are very much to be welcomed.

There have been other positive developments, including progress on integrated care, the establishment of health and wellbeing boards to link councils and clinical commissioning groups, and the provisions of the Care Act 2014, which are an important step towards the fairer system of funding long-term care called for by the Commission on the Future of Health and Social Care in England. In reality, most of these developments could have come about without the 2012 Act, and we shall never know how much more could have been achieved if ministers had opted for evolutionary rather than revolutionary reforms. What is not in doubt is that the government has had to use a lot of political capital to overcome opposition to the Lansley reforms and assure the public of is true intentions towards the NHS.

It is a tribute to the 1.4 million staff working in the NHS that, as the parliament nears its end, public satisfaction remains high and productivity has increased at a faster rate than in recent years. On the other hand, there is growing evidence of financial distress and widespread problems in delivering key targets. Our assessment of performance over the period since 2010 – published next month – will set out in detail what the balance sheet looks like to help inform debate on the public service that matters most to the public.

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Comments

#528089 Robert Park
Lay Member
Southwark CCG

As a former PCT NED, and now a CCG Lay Memebr, I could not agree more with your analysis of the Lansley reforms. The complexity of the current system is frightening, and I believe results in lack of transparency of accountability across all the different bits. However, one major benefit I have seen at first hand is the hugely increased clinical engagement and leadership shown at a local level by GPs through their CCGs, certainly in my part of London. Of particular note has been their commitment to improve the quality and consistency of care at a primary and community level, notwithstanding the fact that to date, CCGs have not been responsible for the main contracting of primary care services. It would have been interesting to have heard more about this aspect of the Lansley reforms in your overall report. Is my experience the exception or the rule across the country?

#528549 John Kapp

This was the greatest devolution of power since Magna Carta, with £65bnpa being devolved from the Health secretary to 30,000 GPs, who now get £2mpa each, or £8,000 per woking day, or £200 per patient contact. Theoretically they can give each patient the NICE recommended treatment they need. However, it is Hobson's choice of drugs or drugs, as talking therapies are only commissioned for 16% of the 31,000 depressed patients in Brighton, leaving 26,000 on just antidepressants, against NICE guidelines. The cause of the crisis is side effects which make patients keep coming back, clogging the suystem and burning out GPs. I have been campaigning for medication to meditation, by a licencing system of mindfulness facilitaters so that GPs can prescribe mindfulness courses as easily as Prozac, see papers on section 9 of www.reginaldkapp.org. My HWB authorised the director of public health to consider this solution, which I believe could transform mentalhealth outcomes and reduce inequalities.

#528585 James Fraser
Meditation teacher
Soul Meditation

Completely agree of course John - viable drug free alternative with real prospects of change and recovery, less substance abuse and depression, genuine chance of raising consciousness on the planet, better health, greater connectedness......obviously a terrible idea for public health and the NHS workforce. When I suggest this in Lancaster I cannot even get a phone call or email returned from my CCG, I can only conclude that there are forces at work that don't want people to get better. But that would be insane state of affairs.....

#529540 Giselle
Retired
User of National Health SERVICE for England (Only)

"Reforms that were intended to simplify and streamline the organisation of the NHS" - Kings Fund

Are you serious? I believe you must be one of the few who've been taken in by this - because it suits the agenda? There was never any intention, in my opinion, to simplify and streamline - the intention was to make it impossible to do such a thing so that the "marketisation" as you want to call it but "privatisation" as I prefer to call it could just continue until zero services were fully provided by the State Provider, the National Health SERVICE (that's a clue) (for England Only of course).
By the way, I live in Peterborough, Cambridgeshire where the privatisation by the Cambridgeshire people in charge over many years is vey well established - providing me with either little choice as a patient or zero choice. I don't want an NHS logo providing my healthcare, where it can be abused and mis-used, as it is currently, pretending that something is the NHS when it's not as it's usually a private corporate vulture. By the way, have you any idea how much the taxpayer is receiving for allowing the use of the NHS logo by these other "organisations"? I would have thought it would be worth multi-millions to the taxpayer!

#540391 Misra Budhoo
consultant surgeon
sandwell and west birmingham nhs

It's unlikely that any government set out to do anything but attempt to improve the NHS. Sadly over the decades this also included wanting to impose thier 'own brand' of improvement instead of step change. the NHS plan under labour was migrating towards both local devolvement as well as emphasis on clinical quality (something tatcher govt started in marketisation). RigThe imposed changes merely served to detract and waste billions in reorganisation.

Important that we move on and ensure that changes and improvements are independent of both political bias as well as parties wish to 'impose' or make their own mark. Incidentally whether or not we integrate or have managed market or managed market with integration is all likely irrelevant. What is important is change in culture to 'do the right thing' and bear in mind that quality is objective, subjective as well as carries a price....

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