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On the day the abolition of NHS England was announced, I had a message from a colleague who doesn’t work in health: ‘What does this mean for patient care? What impact will it have on the front line?’ My answer reflected my experience of working in health at the time NHS England was created (or the NHS Commissioning Board as it was then), as part of the Lansley reforms. I replied with version of ‘not much immediately, but wait and see.’
As others have written about, the near constant re-organisation of the NHS is a peculiarly English affliction. Our international counterparts don’t do this, or at least not as frequently. Other public services don’t suffer quite the same fate, see education, policing etc. And yet we constantly reach for the lever of restructure over other approaches. But there is no strong evidence it improves health outcomes, and there is a significant opportunity cost. In opposition, Labour said they wouldn’t overhaul our health structures for these reasons, but here we are again. An NHS Modernisation Bill that seeks to put on a legal footing the biggest re-organisation of the NHS in over a decade.
So will it make any difference, and how will we judge it? I have five tests for the Bill.
1. Can it make a difference to patient care?
The most important question. Much of the Bill is concerned with the legal necessities of abolishing NHS England, integrating several functions back into the Department alongside other structural changes, for example to the composition of integrated care boards (ICBs). But the provision to create a single patient record could have a significant and positive impact on patient care.
Both staff and patients reflect ongoing frustrations that records are often fragmented. Patients are constantly required to retell their stories and repeat tests in different care settings. Some places, like Greater Manchester, are further ahead in creating shared care records but the move, at national level, to accelerate the sharing of data across health and social care could make a big difference to how people experience services, and for research to improve health and care.
The government believes that by putting single patient record clauses on the face of the Bill, they will win the argument, in parliament, that the benefits outweigh the privacy risks of a single record. The real test therefore is whether these provisions can be retained in the wake of opposition and successfully implemented in practice.
2. Will it reduce bureaucracy?
The government’s rationale for pulling NHS England functions back into the Department of Health and Social Care and abolishing a number of other arm’s-length bodies is that the health system has become bloated and hard to navigate. There are too many bodies with overlapping responsibilities. Local health systems are bombarded with directives and are servicing ‘two centres’ in NHS England and the Department.
It’s true there is some duplication and staff numbers have grown. The changes could help simplify the landscape but the claim that 50% of staff nationally will be cut and £1 billion saved by the end of this parliament remains to be seen. And the tendency to issue directives from the centre is deeply ingrained and politically attractive (to show you are doing something). Tackling this is as much about behaviours, culture and a genuinely different kind of leadership. Can successive politicians embrace this approach?
3. Will it boost patient voice?
Handing power to patients has been a central ambition of this government’s policy-making. The decision to abolish Healthwatch England and local Healthwatches can therefore be read two ways. On the one hand the government argues that the proposals simplify the patient voice landscape and bring the responsibility for listening to (and acting on) concerns raised by patients closer to decision-makers. You wouldn’t devolve your customer services department to an arm’s length bolt on in any major business, the argument goes, you’d want it at the top table.
On the other hand, Healthwatch England and their local branches have played an important role in listening to communities that don’t always have a hotline to NHS HQ. They have used their independence to raise issues that were not high enough on the to-do list of decision-makers, dentistry and NHS admin being good examples. With the proposed model, what’s the assurance that the NHS will listen and act on things it may not be looking out for, or wish to hear? The test is whether the newly created Patient Experience Directorate, and reimagined local patient voice network, can do the job of acting on what they hear, and make space for unsolicited feedback too.
4. Will it improve patient safety?
We are stuck in a vicious circle of investigating awful cases of patient harm or system failure, making numerous recommendations to improve safety and swiftly repeating the same mistakes. So I have sympathy with the intention to reduce duplication. The proposal to give CQC longer to bring legal action against a provider is sensible.
However, moving the Health Services Safety and Investigations Body (HSSIB) is complex. HSSIB has worked hard to win the trust of patients and staff in learning lessons of safety failures. It holds information confidentially and doesn’t penalise NHS organisations. This will be put at risk if folded into the regulator with a different remit and reputation. And again, improving patient safety is at least as much about supporting the right kind of leaders and a culture where staff feel it is safe to speak up, and quality is prized above other things, as getting the right organisational design.
5. Will it stabilise (rather than destabilise) the NHS?
The Bill gives the Secretary of State more direct powers over the running of the health service, because there isn’t an operationally independent NHS England. The official line is that similar checks and balances remain, and we are simply reverting to a pre Lansley era. But this will need to be tested as the legislation is scrutinised. The risk is an interventionist health chief could de-stabilise an already jaded workforce with a slew of new directives and politically charged appointments.
The Bill also introduces more complexity. The centre will argue this reflects the messy reality of change and gets the system away from a cookie-cutter approach, but it means we will have a more varied health system, with integrated care organisations, advanced foundation trusts and a stronger role for mayors. Will this improve democratic accountability by making the system more responsive to local needs, and give greater financial control to high performing organisations? Previous experience in England and internationally suggest integrated care organisations and foundation trusts aren’t a silver bullet to transforming health outcomes.
What's not in the Bill
This isn’t so much a test as a reflection of all that’s not covered. No mention of public health or reforming social care. You can do a lot without legislation of course, but if the government is serious about its prevention revolution, it could take bolder legislative action to tackle alcohol misuse, address obesity, secure cleaner air. And the lack of meaningful mentions of adult social care in the government’s legislative agenda is an all-too-familiar reminder of where it sits in the government’s overall plans. There is still a real risk that, even if the Casey Commission delivers robust proposals, they cannot be delivered until the 2030s. That is too long for the people who rely on care and support to wait.
Much of the work to improve the nation’s health and NHS performance has nothing to do with legislation. My hope is this Bill doesn’t detract from that.
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