Politicians should avoid the temptation of another NHS top-down re-organisation

Most commentators think a general election is not far off. Whether the current incumbent returns or there is someone new in the hot seat that is the Secretary of State for Health and Social Care, there will be no shortage of complex and urgent issues to occupy their attention, whether it’s overcoming deep and pervasive workforce shortages or grasping the nettle of social care funding and reform.

If the Secretary of State and the government wish to make progress at pace in confronting these and other challenges, one thing they will need to avoid is the self-inflicted wound of a new round of wholesale NHS re-organisation. If the NHS England proposals noted in today’s Queen’s Speech translate into manifesto commitments, this suggests the current party of government may have learnt from experience that it is best to be cautious with far-reaching structural changes. Meanwhile Labour and the Liberal Democrats are both currently proposing (different) large-scale reforms to NHS structures. Labour intend to repeal the 2012 Health and Social Care Act, which, given it is not possible to turn back the clock in any simple or straightforward manner, will mean a wholesale re-organisation. The Liberal Democrats are scarcely less radical, proposing to pass the commissioning carried out by clinical commissioning groups (CCGs) over to local authorities and to generally strengthen the hand of local democracy.

'If the Secretary of State and the government wish to make progress at pace in confronting these and other challenges, one thing they will need to avoid is the self-inflicted wound of a new round of wholescale NHS re-organisation.'

Let’s recap the history. The last (and possibly largest) set of organisational reforms came from the coalition’s 2012 Health and Social Care Act. In 2015 The King’s Fund concluded on these changes that, they were ‘distracting and damaging’. From the perspective of 2019, the verdict would only be worse as we might add the phrase ‘pointless’, given the world of competition that was enshrined has been abandoned. Instead, co-operation and integration have become the strategic direction for health and care. A direction driven by the underlying needs of the population, and one common to many other countries too.

Major changes will eat up legislative time. Leaders’ minds (whether political, national or local) will turn to closing old organisations, opening new ones and re-establishing governance and accountability frameworks. Then there’s the great pain of redundancy, appointing swathes of staff to new roles, the intricacies of the Transfer of Undertakings (Protection of Employment) regulations (TUPE), and the anxiety all this inflicts on staff. This also risks pitting the government against the NHS just when clear and common purpose is needed. Political leaders must be overwhelmingly confident that they have the right and enduring ‘answer’ to the question of the best organisational structure for the NHS, and also be just as confident that ‘right now’ is the time to launch it.

Some legislative changes need to be made, and these are better made sooner rather than later in order to accelerate the integration agenda that all parties support. Ending forced competitive procurements and removing some of the blockages that make it harder for NHS providers and commissioners to work together are two of them. NHS England also has a longer list developed in conjunction with the NHS and key partners (including us). Taken together these changes will alter the way the system works, rather than uprooting the system itself. This is not to dismiss understandable concerns around emerging non-statutory bodies who seem to be making decisions outside of a clear and transparent system of governance (nor indeed the rising tide of mergers among CCGs). Many also agree that the 2012 Act (and its predecessors) does not form a lasting legislative basis for an integrated health and care system. The problem is that it is not yet clear exactly what does. Any attempt to clarify now the future statutory model for providers, commissioners, integrated care systems or, indeed, primary care networks risks getting it wrong: this is still work in progress across the NHS and no obvious blueprint yet exists. The emphasis here, though, is on the ‘yet’.

'It is unwise to begin a re-fit of the NHS ocean liner in the midst of a hurricane.'

There is also, unfortunately, good reason to fear that large scale re-organisation in 2020 could be more damaging than in 2012. At the end of 2019 the NHS is showing signs of the strain of a decade of austerity, whether in workforce or in performance. By contrast in 2012 the system still had depths of resilience: NHS providers had just clocked up surpluses of over £500 million, performance against the 4-hour accident and emergency target was still over 97 per cent, the 18-weeks waiting standard was safely in target and waiting lists were stable. It is unwise to begin a re-fit of the NHS ocean liner in the midst of a hurricane.

Looking outside the NHS there is a pressing need for major legislative change: reform of social care funding should surely sit close to the top of the agenda for any government seriously tackling the problems of the day. Early, major NHS legislative reform is not only a risk to the NHS itself – it also risks gobbling up the political capital and energy that will be needed for this and other key areas of domestic reform.