The NHS under the coalition government

Part one: NHS reform
The 2010–15 parliament has been a parliament of two halves for the NHS. The first half was dominated by debate on the Health and Social Care Bill (which was largely designed to devolve decision-making, put GPs in control of commissioning, and extend competition and choice). The second half was taken up with limiting the damage caused by the Bill, with less emphasis on competition and greater efforts to strengthen the regulation and quality of care and prioritise patient safety.

Throughout the parliament, the NHS has come under pressure from constrained resources and rising demand for care, with an increasing number of providers falling into deficit and targets for patient care being missed.

This report covers six major themes of the coalition government’s reform programme: 

  • commissioning of care
  • provision of care
  • regulation of care
  • competition
  • governance and accountability
  • integration of care.

For each theme, it describes the situation the coalition government inherited when it came to power in 2010, the policies it has pursued, and (where available) evidence of their impact.

Key findings 

This report concludes that the:

  • coalition government’s reforms have resulted in greater marketisation of the NHS but that claims of mass privatisation are exaggerated
  • reforms have resulted in top-down reorganisation of the NHS and this has been distracting and damaging
  • new systems of governance and accountability resulting from the reforms are complex and confusing
  • absence of system leadership is increasingly problematic when the NHS needs to undertake major service changes
  • Care Act has created a legal framework for introducing a fairer system of funding of long-term care.

Policy implications

  • The next government should continue the emphasis on patient safety and quality of care but with less emphasis on regulation and more on supporting NHS leaders and staff to improve care. 
  • Further top-down reorganisations must be avoided, but evolutionary and bottom-up changes to the organisation of the NHS are needed to reduce the complexity and confusion of the structures introduced by the coalition government and to allow the implementation of the NHS five year forward view.
The NHS under the coalition government - Part one: NHS reform | by Chris Ham, Beccy Baird, Sarah Gregory, Joni Jabbal, Hugh Alderwick

Print copy: £10.00 | Buy

No. of pages: 83

ISBN: 978 1 909029 45 3

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#527456 Tony Davis
Patient Participation Group Corringham, a Essex.

I am looking forward to reading this report and to persuade my MP and others in our group to read. We do not have many more chances to correct the damage that has been done and to improve the NHS for patients. I will comment again once I have read the report. Thank you.

#527578 Kit Harbottle
Freelance thinker

The middle three bullet points above sum up the problems I have observed both as a citizen taking part in consultations and in professional contacts. The advantages of being user focused and working in a cross cutting way are known. Both commissioners and providers want to do this, but the system is more complex and unaccountable than I have seen in decades. Even the "informed" public get confused, so time at consultation events is spent in explanations rather than in shaping future services.

#528097 Phil Taylor

I can't see how you can do an honest review of the Coalition and fail to mention the £20 billion Nicholson Challenge that was kicked off in 2009 and confirmed on page 4:3 of the 2010 Labour manifesto.

Nicholson was built into the NHS before the election and the Coalition had little choice but to go with it.

The HCA savings were £4.5 billion in first five years and £1.5 billion thereafter. In the context of Nicholson's £20 billion savings and Stevens' £22 billion savings it's hard to know how you wouldn't take the HCA savings.

Big omission.

#528216 John appleby
Chief economist
The Kings fund

Phil, not forgotten, funding etc coming up in our election audit part 2.

#528311 maurice neville

I find the statements on privatisation in this report both complacent and misinformed. No-one has claimed that there has already been huge privatisation ... why the straw man ? There is abundant evidence of both an accelerating trend towards privatisation and an intent to privatise which is simply ignored. I would be interested for example in the author's response to a survey of GPs by Pulse magazine in which 86% consider the NHS will be fully privatised within ten years.

#529367 Eileen Morris
user of the Health Service

It does not fill me with confidence when from reading the 'bio' of those doing the report none of them appear to have had a real hands on job. Of course getting rid of a layer of administration would fill them with panic. Think getting rid of all that extra form filling and letting the Doctors get on with their job and helped by a good practice manager one ends up with an efficient Health Centre providing all sorts of services. The same applies to a Hospital. Of course they talk to each other and if more services are required then they provide them. Theory is all very well but it is not a substitute for the real thing.

#529527 Anton E Joseph
Retired Consultant Radiologist, Locum Consultant
St. George'd Hospital, now Mayday University Hospital

Andrew Labsley was deceptive right from the presentation of the 2012 Health Act. It is difficult to decide whether it was deception or downright ignorance of the 1999 Health Act when he wrote: "The NHS currently has no legal obligation to improve continuously the quality of care"1. This despite the definition of clinical governance based on the Duty of Quality laid down in the Act by which 'NHS organisations are accountable for continuously improving the quality of their services'. The similarity in the wording of his comments are so close to the wording in the definition of clinical governance that he could not have been ignorant of the existing requirements in law or he blindly put his name to an article written by another ignoramus.

#529557 Alison Powell

I find it very odd that p5 of the report states that "As partners in the coalition government, the Liberal Democrats’ main contribution was to reinforce concerns about Lansley’s reforms and to support Hunt’s damage limitation efforts".

As the "Never Again?" (2012) report published by the King's Fund clearly states, without Liberal Democrat votes the legislation would not have been passed at all. That is their much more significant contribution and one which many voters will never forgive or forget.

#529602 John Barnshaw
NHS Manager

It's now 2015, it's taken you this long to state the obvious ! A good report all the same but come on, almost every NHS worker could tell you that the reforms have been the worst ever and hugely damaging, and the signs came pretty early. It wasn't in the Tories manifesto, they even said no top-down reorganisation - demonstrating how trustworthy they are.

Just as a little evidence of the shambles, in my area two Chief Executives and two Directors of Finance were responsible for 6 PCTS. They were replaced with 5 Chief Operating Officers (same role as a Chief Exec but you can't call them that because you be guilty of constructive dismissal of the previous) and 5 Chief Finance Officers (same role as a Director of Finance but same as above). 4 people replaced by 10 on salaries not to far away from the PCT staff. Labours 'bloated bureaucracy' - my backside.

#529685 Michael Loyd
In this context KONP

An excellent survey of the disaster which has been the HSCA and its aftermath.You are right to point to marketisation rather than privatisation as the issue. It is a neo-liberal conceit that the market and transactional relationships are the only efficient form of socio-economic organisation. Moreover, pace Monitor competition and integration are antithetic.

#533326 Misra Budhoo
Sandwell and West Birmingham NHS trust

The previous government in effect made many significant changes in improving the NHS over the 10 yr plan and essentially built on the Tatcher regime of Marketisation although the was increasing recognition that this is managed market rather than open market. The expensive changes introduced were unnecessary and did little to improve care. emphasis in the later part of the Plan was already being focused on quality and safety once the resource issue was addressed. These changes were compounded by the downturn in world economies

#533490 Alasdair McEwan
Practice Manager
Primary Care

You have merely stated the obvious and what anyone working on the ground has known since this whole fiasco started-only you do not go far enough in your criticisms. I find it very hard to give the KF any credit for taking this position given that it is only a couple of years since you were so vociferously in support of the reforms. You have finally smelt the coffee beans pity it wasn't earlier.

#534052 Paul McCrone
Professor of Health Economics
King's College London

Very good report. However, the positive things said about more of a focus on care quality are all very well but surely such quality is totally compromised by so-called efficiency savings. There was no way the Trusts could accept the reduced tariff the other week and they quite rightly rejected it. Increasing waiting times etc seem indicative of falling quality.

#543487 Joan Smith
Carer for my husband John at home

Are you going to give older people the care that they really need at home, with out them picking up the tab? and stop the NHS from passing the butt?

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