The NHS under the coalition government: Part one: NHS reform

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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.


Misra Budhoo

Sandwell and West Birmingham NHS trust
Comment date
09 February 2015
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

Alasdair McEwan

Practice Manager,
Primary Care
Comment date
09 February 2015
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.

Paul McCrone

Professor of Health Economics,
King's College London
Comment date
09 February 2015
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.

Joan Smith

Carer for my husband John at home,
Comment date
11 April 2015
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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