Charting a new course for the NHS

At a time when the NHS is liv­ing through the most seri­ous chal­lenge in its his­to­ry, along comes the biggest shake-up of the health ser­vice in more than a decade. The government’s Inte­gra­tion and Inno­va­tion white paper, pub­lished in Feb­ru­ary, is the first seri­ous attempt to unwind the reforms of the 2012 Health and Social Care Act, which was mar­shalled by the then health sec­re­tary Andrew Lans­ley.  

The pro­pos­als have pro­voked fierce debate about the future of the NHS and the best way for­ward. How­ev­er, there is almost uni­ver­sal agree­ment that the Lans­ley reforms were a cost­ly mis­take, bring­ing dis­ag­gre­gat­ed lead­er­ship and the chaos of com­pe­ti­tion. Roy Lil­ley, health pol­i­cy ana­lyst and for­mer chair­man of an NHS trust, described the white paper as a “40-page Tory apol­o­gy to the NHS for screw­ing it up”. 

As for the tim­ing, the BMA med­ical union said the pro­posed reor­gan­i­sa­tion must not be rushed through at a time when staff are “phys­i­cal­ly and emo­tion­al­ly exhaust­ed”, with the NHS still under enor­mous pres­sure in the fight against COVID-19. 

Chaand Nag­paul, BMA coun­cil chair, says the NHS is fac­ing the great­est back­log of care. Deal­ing with this would require “sig­nif­i­cant new resources and an imme­di­ate action plan” and invest­ment must not be divert­ed to the reor­gan­i­sa­tion, he says. The counter-argu­ment is that the pan­dem­ic forced health and care ser­vices to do things dif­fer­ent­ly and now is the time to build on what worked well. 

So, what is the reor­gan­i­sa­tion all about? Media cov­er­age has main­ly focused on new pow­ers giv­en to the sec­re­tary of state for health and care over the NHS. It would allow him or her to inter­vene in any ser­vice recon­fig­u­ra­tion with­out need for a refer­ral from a local author­i­ty. The depart­ment of health and social care would also be able to recon­fig­ure and trans­fer the func­tions of arm’s‑length bod­ies such as the Care Qual­i­ty Com­mis­sion and the Nation­al Insti­tute for Health and Care Excel­lence, includ­ing clos­ing them down, with­out pri­ma­ry leg­is­la­tion.

Some have seen this as an attempt by the gov­ern­ment to seize back some of the pow­ers that, in the­o­ry, were devolved to NHS Eng­land under the Lans­ley reforms. The NHS Con­fed­er­a­tion says these new pow­ers of inter­ven­tion are “an area of con­cern”. How­ev­er, the real­i­ty is it is hard to see how the reor­gan­i­sa­tion gives addi­tion­al pow­ers to min­is­ters to do things they can’t already do. 

The pan­dem­ic pro­vides a num­ber of exam­ples of gov­ern­ment tak­ing the lead, among them the Nightin­gale hos­pi­tals, the shake-up of Pub­lic Health Eng­land and per­son­al pro­tec­tive equip­ment pro­cure­ment. In any case, tax­pay­ers prob­a­bly expect the gov­ern­ment to hold the keys to an organ­i­sa­tion that spends more than £100 bil­lion of our mon­ey every year. 

From the point of view of patients, the most impor­tant change tak­ing place across the NHS is the shift away from the old leg­isla­tive mod­el of com­pe­ti­tion between health care organ­i­sa­tions towards a new mod­el of col­lab­o­ra­tion, part­ner­ship and inte­gra­tion. Over the past three years, the NHS has been cre­at­ing what are known as inte­grat­ed care sys­tems (ICSs) across Eng­land. This is where the NHS, local coun­cils and vol­un­tary organ­i­sa­tions come togeth­er at a local lev­el to design and pro­vide ser­vices to meet local needs. 

The ambi­tion for the fledg­ling ICSs is to pro­vide joined-up care for patients. An exam­ple is when elder­ly patients are dis­charged from hos­pi­tal. In sim­ple terms, at this point they cease to be the respon­si­bil­i­ty of the NHS hos­pi­tal trust and the local author­i­ty takes over, arrang­ing and pay­ing for domi­cil­iary care or a care home. 

At present, many peo­ple are stuck need­less­ly in hos­pi­tal because this process breaks down. The role of the ICS is to ensure this process takes place seam­less­ly. Each sys­tem is giv­en the free­dom to remove any bar­ri­ers that block col­lab­o­ra­tion in local com­mu­ni­ties. The mes­sage is: if you think this is what needs to be done, go do it. 

Bridg­ing the gap between health and social care has been a pipe dream for many years and numer­ous ear­li­er attempts have failed. Per­haps there are bet­ter grounds for opti­mism this time because the lat­est blue­print does not rely on a Big Bang reor­gan­i­sa­tion, with thou­sands of peo­ple mov­ing from one organ­i­sa­tion to anoth­er. ICSs have qui­et­ly been find­ing out what works best in local com­mu­ni­ties and form­ing myr­i­ad part­ner­ships with dif­fer­ent organ­i­sa­tions for dif­fer­ent tasks. The white paper pro­pos­es putting them on a statu­to­ry foot­ing, which is nec­es­sary in terms of cor­po­rate gov­er­nance and pub­lic account­abil­i­ty. 

Anoth­er sig­nif­i­cant change con­cerns pro­cure­ment. The white paper aims to remove, or at least blunt, the need for a com­pet­i­tive mar­ket in health pro­cure­ment, some­thing which was at the heart of the Lans­ley reforms. Com­pul­so­ry ten­der­ing of clin­i­cal ser­vices is abol­ished, leav­ing NHS organ­i­sa­tions free to com­mis­sion ser­vices they agree will work best for their patients in their local com­mu­ni­ties. This is seen as crit­i­cal to the suc­cess of the ICSs, whose lead­ers want to strength­en local ser­vices with­out the require­ment to embark on a lengthy and cost­ly nation­al pro­cure­ment process. 

Richard Mur­ray, chief exec­u­tive of The King’s Fund, the health and care think tank, says: “By sweep­ing away clunky com­pe­ti­tion and pro­cure­ment rules, these new plans could give the NHS and its part­ners greater flex­i­bil­i­ty to deliv­er joined-up care to the increas­ing num­bers of peo­ple who rely on mul­ti­ple dif­fer­ent ser­vices.”

This pro­pos­al has been wel­comed by those who fear pri­vati­sa­tion by stealth of the NHS, though some warn it is open to abuse. In an analy­sis of the white paper, Allyson Pol­lock, pro­fes­sor of pub­lic health at New­cas­tle Uni­ver­si­ty and a for­mer mem­ber of inde­pen­dent SAGE (Sci­en­tif­ic Advi­so­ry Group for Emer­gen­cies), and Peter Rod­er­ick, prin­ci­pal research asso­ciate at New­cas­tle Uni­ver­si­ty, warn: “We see no place for a mar­ket bureau­cra­cy in the NHS. But far from need­less, trans­par­ent­ly com­pet­ing for con­tracts is the check against cor­rup­tion and crony­ism with­in a mar­ket mod­el. Con­tracts worth £10.5 bil­lion were award­ed direct­ly with­out any com­pe­ti­tion dur­ing the pan­dem­ic to the end of July 2020; this will now become the norm.”

There is now a peri­od of con­sul­ta­tion, with the bill reach­ing par­lia­ment in ear­ly-sum­mer and imple­men­ta­tion get­ting under­way in 2022. With sig­nif­i­cant NHS and polit­i­cal sup­port behind them, these pro­pos­als are unlike­ly to prove as divi­sive as the Lans­ley reforms. Dan­ny Mor­timer, chief exec­u­tive of the NHS Con­fed­er­a­tion, says: “There is often anx­i­ety about ‘anoth­er NHS reor­gan­i­sa­tion’, but the NHS and the part­ners we work with across oth­er pub­lic ser­vices have been on this jour­ney now for sev­er­al years. This is the log­i­cal next step.”

NHS lead­ers will be hop­ing for a smooth pas­sage of the bill and quick imple­men­ta­tion peri­od, for they can­not afford to be dis­tract­ed from the fight against COVID and deal­ing with the mas­sive back­log of patients await­ing non-COVID care.

Mur­ray, at The King’s Fund, con­cludes: “Health and care ser­vices are fac­ing chron­ic staff short­ages, deep health inequal­i­ties laid bare by the pan­dem­ic and an urgent need for long-term reform of social care. In addi­tion to the struc­tur­al reforms pro­posed in this white paper, there is a press­ing need for the gov­ern­ment to chart a way out of these deep-seat­ed chal­lenges.”