Politicians often find to their disappointment that the normal policy levers they pull have surprisingly little immediate effect in the NHS. This has often driven them to structural change – abolishing, establishing and merging the bodies that make up the health service in the hope of changing how it works. In 2010, I calculated that the average NHS commissioning organisation lasted just three years. Their prospects have not improved.
Since the disastrous 2012 Health and Social Care Act, “NHS reorganisation” has become a phrase politicians shy away from, with a significant lull in major overhauls. But partly because of the complex mess left over from that Act, in this election each party has come forward with a new proposal to remodel the service.
Reviewing the reforms
The Conservatives say they will legislate to support the implementation of the NHS Long Term Plan within the first three months of being in government. This has been interpreted as a reference to implementing NHS England’s proposals for legislation, committed to in the last Queen’s Speech.
These proposals would partly formalise the unofficial reorganisation that has already been going on. That would mean the merger of the national bodies NHS England and NHS Improvement, and new powers to pool and merge powers locally to create the “integrated care systems” envisaged in the Long Term Plan. That would leave some unanswered questions. For example, ICSs would be expected to run health services and even social care locally without having a clear legal role. But it does have the virtue of being reasonably close to organic changes already happening, rather than a dramatic change of course mandated from Whitehall.
The Liberal Democrats similarly support NHSE's proposed changes. They will also encourage emerging governance structures for integrated care systems to include local government and be accountable to them.
Serving the two masters of the NHS and councils together will not be easy – they have different cultures, aims and funding. I wrote recently about Tameside, which has managed to make this work, but they do so at a much smaller scale than an ICS, and benefit from particular leadership and ethos.
Adding to the difficulties, many ICSs cover multiple county councils, with different interests and political leanings. Greater Manchester has created mechanisms to address but it has taken time, even with years of previous work to build on. It has also benefited from Manchester being a place that ordinary people would recognise – many ICS areas are not – and from the fact that nearly all its councils are run by the same party.
Labour have by far the most radical proposals. They have vowed to repeal the 2012 Lansley Act, to integrate care via unspecified “public bodies” and to take steps to ensure that all services will be delivered “in-house”.
Repealing the 2012 Act would take us back to the NHS before this, with no independent NHS England, but still with a strong internal market and outsourcing to the private sector. This in itself would be a massive reorganisation, but if Labour truly want to end competition then an even more complex overhaul will be needed.
Bringing private sector provision back into the NHS will also require organisational change on the front line – particularly for many staff in community services. In mental health, trusts would need to develop whole new services for fields such as eating disorders and forensic psychiatry, which have long been outsourced. Hospitals will find they can no longer use the private sector to clear waiting lists, and will need to be re-engineered to do more, at considerable cost.
Expecting different results
Ahead of the Long Term Plan, we looked back at the history of NHS reorganisation to draw out lessons and see what went wrong previously. That troubled history suggests there are two tests we ought to apply to any proposal to undertake major structural change.
First, are the proposals flexible enough to reflect the differences between areas of the UK, or do they risk disrupting important local relationships? Or does there appear to be an attempt to find the ‘right’ size and set of relationships to roll out everywhere?
The last few decades suggest one may not exist.
There seems a risk that the Liberal Democrat model might impose a particular role for councils in areas where this becomes very messy. If Labour truly plan to return to the world before the 2012 Act, they will be committing to the fairly rigid structure of commissioners and strategic health authorities that then ruled the health service – the Whitehall Powerpoint ideas of an earlier age.
The Conservatives’ flexible proposals would allow for more variation – but leaving most legal duties where they are now might mean that the current fragmentation across NHS trusts and clinical commissioning groups continues.
The second and wider test is whether the disruption of a major change is worth it. The loss of momentum, well-developed working relationships and organisational memory has often set the NHS back by years.
At this stage it is not entirely clear how major a shift any of the parties envisage. But we must not repeat the mistake of 2012, where the government was halfway through a massive overhaul before senior coalition figures started to ask hard questions about whether it was worth the trouble.
The end of the org chart?
There is a deeper question: should detailed management structures for a very large and complicated system like the NHS be designed centrally at all?
It is certainly right for politicians to set out policy principles – an underlying theory about what the structures are supposed to be doing and the relationships they need. But it’s difficult to point to reform setting out the exact structure of who is in charge, and what they do in each local area, that has been unambiguously successful.
Each time an incoming government notices the flaws of the last redesign and decides the suitable thing to do is to reach for another one, we risk getting caught in an endless cycle that produces problems rather than solve them.
Edwards N (2019) “Is the 2019 general election seeing a reorganisation relapse?" Nuffield Trust comment.