With waiting times growing and the NHS in the grip of its toughest winter for decades, it has been reported that the prime minister wants to assert more authority over NHS England, the body created in 2013 to provide day-to-day running of the health service.
Dominic Cummings, the PM’s chief aide, is said to be unhappy that its chief executive, Sir Simon Stevens, cannot easily be told what to do, and Downing Street wants NHS England to be more ambitious in making legal changes to local NHS bodies. Legislation to enable ministers to give direct orders to NHS England and reorganise local services is planned for later this year.
So, as this power struggle plays out, what can we learn from history to ensure that legislation doesn’t prove an unhelpful distraction?
The first is the lesson of the infamous reforms started under Andrew Lansley in the coalition years: do not underestimate the risk of reorganisation. Having entered government with a pledge that there would be “no top-down reorganisation”, the coalition presided over exactly that: a change to NHS structures described as “so big you can see it from space” by David Nicholson, who was the lead civil servant responsible for the health service.
While it is not clear that change on this scale was actually the government’s intention, the NHS responded by reorganising somewhat over-enthusiastically. This undoubtedly set the NHS back a couple of years, led to a loss of talent and expertise and left behind the mess that the current proposals are supposed to fix.
Since the early 1970s, each frequent reorganisation seems to have contained the seeds of the next: each new structure turning out to be poorly suited to some places or tasks, resulting in a temptation to replace it.
The second lesson is that context matters. It may be tempting to reintroduce the rigorous performance management of the health service from No 10 that seemed to work in the Blair era. But the context then was very different.
Back in the early 2000s there was a lot of extra money going into the health service. In spite of the government’s claims, that is not really the case now — the recently announced increase is less than what’s needed to meet more demand for care. The current shortages of key staff is also a real obstacle — one that is fairly impervious to performance management.
A further lesson from the Blair years is that success is rarely the result of a single approach. The NHS focus then was on a small number of health care targets, backed up with quality improvement programmes and more capacity. Rigorous oversight and monthly meetings between No 10 and the NHS were claimed as the source of success, but without a parallel focus on change management at a more local NHS level they would almost certainly have been insufficient.
It’s unlikely that the NHS’s problems at present are the result of a lack of prime-ministerial oversight or managerial grip. Setting unrealistic timescales for change, altering structures and shouting louder have all been tried — with limited success.
In fact, our obsession with policy-makers directing change in the health service may well be the real reason that driving improvement in the NHS is so hard. They are prone to over-optimism about how quick change is possible in complex organisations. Yet no other large western country, even those with NHS-type systems, tries to run health systems from the centre.
As ministers consider a ‘power grab’ for the NHS, they would do well to heed the lessons of history and proceed with humility. When central government has taken more control of the NHS, it always wins itself a bigger share of the blame — but not always the credit.
Edwards N (2020) "The risks of NHS reorganisation: lessons from history”, Nuffield Trust comment.