You might expect, in the midst of a global pandemic, that unpicking the inner workings of the organisations that run and oversee the national health service would be far from front of ministers’ minds. But recent reports would indicate this is not the case. The question of a large-scale NHS reorganisation—which seems to tempt governments of all colours with remarkable regularity—is once again being mooted.
If reports in the media are to be believed, parts of government have set their sights on a radical shake up of NHS structures, including an attempt to restore minsters’ direct control over the NHS by restricting the operational independence of NHS England created under the 2012 Health and Social Care Act. Quite why this is deemed necessary at this moment in time is unclear. There are reports of ministerial frustration at the role some health agencies have played during the pandemic, but some of the areas of greatest concern—such as the faltering start to the Test and Trace programme, and the provision of personal protective equipment (PPE)—were the responsibility of agencies already under the direct control of ministers (Public Health England is an executive agency of the Department of Health and Social Care while the NHS supply chain is set up as a limited company, wholly owned by the Secretary of State for Health and Social Care). Restricting the independence of NHS England is therefore not a logical response to these concerns.
Reportedly also under consideration is the option of turning integrated care systems—which are currently voluntary local partnerships bringing together providers and commissioners of NHS services with local authorities and other partners to collectively plan and integrate care—into legal entities with budgets and statutory responsibilities. There are legitimate questions about how to ensure appropriate transparency and accountability for Integrated Care Systems if they are to have greater responsibility for planning services and managing resources, but setting them up as a new legal entities would have far reaching implications for the governance and accountabilities of existing organisations such as clinical commissioning groups and NHS Trusts and Foundation Trusts.
If there is one lesson from the history books of NHS reform, it is that attempts at large-scale reorganisations should be approached with considerable caution. In 2015, The King’s Fund concluded that the last, and possibly largest, set of organisational reforms (the coalition government’s 2012 Health and Social Care Act) had been “distracting and damaging”. With the benefit of hindsight, an even less favourable conclusion might now be reached. NHS leaders have spent the years that followed having to unpick and work around many of its core features as the strategic focus of the NHS has shifted away from the world of competition enshrined in the Act, in favour of collaboration and integration in response to changing population need.
Structural reorganisations consume significant time and resource, distract leaders and staff from other priorities, and often fail to deliver intended benefits. The system can ill afford such upheaval at the same time as facing potential further waves of covid-19 and dealing with the complexities of restoring and renewing services.
So, what is the alternative? A focus on improving collaborative behaviours between NHS organisations, and between the NHS and local government, would likely deliver more positive impact more quickly than an extensive reorganisation. Targeted changes to support the integration of services would be preferable to wholesale changes to structures. This includes changes to end the forced competitive procurement of some services and remove some of the blockages that make it harder for NHS providers and commissioners to work together. Proposals for just such a limited set of changes have already been put forward by NHS England, supported by stakeholders across the health and care system, including The King’s Fund.
Instead of allowing a reorganisation of NHS structures to consume valuable energy and political capital, the government would do better to direct its attention to social care. The impact of covid-19 on people who rely on social care has provided more evidence (if more was needed) that the sector has been overlooked for too long and is in desperate need of attention, investment and reform.
The Conservative Party manifesto made the NHS a key priority, making a series of commitments to grow and support the NHS workforce. It also promised to solve the problems in social care to give every person the dignity and security that they deserve, and to “level up” every part of the country by addressing deep-rooted economic and social inequalities. While it is easy to assume that the coronavirus has changed everything, the pandemic has underlined that these priorities—supporting the workforce, reforming social care, and tackling inequalities in health—are now more important than ever. Entering into yet another attempt to rearrange the NHS deckchairs will not solve these problems and risks distracting attention from making the changes that would.
Anna Charles, Senior Policy Adviser, The King’s Fund
Competing interests: None declared