Those of us who have been involved in the NHS for a long time will have felt a sinking feeling when they read recently that Boris Johnson, the UK prime minister, is planning a “radical shake-up of the NHS in a bid to regain more direct control.”
Some of the changes appear to be an attempt to deal with the problems resulting from the 2012 NHS Health and Social Care Act that is widely regarded as a major policy error. The act created NHS England and Public Health England (PHE) as arm’s-length bodies, and removed NHS England from the direct control of ministers.
The new proposals are reported to assert more direct control over NHS England and PHE, and in particular would hold NHS England more closely to account and deal with perceived PHE failings. This is seen as necessary to deliver the government’s manifesto commitments in areas such as waiting times and improved access to GP appointments. There is also a proposal to remove the independence of foundation trusts to allow better control over the system.
There are well-known perils in any reorganisation, and it is not clear that the absence of powers to control NHS England and weak accountability were why the NHS was struggling with meeting its targets prior to the pandemic. A decade of austerity, long-term under-investment and shortages of key staff seem more likely candidates.
In fact, the NHS is already very centralised in comparison with other health systems like those in Germany and Spain. Less centralised health systems such as those have a comparatively weak line of accountability between the minister of health and the health system, and yet seem to perform at least as well, if not better.
Lessons not learned
All of this points to some worrying issues about the underlying logic and approach.
First, there appears to be an assumption that without detailed oversight and ministerial direction, the leaders of the NHS will fail to give their best. But organisational studies suggest that low trust managerial approaches are associated with poorer results than those which start with an assumption that employees can be trusted.
Second, there seems to be a lack of appreciation of the hazards of over centralisation and an unwillingness to learn from other health systems about more effective devolution and delegation. Centralised decision making has its place, but so has local agility and adaptability. Yet the NHS and central government have struggled to determine where to use devolved rather than centralised approaches.
The temptation has been for central government to take control and to exploit economies of scale. But policy makers have found that these benefits are quickly offset by the costs of coordination and complexity. The opportunity to mobilise local resources is missed because they are too distant from Whitehall and are poorly understood.
This has been a long standing tension in British politics, which the pandemic has laid bare. The argument for central control has been weakened by serial failures in areas such as testing, the tracking app and tracing service, the supply chain, and the issuing of consistent guidance in areas like personal protective equipment (PPE) or school reopening. All these areas were under the control of central government, or agencies over which they had direct oversight.
Third, the continued emphasis on manifesto commitments about GP appointments and waiting lists carries the worrying implication that politicians have not grasped the huge long term impact on productivity of running health services in situations where covid-19 is endemic, the additional burden of the tail of post-covid problems, or the impact the crisis may have had on staff.
Digital diligence needed
The government’s planned shake-up of the NHS also includes extending and cementing the move to digital, phone and video consultations. This hints at another hazard for policy makers: the promise of technology as a magic bullet.
While there has been a very impressive effort to redesign services to remove face-to-face elements, we need to be cautious in assuming that this is more productive, how many patients it is suitable for, and the assumption that it is quicker or reduces workload.
For long-term sustainability, technology needs to be carefully designed into working practices. This requires the sort of detailed thought and work that cannot be nationally directed.
Understandably, the government feel the burden of meeting public expectations created by commitments to provide additional funding. But they would be well advised to remember that attempts to centrally control such a complex system tend to fail. In his report on safety in the NHS, Don Berwick called on the health service to focus on improvement and learning, to eliminate fear and to rethink its approach to performance management.
This, alongside what we have learned from the response to covid-19, suggests that we should be fundamentally examining the assumptions we make about how the NHS is governed, how it works with local systems, and the scale on which it operates.
There were plenty of clues to suggest that before the crisis, but now that we have the chance we should be thinking about less centralisation, not more. However, change needs to be careful and organic. The NHS has had too much big, bold, top-down change over the last 40 years—another one now is the last thing it needs.
Nigel Edwards, CEO of the Nuffield Trust
Competing interests: None declared