Restoring our NHS: abolishing marketised commissioning is a good start but not enough

The government’s long parried acknowledgement of the unviability of many years of NHS reforms will be welcomed by almost all its healthcare staff. But this proposed reform of reforms overlooks many of our recently accrued problems, says David Zigmond

At last this citadel—that of successive governments’ commercially modelled reforms of the NHS—seems now to be crumbling.

At the beginning of February, the news briefly headlined a leaked government white paper that proposed major reforms to the NHS. Five days later, these reports were confirmed. Central to the proposals is the abolition of the purchaser–provider split, with its complex and cumbersomely contentious marketised commissioning. If this white paper leads to these recommendations being acted upon, it will surely be an important first step towards restoring the more viable and less fractious NHS that many have been long campaigning for.

But any celebration of this needs caution: there are other, equally important, recent developments that need rescinding yet which remain largely unacknowledged in this report. Here is a brief overview.

Firstly, the recommendations.

For 30 years successive governments have cleaved to the mistaken notion that high quality healthcare was best assured by “market discipline”; this principle was zealously amplified by Lansley’s 2012 Health and Social Care Act. Yet for these three decades, governments have had mounting feedback from practitioners, researchers, and patients about the speciousness of these reforms. Instead of receiving “market discipline” we were getting not just market mendacity and expedience, but the kind of anomie, human heedlessness, and mistrust that can come from the worst kind of corporate commercialism.

It became increasingly recognised that the competitive marketisation of our NHS is divisive and erosive of trust, rapport, and care. It is widely implicated in our growing crisis of staff retention. It has magnified the gap between health and social care. The government may be tempted to think that merely rescinding such marketisation will be sufficient to reintegrate those welfare services that have become so fragmented and dispirited. Consequently, there is much talk of restorative integrated care services, themselves serviced by primary care networks—enormous conglomerates of flexibly deployed GPs.

What is the government overlooking here?

Well, such hopeful initiatives will still be stymied by two other legacies of our 30 years of reforms: the reforming programmes of giantism (eg, increasingly large, centralised, and remote hospitals, GP surgeries, etc) and coercive bureaucracy (remote regimes of management, inspection, and compliance). These two have been developed as expedient cohorts to the creation of an industrialised healthcare complex that has divided and estranged colleagues; all have combined to sever our richer human contact with patients.

Any potential major reform should first recognise, and then prioritise, that much of our most effective healthcare depends upon personal understanding, trust, and bonds. These can only grow if practitioners have the necessary headspace and heartspace to invest not just in their patients, but also in their colleagues. Such interprofessional dialogue and care thus works best in smaller units with stable, personally familiar working teams where healthcarers get to know one another and their patients: professional communities serving communities of those in need. This was the strength of our NHS before it was serially reformed. “Integrated care” is much easier to deliver when we know who we are dealing with—whether they are patients or other professionals.

Can we still provide sensitive and intelligent care with the now vaunted systems of algorithms and procedures that instruct professionals who remain subordinated to vast institutions, and who have neither the time nor the proximity to get to know the people they must care for and work with?

This is a critical question that this white paper seems not to heed.

David Zigmond is a GP in London.

Competing interests: I declare that I have read and understood BMJ policy on declaration of interests and I have no relevant interests to declare.