At a time when the NHS is living through the most serious challenge in its history, along comes the biggest shake-up of the health service in more than a decade. The government’s Integration and Innovation white paper, published in February, is the first serious attempt to unwind the reforms of the 2012 Health and Social Care Act, which was marshalled by the then health secretary Andrew Lansley.
The proposals have provoked fierce debate about the future of the NHS and the best way forward. However, there is almost universal agreement that the Lansley reforms were a costly mistake, bringing disaggregated leadership and the chaos of competition. Roy Lilley, health policy analyst and former chairman of an NHS trust, described the white paper as a “40-page Tory apology to the NHS for screwing it up”.
As for the timing, the BMA medical union said the proposed reorganisation must not be rushed through at a time when staff are “physically and emotionally exhausted”, with the NHS still under enormous pressure in the fight against COVID-19.
Chaand Nagpaul, BMA council chair, says the NHS is facing the greatest backlog of care. Dealing with this would require “significant new resources and an immediate action plan” and investment must not be diverted to the reorganisation, he says. The counter-argument is that the pandemic forced health and care services to do things differently and now is the time to build on what worked well.
So, what is the reorganisation all about? Media coverage has mainly focused on new powers given to the secretary of state for health and care over the NHS. It would allow him or her to intervene in any service reconfiguration without need for a referral from a local authority. The department of health and social care would also be able to reconfigure and transfer the functions of arm’s-length bodies such as the Care Quality Commission and the National Institute for Health and Care Excellence, including closing them down, without primary legislation.
Some have seen this as an attempt by the government to seize back some of the powers that, in theory, were devolved to NHS England under the Lansley reforms. The NHS Confederation says these new powers of intervention are “an area of concern”. However, the reality is it is hard to see how the reorganisation gives additional powers to ministers to do things they can’t already do.
The pandemic provides a number of examples of government taking the lead, among them the Nightingale hospitals, the shake-up of Public Health England and personal protective equipment procurement. In any case, taxpayers probably expect the government to hold the keys to an organisation that spends more than £100 billion of our money every year.
From the point of view of patients, the most important change taking place across the NHS is the shift away from the old legislative model of competition between health care organisations towards a new model of collaboration, partnership and integration. Over the past three years, the NHS has been creating what are known as integrated care systems (ICSs) across England. This is where the NHS, local councils and voluntary organisations come together at a local level to design and provide services to meet local needs.
The ambition for the fledgling ICSs is to provide joined-up care for patients. An example is when elderly patients are discharged from hospital. In simple terms, at this point they cease to be the responsibility of the NHS hospital trust and the local authority takes over, arranging and paying for domiciliary care or a care home.
At present, many people are stuck needlessly in hospital because this process breaks down. The role of the ICS is to ensure this process takes place seamlessly. Each system is given the freedom to remove any barriers that block collaboration in local communities. The message is: if you think this is what needs to be done, go do it.
Bridging the gap between health and social care has been a pipe dream for many years and numerous earlier attempts have failed. Perhaps there are better grounds for optimism this time because the latest blueprint does not rely on a Big Bang reorganisation, with thousands of people moving from one organisation to another. ICSs have quietly been finding out what works best in local communities and forming myriad partnerships with different organisations for different tasks. The white paper proposes putting them on a statutory footing, which is necessary in terms of corporate governance and public accountability.
Another significant change concerns procurement. The white paper aims to remove, or at least blunt, the need for a competitive market in health procurement, something which was at the heart of the Lansley reforms. Compulsory tendering of clinical services is abolished, leaving NHS organisations free to commission services they agree will work best for their patients in their local communities. This is seen as critical to the success of the ICSs, whose leaders want to strengthen local services without the requirement to embark on a lengthy and costly national procurement process.
Richard Murray, chief executive of The King’s Fund, the health and care think tank, says: “By sweeping away clunky competition and procurement rules, these new plans could give the NHS and its partners greater flexibility to deliver joined-up care to the increasing numbers of people who rely on multiple different services.”
This proposal has been welcomed by those who fear privatisation by stealth of the NHS, though some warn it is open to abuse. In an analysis of the white paper, Allyson Pollock, professor of public health at Newcastle University and a former member of independent SAGE (Scientific Advisory Group for Emergencies), and Peter Roderick, principal research associate at Newcastle University, warn: “We see no place for a market bureaucracy in the NHS. But far from needless, transparently competing for contracts is the check against corruption and cronyism within a market model. Contracts worth £10.5 billion were awarded directly without any competition during the pandemic to the end of July 2020; this will now become the norm.”
There is now a period of consultation, with the bill reaching parliament in early-summer and implementation getting underway in 2022. With significant NHS and political support behind them, these proposals are unlikely to prove as divisive as the Lansley reforms. Danny Mortimer, chief executive of the NHS Confederation, says: “There is often anxiety about ‘another NHS reorganisation’, but the NHS and the partners we work with across other public services have been on this journey now for several years. This is the logical next step.”
NHS leaders will be hoping for a smooth passage of the bill and quick implementation period, for they cannot afford to be distracted from the fight against COVID and dealing with the massive backlog of patients awaiting non-COVID care.
Murray, at The King’s Fund, concludes: “Health and care services are facing chronic staff shortages, deep health inequalities laid bare by the pandemic and an urgent need for long-term reform of social care. In addition to the structural reforms proposed in this white paper, there is a pressing need for the government to chart a way out of these deep-seated challenges.”