The NHS reform cycle continues - when will it end?

Profile picture for user ddpreez By Derek du Preez February 11, 2021
The British government is once again looking to flex its legislative muscle and ‘fix’ the NHS by addressing structural changes aimed at improving integration. We’ve been here many times before.

Image of a doctor in a hospital

This week the British government has set out new proposals to once again reform how the NHS operates - reversing legislation that was brought in a decade ago by then Prime Minister David Cameron. The latest set of reforms aims to improve integration across health and social care services - supported by ‘transformative' digital tools and data sharing.

Health and Social Care Secretary Matt Hancock said that the COVID-19 pandemic has proven that structural change is necessary and that the new legislative framework will result in a more innovative and responsive NHS. 

I could scream. 

Politicians once again are talking about the NHS like it's some homogenous entity that can be effectively steered like a ship from the centre of government and made world-class by meddling with some structural levers. In reality the NHS is an incredibly diverse, complex, fragmented organisation that has differing needs for health and social care services, depending on local requirements. 

The new legislation aims to remove bureaucracy and promote integration and collaboration between different service providers at a local level - but once again politicians seem reluctant to do the hard work and invest in outcomes focused change that will last for decades. 

We are stuck on some sort of never-ending roundabout of successive governments hoping that by shifting from centralised to decentralised, local to mandated, every ten or so years, will somehow magically create an NHS that is effective at all levels, in all areas. Not to mention that technology is often touted as the silver bullet to fix all problems (remember the paperless NHS by 2020 mandate?) - when in reality it should just be an enabler to support patients, organisational change and teams. 

To be clear: it won't. Whilst some of the messages coming from government this week about reform are sensible (integration is good!), they miss the mark by some way in terms of what is actually required. 

Instead of focusing on high concept legal frameworks that shift decision making at a top level, it would be preferable for Ministers to be thinking about how the NHS can fund and invest in local teams at scale, adopt outcomes-focused design thinking for service delivery, and putting in place interoperable systems that allow for data sharing and knowledge transfer. 

The White Paper this week released touches on some of those points, but won't be the driving force for these changes. The NHS is most successful when its people and experts are trusted to get the job done - as we have seen during the COVID-19 pandemic. 

What is being proposed?

The White Paper that has been released this week can be read in full here. It claims to capture the learnings and lessons from the COVID-19 pandemic and "make permanent" the innovations that COVID-19 has accelerated and encouraged. 

Simply put, integration and collaboration are the flavour of these latest reforms. Getting rid of bureaucracy and overhauling the tendering process, whilst "exploiting" digital and data, are top of the agenda. 

For example, proposals include changing tendering rules, which sees providers and private companies compete to win contracts to run services. The government hopes that this will make it less complicated for councils and different NHS organisations to set up joint teams and pool budgets.

The government is bringing forward measures for statutory Integrated Care Systems (ICSs), which will bring together the NHS, local government and partners, and an ICS NHS Body. These bodies will need to draw on the expertise of front-line staff and legislation will aim to let local areas determine the best system arrangements for them. 

But at the same time, "accountability" improvements are being made, with the merged NHS England and NHS Improvement to be placed on a statutory footing - designated as NHS England. This will be complemented by "enhanced powers of direction" for the government over the newly merged body. 

In addition, social care will be given the power to make direct payments to providers and improved data collection will aim to improve accountability. Whilst for public health, the government is bringing forward measures to make it easier to secure rapid change updates in NHS public health functions. 

Commenting on the proposed reforms, Health and Social Care Secretary Matt Hancock said: 

The NHS and local government have long been calling for better integration and less burdensome bureaucracy, and this virus has made clear the time for change is now.

These changes will allow us to build back better and bottle the innovation and ingenuity of our brilliant staff during the pandemic, where progress was made despite the legal framework, rather than because of it.

The proposals build on what the NHS has called for and will become the foundations for a health and care system which is more integrated, more innovative and responsive, and more ready to respond to the challenges of tomorrow, from health inequalities to our ageing population.

The response

The response to the proposals has been one of trepidation. The idea of better integrating health and social care is clearly welcome, but there is also concern about centralisation and funding. For example, Cllr Ian Hudspeth, Chairman of the Local Government Association's Community Well-being Board, said: 

This white paper provides a promising base on which to build stronger working relationships between local government and the NHS, as equal partners, to address the wider determinants of health and deliver better and more coordinated health and care services. We will be working with councils, the Government and NHS England to better understand the full implications of these wide-ranging proposals.

We understand the desire for greater transparency in social care, but councils need to be an equal partner in the design of any national oversight. This must build on existing sector led improvement work, recognise local democratic accountability and give a voice to people who use and work in social care. It is helpful the white paper recognises the pressures facing social care and makes clear the Government remains committed to reform, but action is needed and proposals must be brought forward as a matter of urgency. These proposals do not address the need to put social care on a sustainable, long-term footing, nor the wider changes needed to ensure care and support can best enable people to live the lives they want to lead.

Public health services run by councils have more than proven their worth through the pandemic, as part of the tremendous local response. Any centralisation of public health powers would be of clear concern and we hope that further government proposals to be brought forward will build on these strong local foundations.

Think tank Nuffield Trust hits the nail on the head and has a similar sentiment, pointing to the complexity of the NHS and the need for government officials to feel like they're doing *something*. Nuffield Trust Chief Executive Nigel Edwards, said: 

Covid-19 has shown how crucial it is that health and social care services in England work well together, and provided brilliant examples at the front line that we need to build on. But we must be careful that in trying to boost cooperation, we don't fall into the age-old traps of distracting, confusing reorganisation, or trying to run Europe's biggest public service from Whitehall.

It's good that the new model for local health services, based on ‘Integrated Care Systems', will try to be flexible to the different needs of different places. But the approach of having three overlapping boards locally for the NHS and social care risks confusion and a clash of agendas. Who holds the real power locally might be contested, especially as powerful independent Foundation Trusts remain. 

The NHS has seen so many restructures that it can shift easily into reorganisation mode, where attention is taken away from patient care to focus on who is on which committee and which lines are on the organogram.

My take

One thing I'm sure of is that in 10 years time we will be writing another piece about how central government is looking to reform the NHS, to make it more efficient, more integrated and make better use of technology. The main problem is that talking about the NHS as a single entity just isn't going to work. The government should be thinking about common standards, interoperable systems, hiring practices, funding mechanisms, outcome focused design, and most fundamentally, EMPOWERING AND INVESTING IN LOCAL TEAMS. Put some of those things in place, put trust in local expertise, and I'm pretty sure we'd see some positive changes.