A 75-page document, promisingly titled ‘Integration and Innovation: working together to improve health and social care for all’, was presented to Parliament by the British Health Secretary on 11 February 2021. The latest government White Paper on the National Health Service aims to lift a service that is “continuing to deliver excellence” in “crisis conditions” to new heights of unsurpassed efficiency.
You have to wade through yet another verbose, repetitive, jargon-ridden and cliché-infested document, filled with upbeat rhetoric and overoptimistic predictions, to decipher the government’s latest intentions. The White Paper lists a number of different proposals, which can be broadly classified under three main headings: working together and supporting integration, reducing bureaucracy, and enhancing public confidence and accountability. Some additional proposals relate to social care, public health, and safety and quality.
The proposed new structure for the NHS in England comprises four “layers”. The NHS and local government will establish partnerships in 42 “places”, defined by local authority boundaries, thereby ensuring closer collaboration between the health care and social care sectors. Provider collaboratives will bring together primary care, community, mental health and acute hospital services within each designated place. NHS providers, commissioners (purchasers) of their services, and local authorities will then form integrated care systems, which will control all NHS resources within each place. These integrated care systems will ascertain the health needs of their local populations, plan services, and allocate funds to support health and deliver healthcare. Finally, a set of regional and national NHS organisations will regulate and oversee these new integrated care systems.
The new proposals have already been criticised by the usual suspects, including the British Medical Association, opposition politicians, and assorted health policy experts. Critics point to a lack of detail, along with many inconsistencies and loopholes, and seem unhappy with the unfortunate timing of the latest reorganisation, in the midst of a pandemic. Then there are fears of the potentially harmful effects of yet another reorganisation on an NHS that is struggling to cope with an increasing demand on its services.
Ever since the ‘Appointed Day’ of July 5 1948, the NHS has been under intense public and political scrutiny, forcing it to adapt to changing circumstances. The first major reorganisation, however, had to wait until 1974, when a new tiered administrative structure of regional, area, and district health authorities was created. Since then, there have been further major reorganisations in 1982, 1989, 1999, 2002, 2003, 2006 and 2012. Common themes have included further changes in management structures, alterations in the regulatory framework, and varying relationships between health care and social care. Various governmental and non-governmental agencies have come and gone, remembered only, if at all, by their catchy acronyms. A series of ill-advised reorganisations has only led to a failure of disenchanted healthcare providers to sign up to the process of change. As a result the users of the NHS have frequently failed to benefit from an expected better standard of care. Successive reorganisations have not only failed to deliver demonstrable improvement, but they have actually had to be reversed by the initiatives that followed.
When it comes to the NHS, overoptimistic forecasts have been undone by the underwhelming results of each successive reorganisation. There is little direct evidence that structural changes in the health service have ensured better use of resources or led to positive health outcomes. In an era of evidence-based medicine, we thus have the paradox of ideologically-driven management change that is not supported by the evidence. While much reorganisation has been driven by a need to make the NHS more efficient, cost-effective and a provider of safe and high-quality care, the various restructuring projects of the past have unfortunately lacked a clear purpose. As the underlying issues have remained unaddressed, the same themes of devolved responsibility, high-quality patient-centred care, integration of services, and reduced bureaucracy have continued to reappear in each successive set of proposals,
The latest set of government proposals are partly a response to the last major reorganisation, which followed the controversial Health and Social Care Act 2012. The replacement of competition with collaboration is welcome, as is the need to reduce delays in the system caused by so-called “transactional bureaucracy”. The government’s proposals for tighter ministerial control over the NHS are, however, being treated with suspicion in some quarters, being seen as a threat to the autonomy of NHS England and other such bodies.
The NHS is facing many challenges. Staff numbers have failed to match increasing demand on services, waiting time and waiting list pressures are worsening across a range of specialties, and there are growing health inequalities related to socioeconomic status and ethnicity. The population is aging, people with chronic diseases are living longer, and expensive new medicines and technologies are becoming available all the time. Add to this the Covid-19 pandemic, and you have a system in crisis. The question is, how much can be achieved by increasing resources and modernising services within the established framework, without yet another wholesale restructuring. What we do know is that reorganisations are costly, disruptive, and often demoralising for already disengaged staff, besides failing to deliver anything useful.
The NHS undoubtedly needs reform as much as it also requires increased resources. It remains to be seen whether yet another wholesale restructuring is the best option, rather than further service improvements within the existing structural framework. The Covid-19 pandemic has forced change upon the health service, especially in the ways people access healthcare. It thus seems the right time to review priorities and redesign health services, but probably not for yet another set of structural changes. If the government does go ahead with its new plans, better evaluation of the impact of the changes is a must.
Ashis Banerjee