Much has been written about the funding issues facing the NHS at 70. Much less has been said about reforming NHS structures.
If we want to create an NHS that is truly sustainable for the future, however, we do need to look again at how it is organised. What we have now is palpably not fit for purpose.
The 2010 coalition government quickly established a programme of ambitious reform across pretty much the whole of the public sector. This was in part driven by austerity but also by the pent-up ambitions of ministers achieving office after a long period in opposition. At the same time, David Cameron significantly reduced the capacity at the centre of government to review and scrutinise what was coming forward from departments.
This “fast and furious” approach to reform brought with it significant problems across government, for example the well-publicised difficulties with universal credit. But by far and away the biggest difficulties came in the reforms brought in by the Health and Social Care Act 2012. A fragmented and depleted structure was created that was singularly ill-equipped to meet the future needs of the health service.
By the end of the coalition government there were two prevailing conclusions about the NHS reforms. First, that they had been a missed opportunity at best and a disaster at worst. Second, that the upheaval and general grief caused by the reorganisation meant that there could be no prospect of further organisational change.
The result of this view has meant that subsequent reorganisation has happened by stealth. Some of this change has not been without merit, for example the creation of sustainability and transformation partnerships. Bringing together clinical commissioning groups in some areas has reduced costs. However the overall effect has been piecemeal and lacking in coherence.
What changes might be needed? First, it is important to say that the way the organisations of the NHS have worked has been significantly influenced by the funding crisis. NHS Improvement, for example—notwithstanding the brave vision of its first chair Ed Smith—has become “NHS Containment” or “NHS Enforcement,” acting on behalf of the secretary of state to bear down on provider finance and performance.
“Cameron significantly reduced the capacity to scrutinise what was coming forward from departments”The most essential task that must be taken first is to “reset” the NHS and put its providers on a path to the sustainability that is taken for granted in other sectors. Funding needs to be adequate to realistically set balanced budgets and deliver the expected performance standards. The tariff funding model needs radical overhaul to make it simpler and more predictable.
If the reset has been done properly, there should then be space for the Department of Health, the national commissioner and regulator to spend less time on fire fighting and more on exploring the longer term strategic issues.
At local level, it is equally important to fix the funding of social care. Without addressing this growing funding gap, the future viability of local government is in doubt and it will certainly not be able to play its part in developing joint systems of health and care.
A huge simplification and reduction in costly bureaucracy could be achieved by moving away from the current commissioner provider split at local level and introducing long term 10-year contracts based on the size and needs of the local population. More of the NHS commissioning budget, for example for mental health services, could be determined locally. There should be the opportunity to reconfigure clinical commissioning group boundaries to better align with those of local government.
Tempting though it might be to some, I would not advocate taking social care funding out of local government; it is too entangled with the wider funding changes there.
Finally, as part of freeing up decision-making at local level, the “any willing provider” provision in the 2012 Act should be removed. It is likely that a mixed market of provision involving the private and independent sector will need to continue, if only to deal with peaks in demand. However there should be more local discretion on what to buy externally and who to buy it from.
Structural change always brings with it additional uncertainty and cost. It should not therefore be entered into lightly. It would almost certainly require new primary legislation. However I think it is time to recognise that the problems created by the 2012 Act cannot be fully addressed without this.
There is little doubt in my mind that change is needed.
This article is an edited extract from the Fabian Society report "A Picture of Health"
