NHS reform: the gloves are off!

The Coalition government’s health reforms are moving ahead at speed, despite the reservations of NHS staff, trade unions and academics. Make no mistake, these are large scale reforms, and compare with the great (and very unsuccessful) reorganisation of 1974, the internal market reforms of the 1990s, and New Labour’s reforms in the aftermath of the NHS plan of 2000. However, the current reforms are in many respects a continuation of recent policy trends – increased use of the private sector and social enterprise, more competition and use of market forces, a greater emphasis on choice and personalisation, a stronger voice for patients and more accountability, greater responsibilities and autonomy for health organisations and professionals at local level and less interference from politicians,  a focus on improved health outcomes, better joint working between health care, social care and public health bodies.

No one could disagree with the expressed desire to improve outcomes and create a service that is more responsive to patients. But as ever the devil is in the detail. And there is going to be a lot of detail. The Health and Social Care Bill, at almost 370 pages long, is four times longer than the Act of 1946 that created the NHS.  Furthermore, it will spawn plenty of secondary legislation. The key question is how will it be implemented? NHS reform rarely goes to plan. History teaches us that reforms tend to hit problems and further changes are then required. The government has set a timetable for axing the very bodies that implement its NHS policies, while limiting the formal powers of central bodies, including the Department of Health. The key words are going to be capacity, accountability, and fragmentation

There are already concerns about possible lack of capacity among the new GP commissioning bodies at a time when Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) are going to be abolished. There are also worries about the capacity of the three central bodies – Monitor, the National Commissioning Board, and the Care Quality Commission – to regulate the NHS.  Despite what ministers say, the temptation to intervene will be strong.  The fragmentation of the system, local variations in service and individual service failures that arise will stimulate intervention from central policy makers and regulators.

Politically, the government has dug itself in a hole here. The announcement of health reforms in July was like pulling a rabbit from a hat. No one foresaw their magnitude. The Conservative leadership had worked hard to neutralise the NHS as a political issue and had successfully built up public trust in its health policies. The coalition with the Liberal Democrats made widespread reform even less likely, as they too had no plans for root and branch reorganisation. The result of this U-turn is that the NHS is back on the front pages providing plenty of ammunition for the government’s opponents. The spectre of large scale privatisation has been raised, amid greater suspicion about competition and markets, particular in the light of the banking crisis.  One might ask: why should markets work in health care when they demonstrably failed in the financial sector?

The key tests for the reforms are: will they improve health outcomes, reduce health inequalities, improve partnership working, strengthen accountability and responsiveness to patients and the public, and improve efficiency (and in particular, achieve the £20 billion demanded in savings)? There are strong reasons for arguing that such a massive organisational reform will jeopardise all these objectives. It will cause major structural turbulence and will be expensive. It is also likely to distract from the urgent business of improving and protecting and promoting public health, which could be sidetracked as ministers concentrate on the organisational detail of NHS structural reform.

Post by Professor Rob Baggott, Director of the Health Policy Research Unit, De Montfort University

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