Boris Johnson is planning a radical and politically risky reorganisation of the NHS amid government frustration at the health service’s chief executive, Simon Stevens, the Guardian has learned.
The prime minister has set up a taskforce to devise plans for how ministers can regain much of the direct control over the NHS they lost in 2012 under a controversial shake-up masterminded by Andrew Lansley, the then coalition government health secretary.
The prime minister’s health and social care taskforce – made up of senior civil servants and advisers from Downing Street, the Treasury and the Department of Health and Social Care (DHSC) – is drawing up proposals that would restrict NHS England’s operational independence and the freedom Stevens has to run the service.
In the summer, the taskforce will present Johnson with a set of detailed options to achieve those goals, and that will be followed by a parliamentary bill to enact the proposals, it is understood.
“The options put forward to the prime minister will be about how the government can curb the powers of NHS England and increase the health secretary’s ‘powers of direction’ over it, so that he doesn’t have to try to persuade Simon Stevens to do something,” said a source with knowledge of the plans. “[The health secretary] Matt Hancock is frustrated [by] how limited his powers are and wants to get some of that back.”
The proposed NHS overhaul comes amid plans for other significant reforms, including to the universities system and the military.
The coronavirus crisis and an 80-seat majority have made Johnson determined to act. There is ministerial frustration at the role some health agencies have played during the pandemic, notably Public Health England (PHE), and a desire to make permanent some recent changes in NHS working, such as different NHS bodies working closely together, and the huge increase in patients seeing their GP or hospital specialist by video or telephone.
Ministers are also keen to “clip Simon Stevens’ wings”, sources said. There is a widely held view in the government that he enjoys too much independence, and frustration that his arms-length relationship with the DHSC means that Hancock has to ask rather than order him to act. The Treasury in particular is irritated that NHS treatment waiting times continue to worsen, and many hospitals remain unable to balance their budgets, despite the service receiving record funding.
Dominic Cummings, Johnson’s chief adviser, is not a member of the taskforce but William Warr, his health adviser, is. It is chaired by a senior mandarin from the DHSC. Its remit also includes delivery of the array of NHS promises the prime minister made during last year’s election campaign.
The taskforce’s creation last month follows tension between NHS England and the health department over issues that have caused Johnson’s administration persistent problems, including testing of patients and NHS staff, and shortages of personal protective equipment. Sources close to the health secretary say he believes that Stevens has been “invisible” and unhelpful during the pandemic and is not accountable enough for problems such as patients’ long waits for care.
Under one option being discussed, ministers would use new NHS legislation to abolish the foundation trust status introduced by Tony Blair in the early 2000s, under which many hospitals in England enjoy considerable autonomy from Whitehall, as part of a drive to give the DHSC more control over the day-to-day running of the health service.
The taskforce is also examining whether to turn integrated care systems, which are currently voluntary groupings of NHS organisations within an area of England, into legal entities with annual budgets of billions of pounds and responsibility for tackling staff shortages and ensuring that the finances of its care providers do not go into the red. That would add dozens of powerful new bodies into the NHS’s already-crowded organisational architecture and raise difficult questions about the powers and responsibilities of individual hospitals and NHS England leaders.
The prospect of a radical restructuring of the health service has prompted warnings from experts that renewed upheaval could damage the government and destabilise the NHS. Richard Murray, the chief executive of the King’s Fund thinktank, said problems created by the Health and Social Care Act 2012 should caution ministers against a major overhaul.
“Any large-scale reorganisation of the NHS comes at a high price as they distract and disrupt the service and risk paralysing the system. The last major reorganisation came in the 2012 Lansley reforms. These proved hugely controversial for the coalition government but perhaps worse, they have not stood the test of time,” said Murray.
“The changes we see in the NHS now – towards better integration and working across the health and care system – have come despite the 2012 act, not because of it. They stand as a warning against large-scale change that tips the entire NHS into reorganising the deckchairs.”
A shake-up could create problems for Johnson, who has made support for the NHS a key part of his programme for government, Murray added. “To date, many of the promises the government has made – more nurses, GPs and other staff, a new building campaign – do confront the real challenges facing the NHS. On the contrary, while there is a case for targeted changes to legislation, no one asked for large-scale reform.”
The Conservative MP Dr Dan Poulter, a health minister in the coalition, said the 2012 act caused more problems than it solved. “It has resulted in health ministers now wielding little real control over the functioning of the NHS, and the Covid pandemic has crystallised the failure of many of the health system’s arms-length bodies to properly coordinate a rapid national response at a time of great crisis.
“The current structures are not fit for purpose as they focus on competition and not enough on the integrated approach to health and social care that is so badly needed by patients. We need to return to a more streamlined command and control structure for the health system that is more in keeping with [Nye] Bevan’s original vision for the NHS.”
But, he added, “whilst it may be needed, a radical overhaul of the NHS is also fraught with dangers. A focus on structural reorganisation could well result in a worsening of operational performance in the short term and would be all the more challenging during the current pandemic.”
At the request of the then prime minister, Theresa May, NHS England last year brought forward proposals to modernise the way it works, which were due to form the basis of an NHS bill. However, Johnson wants to take a bolder approach to reform than that contemplated by his predecessor.
Downing Street declined to discuss the taskforce or its plans for NHS reform. A spokesperson said: “This is pure speculation. As has been the case throughout the pandemic, our focus is on protecting the public, controlling the spread of the virus, and saving lives.”
NHS England declined to comment.