History shows that NHS reorganisations rarely end well. The last one, the brainchild of the then health secretary, Andrew Lansley, in 2012, nearly tore the Conservative-Liberal Democrat coalition apart. The health and social care bill triggered so much uproar that David Cameron instigated a “pause” on its progress – a move unparalleled in parliamentary history – while a group of healthcare experts made its complex proposals less confusing and more palatable.
Since the bill’s passage into law it has become infamous, widely recognised as a disaster and a test case for how not to reform the health service. It alienated NHS staff, distracted the service for years and yielded almost no lasting benefits, critics say. It had promised to reduce the number of bodies making up the NHS but actually increased them. The National Audit Office, after analysing money spent and outcomes achieved, highlighted “the significant upheaval caused by major organisational restructuring”. What the NHS needed, it concluded, was “a prolonged period of organisational stability”.
Many Conservatives now agree broadly with what Labour, doctors and health thinktanks warned at the time: that atomising existing NHS structures and replacing them with new ones would make it harder for the government and the NHS to improve healthcare. Abolishing an array of NHS organisations such as primary care trusts is now widely seen as having been the wrong response to dealing with the many challenges posed by an ageing and growing population in which long-term illnesses such as cancer and diabetes required collaboration, not competition, between the range of care providers that sit under the NHS umbrella or are local council-funded.
For the government, the key legacy has been less power, influence or control over the NHS in recent years, at a time when growing care needs, austerity and even greater public appreciation of the service have made it a recurring source of political heat.
Sir Simon Stevens, who became NHS England’s chief executive in 2014, has regularly demonstrated the independence of thought and action that the 2012 legislation bestowed on him. Until 2012 his predecessor Sir David Nicholson was a civil servant at the Department of Health, under the control of ministers. But Stevens has used his role’s freedom to plot his own course and not abide by every request or would-be diktat from the department.
In doing so, he has irritated ministers, who want to use the NHS legislation now planned in Downing Street to clip his wings. What ministers see as failings by Stevens and his organisation during the Covid-19 crisis – including lack of testing of patients and NHS staff, shortages of personal protective equipment, and his absence from the public sphere and scrutiny – have intensified that chagrin.
One senior NHS executive observed: “Ministers like people who, when they tell them to jump, ask: ‘How high?’ But Simon’s not like that, and that’s not how NHS England operates or was set up. This antagonism with Simon is part of them looking to pin the blame [for coronavirus pandemic failings] on somebody. It would be very convenient for them to say ‘doctors and nurses did wonderfully well – but the NHS bureaucracy and Public Health England let them down and need sorting out’.”
Almost from when he began the top job, Stevens has been trying to unwind the damage done by Lansley’s shake-up by prompting groups of NHS care providers to work more closely together on a regional basis, through sustainability and transformation partnerships and more recently integrated care systems (ICSs). However, NHS leaders and health experts point out that voluntary, informal arrangements such as these, with no legal standing and no budget, can only do so much.
While integration has been the direction of travel for England’s NHS for years, its organisational structures have impeded progress towards that goal. There has been a growing debate in recent years about whether ICSs should be placed on a statutory footing – made legal entities – in order to solve that problem. That will now be decided by the prime minister and his advisers. Matt Hancock, the current health secretary, was initially sceptical about doing that but has been persuaded of the necessity of it, officials say.
Boris Johnson intends to use planned NHS legislation to undo some of the perceived weaknesses of the 2012 act. In particular, he, the Treasury and the Department of Health and Social Care want – to coin a phrase – to take back control of the NHS by removing some of Stevens’s power and operational independence to decide how best to run the service day in, day out. He may be emboldened by his 80-seat majority to take on the politically perilous task of reorganising the NHS.
It is easy to understand the three goals of his newly created health and social care taskforce: regaining lost power; delivering on NHS commitments in last year’s manifesto; and embedding the best practice that hospitals have displayed during the pandemic, especially the close collaboration between them, such as sharing patients and personal protective equipment.
But it is harder to see what new mechanisms they can create to take back control without risking the drama that new NHS-related legislation always brings. It is also not clear what they would do with any extra power they succeed in grabbing back. If frontline NHS leaders cannot solve deep-seated problems like lengthening delays for care, why will ministers in Whitehall be any better placed to do so? What would they do differently? And if part of their motivation is reducing the criticism they get from the public and media over the state of the NHS, they may find that becoming, once again, the people who are legally responsible for it only increases, and not reduces, the scrutiny.