NHS Reset: We are at a crossroads – which way now?

It has been our mantra in England for nearly a decade: no top down reorganisation! It was loud and clear even before the 2010 election, but ironically, became written in stone after the 2012 restructuring. This was not because it was seen as the reorganisation to end all reorganisations, but because it was regarded by many as the worst of a long line of futile attempts to create coherent structures for the NHS.

The experience from the past shows that structural change is never a panacea. It almost always delivers less than expected, and the service generally progresses despite, not because of, the organisational form in which it operates. But while perfection is not achievable, structures do matter (along with a host of incentives) and they can affect performance and quality of care. Setting the right structural arrangements to govern relationships and accountability is worth our attention.

In many ways, COVID-19 has exposed brutally the divisions and inefficiencies that beset our sector. Providing health and care services is complex, but the array of organisations and vested interests makes it more so. This pandemic has also shown what is possible when all that matters is tackling immediate need. We have long known that our landscape is littered with unnecessary obstacles to more effective working, and the innovations and ‘can do’ spirit of recent weeks have exposed what can be done when there is a will to do so. Somehow, we need to capture this. There is much activity already underway at every level to do this, but creating the right structures and relationships will also play a part.

Reorganisation? What reorganisation?

Of course, the truth is we have already embarked on a reorganisation journey by stealth. What would you call the creation of integrated care systems and primary care networks, the steps to redefine commissioning and the mass mergers of clinical commissioning groups, the establishment of new regional outposts and the merger of NHS England and NHS Improvement? If it looks like, swims like and quacks like a reorganisation, then it probably is one.

While this has been going on though, the politics have changed. Much of the discussion after 2015 was coloured by a view that government had other things on its mind and that the way to deal with the many flaws in the 2012 settlement was to find ways around the legislation. And then with Brexit overwhelming every other political consideration from 2016, and then an even more precarious administration, there was no means or appetite for legislative change.

But that is the past. We now have an administration with a large majority and with a need to focus on the NHS and care system like never before. Ministers will be more conscious than ever about their accountability. Like us, they always understood the challenges of demographics, funding, workforce and expectations and they know now that they will be greater than ever. Creating a COVID-19 and non-COVID-19 service, while tackling the backlog and unmet demand from the pause and the lockdown, is a daunting prospect. And now, whatever they may have wished, the social care crisis will not go away.

Moving forward

We will also have to answer the question as to whether the current developing arrangements are fit for purpose. There are significant and positive signs from the advanced integrated care systems that bode well for what could be achieved. But how far are these dependent on heroic leadership or relationships built over many years? Even leaders in those areas are concerned about the need to move more quickly and at scale. At the same time, we must concede that we have yet to sort the accountabilities in the emerging new order.  

While everyone is focused on the here and now, this may not seem the time to start this debate. But if the service is to make its voice (or to be honest, its voices) heard, this is the time to wake up and take part. In the past, the noise from sometimes legitimate vested interests that hold sway across our sector have hampered these discussions. If we can, we should at least recognise when these are in play. What matters is not the survival of organisational or professional boundaries, but how we can create sustainable joined-up services that meet the needs within local populations.   

It looks likely that by July or August, ideas will be forming about the way forward. Work will be underway on the next Comprehensive Spending Review, which will determine not only the 2021/22 funding round but also longer-term prospects for the NHS and social care. The economic outlook, meanwhile, looks terrible, with only the prospect of a labour market that may be easier from which to recruit.

Influencing this will be more difficult if the service itself is confused or clearly divided. In recent years, the service, or at least NHS England, has largely shaped health policy – the politicians have been quietened by their own troubles. That is likely to change. The tectonic plates are on the move and influencing the outcomes will require clarity and an understanding of where both national and local government stand and what they will be prepared to embrace. The political class may wish to exercise more control from the centre, but that would be a mistake. It is likely, too, that relationships within the centre after COVID-19 will become even more strained. We need a settlement that sorts local and national accountability.

Playing our part

So where does the NHS Confederation stand? As ever, we will be led by our members, but our current view is that while significant legislative change is not the whole answer, it is necessary. We will need more far-reaching measures than those envisaged in the earlier draft proposals, which we helped to draw up. This is a moment for boldness, not tinkering.

We need to determine what we want the health and care system to deliver with what resource and over what timescale. The NHS Long Term Plan in England still looks like a good roadmap, but it will need to be adapted with lessons from COVID-19, it will need to be set with more pace and we need much stronger clarity about workforce supply and retention, as well as honesty about funding volume and flows, and what any settlement will and will not achieve.

At the heart of this will also be the need to solve social care – the role of and relationship with local government, its funding, structure and support, and how we move to parity with the NHS. We will need to agree the nature of the commissioning function for both health and social care, where it should sit and how we want local and national accountability to operate.

At the same time, we have not devoted enough attention to how we retain provider accountability for quality and performance with appropriate autonomy but operating within integrated systems. If integrated services are to mean anything, they will have to operate at place and neighbourhood level and that almost certainly means allowing for different organisational provider models.

This seems the right time for an honest debate with the service, with our watchwords being interdependency and integration. In the end, this is about creating services and pathways that reflect patient needs and make our sector affordable and sustainable. At the NHS Confederation, we have set up our #NHSReset campaign, a key strand of which will be to enable and encourage the NHS and its leaders to help shape this existential debate.

In the NHS, it always seems as if we are at crossroads of one kind or another – now is certainly no exception. 

Niall Dickson is chief executive of the NHS Confederation. Follow him on @NHSC_Niall and the organisation on @NHSConfed