The Lansley reforms of the National Health Service in England, embodied in the Health and Social Care Act 2012, failed. More than 500 pages long, and often opaquely expressed, the legislation stripped control of the NHS from national and local government, and thus from the public, creating a large new bureaucracy to manage healthcare, drive competition and build a regulated internal market.
Owl recalls that, at the time, these reforms were expressed in language so opaque that only the author seemed to understand them. Reason enough for a strong Prime Minister to call a halt. “If you can’t explain it simply, you don’t understand it well enough” – Albert Einstein. Such opacity was contagious and was even infecting EDDC around 2015.
The Guardian view on NHS reorganisation: the need to integrate
Few would dispute that the Lansley reforms of the National Health Service in England, embodied in the Health and Social Care Act 2012, failed. More than 500 pages long, and often opaquely expressed, the legislation stripped control of the NHS from national and local government, and thus from the public, creating a large new bureaucracy to manage healthcare, drive competition and build a regulated internal market. Coming amid fierce spending austerity, the reforms were often seen as the enabler of a programme of cuts and privatisation. “I could and should have stepped in earlier,” David Cameron admitted in his memoir.
Disastrous though the reforms have been, and clear though the case is for replacing them, a new attempt at reorganisation would be destabilising, mid-pandemic, without strong support within the NHS that it can be implemented sympathetically. Matt Hancock embarked on such an attempt on Thursday, in his Integration and Innovation white paper. His proposals unquestionably cut with the grain of much that NHS England has been advocating to improve integrated care in the past two years. But Mr Hancock will have to make a strong case over the coming weeks if the public is to be persuaded that this reorganisation is the right priority in health policy.
That’s because the context is at least as tough today as it was in 2010-11. The NHS is in the midst of the biggest public health crisis it has ever faced. Staff are exhausted and there are large numbers of vacancies. Waiting lists for essential interventions are lengthening alarmingly – nearly quarter of a million people are now waiting more than 12 months for treatment. The care crisis is getting worse and there is no clear plan for reform and financing. The economy is on life support, with public money likely to be very tight for years. Ministers mess with the NHS at their peril.
Exactly why this is the right or necessary time to launch a structural reorganisation of the NHS is not obvious. Higher spending seems a much more immediate and practical response. Mr Hancock says that lessons from the pandemic point towards the need for his new approach. That may well be true. Covid has cruelly exposed some of the multiple fragmentations in the health service – not just between health and care, but between proactive and reactive health services, between hospitals and GPs, and between physical and mental health. Nevertheless, Mr Hancock was very selective in the lessons he cited to MPs. Nor were the lessons he mentioned new discoveries.
It is true that the Covid-19 crisis shows the need for better integration. This is something for which NHS England has been pressing, in the form of what it calls integrated care systems. But the largest single example of the current fragmentation – the relative neglect of care homes in relation to hospitals – will remain unaddressed until there is a proper spending programme, which forms no part of the white paper.
The past 12 months have exposed several ways in which the health department and NHS England have struggled to respond as effectively as they should. But it is far from obvious that these would have been better handled by Mr Hancock taking more powers from the NHS England chief executive, Simon Stevens, as he proposes to do. It is not clear that an empowered Mr Hancock would have avoided many of the most significant failures of the pandemic to which he conspicuously did not refer in the Commons on Thursday. These include major failures of equipment provision, staffing shortages, lack of proper training for the Nightingale hospitals, poor coordination, IT deficiencies, the abortive test-and-trace system, and the appointment of inadequately qualified cronies to management roles. After the immense efforts and sacrifices made by NHS and care workers, Mr Hancock needs to proceed with a humility that his tin-eared predecessor failed to show a decade ago.