“Death and taxes and childbirth (and NHS reorganisations)! There’s never any convenient time for any of them” – with apologies to Margaret Mitchell 1900-49
One cannot help but admire the work ethic of the Secretary of State for Health. If Matt Hancock is not managing the pandemic response, sorting out the vaccination programme, handing personal protective equipment (PPE) contracts to chums, Tory donors or companies with no record in the field, he now wants to reorganise the National Health Service (NHS).
The Tory Party and reorganising the NHS is somewhat like a six-year-old and the cookie jar – temptation cannot be resisted. If it goes ahead it will be the first NHS reshuffle that I will not have been involved in since 1968. To some extent my feelings about Hancock’s plans could best be summarised by Rhett Butler’s “frankly, my dear, I don’t give a damn”. Over my nearly 50 years of association with the NHS there was hardly a year when it was not being prepared for a reorganisation, being reorganised or recovering from a reorganisation.
Strangely for over 30 years following its establishment, the Government left the NHS alone. Despite ganging up with the doctors in their opposition to its founding and voting against the legislation when the Tories returned to Government in 1951, they left it alone. Perhaps the penny had dropped that patients quite liked being able to see the doctor without first checking the depth of their purse or width of their wallet.
Through the 1970s the occasional article appeared about changing structures but gained little momentum. This changed when Margaret Thatcher entered Downing Street in 1979. The first to have a go was Keith Joseph who subjected the NHS to a massive, bureaucratic and slow-moving shuffle of the chairs. Services were transferred between the NHS and local government bodies were abolished and new ones created. The implementation dragged on interminably. I am still waiting to be called for interview for a job I was interested in – perhaps I should stand down now!
Thatcher met President Reagan and was persuaded the post-WWII social democrat settlement had served its day. The time had come for the state to butt out of providing services. Only the private sector could promote quality while delivering value for money. Thatcher appointed the boss of Sainsbury’s to do a review. He declared that on the wards nobody knew who was in charge. Out went Joseph’s consensus management and in came Chief Executives – and preferably ones from the private sector.
Now there was hardly a flood of invaders from across the private/state divide, but some made the journey. They accepted much lower salaries than they could command in the private sector in the interests of Thatcher’s ideology. Although she was in favour of all things private and profit-driven, this stopped at paying private sector level salaries from the public purse.
Arguably Thatcher’s biggest innovation was the introduction of the NHS internal market. No longer was the NHS a collaborative venture, it was now a market. Hospital, community and mental health services were organised into discrete provider organisations who were no longer awarded budgets but instead had to bid for contracts that were performance based.
The newcomers quickly realised they could not make tricky decisions in secret and hide their true intent behind a carefully worded press release. The public had a legal right to attend Board meetings where plans to balance budgets were discussed. Often this would involve closing services. Even plans for reforming and moving services to different locations were often bitterly fought battlegrounds with lobby groups unwilling to contemplate any kind of change. If the doctors took a dislike to a CEO, they could gang up and ring some pals up the NHS food chain. A CEO rarely survived this kind of undermining. For many of the private sector imports, these were all impediments beyond the pale and they promptly returned to the quieter waters of the private sector. The prospect of managing in a goldfish bowl and being stabbed in the back by the vey people you were supposed to be managing was just too much.
To his credit, Tony Blair avoided reorganising the NHS. Instead, he found ring-fenced funding and targets were the way to go. He increased funding to record levels which the Tories, despite all their bluster, have yet to match. Ring-fenced money was provided, and performance targets set. As a result, waiting times and waiting lists fell to historically low levels and public satisfaction with the NHS soared to historically high levels – again something the Tories can only dream about.
After nearly 20 years of relative organisational calm, the Tories returned to power in 2010 and could not resist another visit to the cookie jar. It was time for Andrew Lansley to have a dabble. He wanted to give control to the doctors so Clinical Commissioning Groups were formed – lots and lots of them. Contracting between commissioners and providers was reinforced and the private sector was allowed in. So after Virgin Brides and Virgin Holidays we now had Virgin Healthcare. The Thatcher reforms were reinforced and extended.
Over my 50 years, the NHS worked its way through Hospital Management Committees, Boards of Governors, Regional Hospital Boards, Unit Administrators, District Administrators, Regional Administrators, District Health Authorities, Regional Health Authorities, Area Health Authorities, NHS Trusts, NHS Foundation Trusts, Partnership Trusts, Clinical Commissioning Groups etc etc. I feel sure I have missed some!
So did all these changes make any difference to patients apart from a change on the letterhead? Did they improve the delivery and quality of healthcare patients received? In my experience – NO.
Despite all these changes, the occasional but very damaging patient scandal was not avoided. The maternity scandal in Shropshire, bad care of people with a learning disability in Hampshire and various examples of poor care in psychiatric settings were not avoided. I would suggest the focus on winning new contracts actually encouraged some leaders to take their eye off the ball.
All the reorganisations were surrounded by slogans about “putting the doctors in charge”, “cutting management costs” and “reducing bureaucracy”. Nobody carried out post reform studies to establish whether these goals were achieved.
My experience tells me that the route to improving the quality of patient care and outcomes for patients lies through audit, data collection and sharing, promoting and sharing good practice, research, technological innovation and the introduction of new drugs. This does not require major structural change but does require effective local and focused leadership.
And so, we come full circle to the Hancock reforms. Apparently, he is up for health and social care integration. Legislation will be passed to make working together across the NHS/Local Authority divide easier.
Now this appears very attractive – a vote winner perhaps. Who does not want to work in a more integrated way? Sadly, it is a pathway littered with land mines. First, there is little political appetite for the not insignificant challenge of integrating health and social care. Secondly, the reason for this is healthcare is free at the point of use but social care is means-tested. Merger raises the somewhat significant question of what remains free and what gets means-tested and who gets to decide. Thirdly, social care is accountable through local authorities to local electorates while the NHS is accountable to voters via Parliament.
As things currently stand, social care money can only be used for the provision of social care and, likewise, NHS money can only be used the provision of health care. However, mechanisms already existed for budgets to be pooled. The intention being, without crossing the Rubicon, that social care money is used for social care and health care money used for health care but done in a way that provides a seamless service for the patient/client.
So why does not Hancock invest in getting the current mechanisms to work properly? Why not pass legislation that allows health and social practitioners to see the care and treatment plans of clients on which they are supposing to be working together?
This already happens in some places so why not source the best practice and promote it to the laggards but with penalties for dinosaurs who want to hide behind barriers erected in a different time.
I doubt Hancock is planning legislation to make social care-free at the point of need (a case for that can be made given the costs around running a means-tested system) which would largely remove the problem he is trying to resolve. However, there is little appetite for this, and it could deliver a bitter fight with local authorities.
What I suspect will happen is, that in a bit of self-promotion, Hancock will pass a lot of wordy and mildly threatening legislation that he will claim delivers integration – job done so let us move on and perhaps no need for social care reform after all.
The reality is that integrated care can already be delivered. It just needs to be made to work properly and the route to that lies through the sharing of good practice within a legislative framework that sets the right tone and the ground rules. Sadly, there is no political glory in doing that.
The real problems are the underfunding of social care leading to reductions in service including people getting stuck in a hospital bed unnecessarily and best practice on working together across the health/social care divide not being universally applied. These two challenges do not need legislation to fix which would only serve as diversion.
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