Big picture: a closer look at health system reform

The NHS in England is set for another round of reform. Earlier this month, the Department of Health and Social Care published a new white paper, called Integration and innovation, proposing changes to NHS rules and structures. A pandemic may feel like odd timing. (It is.) But the proposals follow a series of requests from national NHS bodies for changes to NHS legislation in England.  

The Health Foundation’s policy team has been assessing these proposals for reform, and will be producing more analysis on how national policy changes impact health and care throughout the year. 

So, why do government and NHS leaders think that changes to legislation are needed now?  

This depends on who you ask. For NHS leaders, the rationale is that legislation is needed to make it easier for NHS organisations to work together to improve local services. Andrew Lansley’s Health and Social Care Act 2012 – the last round of major NHS reform in England – sought to strengthen competition within the health care system and created a fragmented and complex NHS structure. But Lansley’s reforms didn’t turn out as he hoped. NHS leaders embraced collaboration instead, and created things called sustainability transformation partnerships (STPs) and integrated care systems (ICSs) – partnerships of NHS commissioners, providers, and local government – to join up local services. But these partnerships are a workaround: they have no formal powers and the 2012 Act’s rules on competition can make collaboration difficult. 

As a result, NHS leaders want to reverse key elements of the 2012 Act – including by removing requirements to competitively tender some NHS services, scrapping clinical commissioning groups (CCGs), and formally establishing new area-based agencies within the NHS (ICSs) to make decisions on local priorities and spending (with ICSs taking on the functions of CCGs). The changes seem to mark an end to the NHS’s 30-year experiment of encouraging competition within the health system. 

Encouraging collaboration to improve services makes sense, and the need for legal changes to reduce fragmentation and complexity in the NHS has long been recognised. But there are clear risks. The benefits of integrating services are perennially overstated by policymakers. And merging and creating new agencies can cause major disruption. The proposals are also not clear on how ICSs will work in practice, and the role of local government in the new system proposed is poorly defined.  

But this is only half the story. The white paper also includes a set of political changes proposed by government to strengthen ministerial control over the NHS in England. The 2012 Act sought to reduce political interference in the day-to-day running of the NHS. But the white paper would see control shift back to ministers – with powers to direct NHS England on NHS policy, transfer duties between and abolish national NHS bodies, and intervene earlier in local service reconfigurations.  

The rationale for these changes is not clear. An early (leaked) draft of the white paper seemed to suggest that the pandemic had illustrated the need for stronger ministerial direction over the health system. But evidence that this would have boosted the NHS’s pandemic performance is hard to find. 

Standing back, the white paper should be understood in the context of the long history of NHS reform. In its first 30 years, the NHS’s structure was relatively stable. But over the past 30, the NHS in England has been on an almost constant treadmill of reform and reorganisation. Overall, evidence suggests that previous reorganisations have delivered little measurable benefit. The danger is that this latest round distracts the system at a time when services are starting to recover from COVID-19. The NHS has a long list of other priorities – including addressing the backlog of unmet care needs, fixing chronic staff shortages, and working with others to help tackle wide and unjust health inequalities. 

The white paper is also silent on how government plans to deliver the Prime Minister's promise to ‘fix’ adult social care in England ‘once and for all’. If it chooses to, government could afford to provide more generous care and support for vulnerable people and their families in England. But by ducking reform – again – government is choosing to prolong major public policy failure instead. 

We’ve been analysing the proposals for NHS reform as they’ve emerged over the past few months. In this piece for the BMJ, we used evidence on past NHS reorganisations to assess the latest proposals and understand their potential effects. We published analysis on what the proposals may mean for primary care networks (PCNs) in England, collaborating with colleagues involved in the University of Birmingham, RAND Europe and Cambridge Rapid Evaluation Centre’s study of the first year of PCNs. And we will be taking a deeper look at the key proposals in our webinar on 11 March: The Health and Care White Paper unbound. We also plan to publish further analysis on the reform proposals as they develop over the rest of the year.  

Health system reform is a core focus of the policy team’s work at the Health Foundation. Aside from the white paper, our research this year will focus on identifying policies to tackle inequalities in primary care, what the NHS can do to address people’s social and economic needs, how policymakers in the NHS and government can plan more effectively for the long term, and more. We will also be looking at the evidence behind major reform approaches in the NHS – such as collaboration between health and social care – and health priorities for the NHS and government as the country begins to plan its recovery from the pandemic. You can read more about the team’s work here.  

Hugh Alderwick (@hughalderwick) is Head of Policy at the Health Foundation. 

This content originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.