Quick thoughts about NHS reorganisation

The White Paper published today had been long awaited and unusually was developed more by the NHS than the Department of Health. Unlike in 2012, this time it has been greeted by more agreement that reform is necessary, although this is less pronounced when it comes to the new powers that the Secretary of State will acquire. However, it is striking that every reorganisation since 1974 contains the seeds of the next one and this is largely because most reforms fail to acknowledge five key tensions in the way healthcare is run in this country. The urge is to do something radical in one direction, rather than learning to live with them.  

The first tension is between localism and a desire for national control. Accountability mechanisms to exert control come to be seen sclerotic and bureaucratic. Often they’re followed by calls to ‘liberate the front line’ which then prove to be difficult to control. And round you go again.  

There is a related tension between political, technocratic and clinical leadership. Ministers want may control but find that the levers don’t work very well, this leads to these being strengthened but at the risk of alienating clinicians.  

It is reported that ministers believe they are getting the blame without being able to control the system. The lessons seem to be 1) you will always get the blame 2) more control increases the probability of blameworthy things 3) reforms might be seen more as a defence against this anxiety than a purely rational endeavour  

The third tension is about scale: administrative units that are too small have difficulties dealing with very large providers. But those that are big enough to do this have problems engaging GPs and local councils

Related to this is the fourth tension: competing geographies. These are usually council boundaries or hospital catchment areas. Choosing one over the other creates tensions that can be difficult to manage. The NHS has a long history of drawing lines on maps that do not reflect how local populations or councils see the world.

The fifth tension is that the NHS is overly fond of different change models which address a particular issue but leads to others being neglected and becoming problems that then need solving.  An example might be that a focus on integration and the removal of activity based payment methods is helpful for a focus on population health – not so good for waiting times

 New change models can require new structures as history often shows:

1974 Hierarchy and consensus – Area and District Health Authorities, community services moved from local government

1983 Introducing managerialism – Unit general managers introduced

1989 Quasi-markets with clinical involvement in commissioning – Trusts, fundholding and a purchaser/ provider split

1997 Hierarchy, regulation and performance management – abolition of fundholding, trusts independence curtailed, CHI, NICE, etc,

2000-10 Money, markets, more performance management, improvement methods, provider autonomy. payment model reform, clinical commissioning and more regulation – PCTs and SHAs, HCC and then CQC

2012 Different type of market – CCGs, NHSI, TDA, Monitor

2014 Integration and planning – NHSE, STPs and ICSs

 Perhaps the advantage of the current proposals is that they allow a little more scope for local variation which may offset some of these tensions. Experience suggests that this good intention is often reversed due to anxieties about variation and, it seems, a desire for neatness. 

 The pattern is that the enthusiasts for reform were often equally enthusiastic last time. Failing to learn to adapt to these tensions will mean we go round this loop again sooner than we might wish.