Hancock’s NHS Reforms
On the 11th of February Health Secretary Matt Hancock announced wide ranging reforms to the current structure of the NHS. In the House of Commons Hancock said:
“At its heart, this white paper enables greater integration, reduces bureaucracy and supports the way that the NHS and social care work when they work at their best: together.
It strengthens accountability to this House and, crucially, it takes the lessons we’ve learned in this pandemic of how the system can rise to meet huge challenges”
“Even before the pandemic, it was clear reform was needed: to update the law, to improve how the NHS operates and reduce bureaucracy.
Local government and the NHS have told us they want to work together to improve health outcomes for residents.
Clinicians have told us they want to do more than just treat conditions – they want to address the factors that determine people’s health and prevent illness in the first place.
And all parts of the system told us they want to embrace modern technology: to innovate, to join up, to share data, to serve people and, ultimately, to be trusted to get on and do all of that so they can improve patient care and save lives.
And we’ve listened – and these changes reflect what our health and care family have been asking for, building on the NHS’s own long-term plan.”
The Health Secretary was clearly marking a fundamental change of direction from the Lansley reforms of 2012.
The Health and Social Care Act of 2012, piloted through the House of commons by Health Secretary Andrew Lansley, created a completely new internal landscape for the delivery of NHS services. Primary care trusts and strategic health authorities were abolished. The Secretary of State would no longer be responsible for the running of the NHS, these responsibilities would be devolved to the Head of the NHS, currently Sir Simon Stevens.
Replacing the primary care trusts and strategic health authorities were hundreds of Clinical Commissioning Groups(CCG’s). Currently there are 135 CCG’s which are responsible for approximately two thirds of the NHS budget, some £80 billion in 2019/20. Comprised of doctors and other health professionals in a geographical area they are responsible for the purchasing of services for their local community from any service provider that meets NHS standards and costs. CCGs are overseen by NHS England including its Regional Offices and Area Teams. These structures manage primary care commissioning, including holding the NHS Contracts for GP practices NHS.
Many of these service providers will of course be other neighbouring CCG’s. But the Centre for Health and Public Interest estimated that in 2013–14 there were about 53,000 contracts between the NHS in England and the private sector, including contracts for primary care services.
According to Christian Mazzi, head of health at Bain & Company, in September 2015 70% of CCGs had failed to monitor their private sector contracts or enforce quality standards. 12% had not carried out any visits to private providers, and 60% could not say if they had done so.
Essentially then the 2012 Act extended the scope of the market within the NHS. The internal market was first introduced in 1990 and separated the role of purchasers and providers within the NHS. The 2012 Act was intended to open up the internal market to external competition.
To implement all the changes contained within the 2012 Act was going to be a mammoth undertaking both in terms of its institutional changes and in personnel. By 2014 the head of NHS England, Simon Stevens (now Sir Simon Stevens) had produced a plan to implement the 2012 Act, the Five Year Forward View (FYFV).
This was not so much a plan more a subtle reinterpretation of the broad direction of travel. The internal and external market functions would have to remain but, there would be “meaningful local flexibility in what payment rules, regulatory requirements and other mechanisms are applied”. There was to be a big role for the centre: “the national leadership of the NHS will need to act coherently together”.
Simon Stevens appeared to recognize fairly rapidly that the process of change indicated by the 2012 Act needed subtle reinterpretation rather than outright opposition. Rather than allowing the market let rip he sought to impose some coherence from the centre while at the same time devolving much of the day to day clinical functioning to local bodies.
Over the intervening years there has been a process towards integrating services. The number of CCG’s has fallen from 225 to 135. In so doing many of the clinical and other health services have a far more integrated feel to them. But there is also no doubt that many of the contracts that regulate the relations between CCG’s and other parts of the health services hinder the development and application of new and cost effective treatments and services.
Since 2015 Stevens has clearly been pushing back on the logic of competition and chronic underfunding, he has stated that “ there is also value in a forum where key NHS oversight bodies can come together regionally and nationally to share intelligence, agree action and monitor overall assurance on quality”. He clearly recognised that the entire financial, legal and transactional mode of the current NHS system was not up to coping with the increased demands being placed upon it together with sustained underfunding: “our future lies in networks and health systems, not individual go it alone institutions, a circle has to be squared”.
It is clear that Sir Simon Stevens and NHS England have been pushing in a different direction from that contained within the 2012 Act. Not overtly, that would be political suicide. But in a far more subtle manner. While not ignoring the major institutional changes the Act brought about they have attempted to limit their effects and push their operation in a different direction.
Within that framework Hancock’s announcement of a new NHS white paper looks more like a development of the Stevens plan rather than a complete U turn from 2012. So what exactly is Hancock proposing? First and foremost the market is to be substantially reduced. It has not functioned as intended and has hindered the integration of services, out goes competition and competitive tendering. There will now be a duty to collaborate across all healthcare, public health and social care systems.
Integrated care systems are to be established on a statutory footing through a NHS ICS board which will include local authorities. This body will be responsible for the day to day running of the NHS, including planning and allocation decisions. The establishment of these partnerships will bring together the NHS, local government and other partners such as voluntary organisations and the social care sector. Integration and co-operation are the new competition.
According to NHS England the new NHS ICS body will receive a single budget which will merge the budgets for general practice with acute and other services. It will also take on the commissioning functions of the CCG’s and some from NHS England. Its governing board will be comprised of representatives of NHS trusts, local authorities and general practice and others “determined locally”. This would also include representative from the large international medical corporations which are currently making significant inroads into general practice.
These reforms will also place the Secretary of Health back in charge of the NHS and other arm’s length bodies (ALB’s) through new statutory powers. The secretary of state will be able to intervene in service reconfiguration changes without the need for a referral from a local authority by using the statutory instruments contained within the bill to transfer functions either within the NHS or possibly external organisations.
However there is much that is left out of this Bill. The massive workforce shortage is completely ducked. The secretary of State will only have to publish once to every Parliament the roles and responsibilities for workplace planning. There is at present no plan for dealing with the current massive shortfall in staffing levels across all areas of the NHS.
The Bill also maintains that patient choice will be maintained. Of all the reforms contained in the 2012 Act this has proven to be one of the most popular with the public and clinicians alike. There is at present no clear indication from the Secretary of State of how this is to be accomplished. The white paper simply states that an integrated care model will provide patents with clear information on how and where their care is delivered.
One of the big omissions from this white paper is the government completely opting out of reform of the social care system. Clearly the social care system needs fundamental and far reaching reform. Both Johnson and Hancock are both on record stating as such. It can be argued that Covid has only hastened the need for major reform of this sector, with such a far reaching reform of the system why not now.
I suspect that many in Labour will want simply to oppose the Tories on this bill highlighting the concentration of power in the Secretary of State combined with the ability to award contracts to external bodies as has happened during the pandemic. But with the Tories clearly attempting to shore up their support in the newly won seats in the North I think this would be a significant mistake.
Labour should be highlighting the clear failure of the market and the new emphasis on co-operation as being more efficient at delivering public services. As many of the same failed market functions have been imposed on other sectors, particularly local authorities, Labour should make the case for the removal of the market from these sectors as well.