‘What’s past is prologue’ Is Government planning seismic change in the NHS?

Image of the palace of Westminster, Elizabeth tower, london bridge, and the London Eye to show 'What’s past is prologue' Is Government planning seismic change in the NHS?

Seismic change may be afoot for the NHS in England. That is, if one is to believe the conflicting rumours from various ‘government insiders’ published last month. Claudia Forsyth shares her take.

According to reports in The Times and Guardian, Boris Johnson is pushing a ‘radical and politically risky’[i] reform agenda for the health service in England, that far exceeds the recent news on the planned restructure of Public Health England (PHE).  This more major reform will be orchestrated by the new Health and Social Care Taskforce, formed of senior civil servants and advisors, including Johnson’s controversial special adviser on health, William Warr.[ii]

While the Guardian suggests that with a mandate from Johnson, the Taskforce was seeking to push through legislative change this year, conflicting reports from the Health Service Journal (HSJ)[iii] state that the plans in fact originate from the Department of Health and Social Care (DHSC). HSJ suggests that No.10 blocked the plans that the Health and Social Care Secretary, Matt Hancock, had hoped would be tabled before Summer recess, pushing them back to 2021.

Regardless of where the driving force for reform sits, press coverage describes a menu of potential changes that have their roots not only in the bungled management of the coronavirus pandemic, but back in the much criticised 2012 Health and Care Act.

Integration, integration, integration

It is eight years since the introduction of Andrew Lansley’s health reforms entrenched the purchaser provider spilt, and since that time many have dedicated their efforts to unpicking them.

The belief that the NHS would deliver better care through integration, rather than separation of services and budgets, was formally put to the Government by NHS England in September 2019. In response, the Government agreed to include a commitment to greater integration, by introducing local ‘joint committees’ to support the work of Integrated Care Systems (ICSs).[iv]

Since the pandemic, we now hear that the proposed legislation would go further and make ICSs statutory bodies, fully realising the demands of many for a properly integrated system, and reversing the core principle of the 2012 Act.[v] HSJ reports that the Treasury is also particularly supportive of this move, as it would provide greater clarity on which bodies would control which NHS funds. However, with such a significant shift, we would likely be left with yet another layer of bureaucracy in the complex NHS England infrastructure.

There has already been push back even from those acknowledging the shortcomings of the current NHS structure, such as from former Conservative Health Minister Dr Dan Poulter MP.  Poulter warns against the dangers of such upheaval, which could lead to worse outcomes over the short term and further chaos in a health system already under pressure.[vi]

A non-departmental public body?

In addition to dismantling the NHS as we know it, it is expected that legislation would seek to bring NHS England under closer direction from the Secretary of State.[vii] We have already seen a move in this direction with the reform of Public Health England, and the installation of a Conservative Peer at its helm. The seed for this desire for greater governmental control was likely planted in the halcyon days well before coronavirus, as Johnson asked DHSC staff to be ‘more assertive’ with NHS officials, following his election.[viii]

It is no secret that Simon Stevens has been an outspoken critic of the Government at times during his six-year tenure as NHS Chief Executive. Most recently during an interview with the BBC, he criticised the Government for their lack of action on social care, calling for clear policy direction and change within a year.[ix] However, wresting control from a seasoned professional such as Stevens, and putting it in the hands of a minister, would surely have repercussions.

Where do we go from here?

No irony is lost in the prospect of the Government stripping Stevens of his autonomy, while simultaneously granting the reform he has been orchestrating since his appointment. But what would the passage of these reforms mean for pharma and those working with the NHS, and how, if at all, could the move towards greater governmental control impact the possibility of greater integration?

Many will welcome the prospect of integration of services, long been recognised as a potential solution to much of the current problematic siloed thinking and decision-making. However, one must consider the way in which these changes would be introduced and what they may displace. In an already crowded commissioning landscape, the way any reforms are communicated would be vital, along with appropriate validation and testing of suggested changes. On this basis, moving the tabling of new legislation to 2021 is a wise move, particularly considering the current pressures and priorities. Similarly, proper transparency and opportunities for meaningful input into any proposed legislation would be essential early next year.

The impact of greater government oversight of these reforms may not be material, providing that prevailing political opinion is supportive of greater integration, and continues to be so through any implementation period. It is possible that with ministerial involvement may come a clearer line of accountability, and ensuring this features in future reforms will be important for interested stakeholders.

However, the suggested changes could mean the politicisation of individual decisions about the running of the NHS. This could even reach so far as individual services and availability of treatments. For example, one might ask what the potential repatriation of powers to government might mean for the NHS Commercial Directorate, which continues to flex its considerable muscle to grant access to high-cost medicines. Should there be greater government involvement, we may see an increase in decisions made on the basis of political expediency, and who-can-shout-the-loudest, as is often the case in other policy areas. While industry may agree that the current system for granting access to treatments on the NHS is far from perfect, surely we would not advocate moving questions about access further into the political sphere?

The answer to this question may not be a straight-forward one, as anyone who has followed this discourse play out in the political and public sphere will tell you. However, when thinking about where power lies in our health system, we must consider the necessary balance between public accountability and evidence-based decision-making. It has yet to be seen whether reforms mooted by government sources will upset the equilibrium.

[i] https://www.theguardian.com/society/2020/jul/10/boris-johnson-plans-radical-shake-up-of-nhs-in-bid-to-regain-more-direct-control

[ii] https://www.bmj.com/content/366/bmj.l5309 | https://www.politico.eu/article/boris-johnson-william-warr-health-adviser/

[iii] https://www.hsj.co.uk/policy-and-regulation/exclusive-no-10-tells-hancock-wait-until-2021-for-nhs-law-change/7028058.article

[iv] Ibid.

[v] Ibid.

[vi] https://www.theguardian.com/society/2020/jul/10/boris-johnson-plans-radical-shake-up-of-nhs-in-bid-to-regain-more-direct-control

[vii] https://www.hsj.co.uk/policy-and-regulation/exclusive-no-10-tells-hancock-wait-until-2021-for-nhs-law-change/7028058.article

[viii] https://www.thetimes.co.uk/article/no-10-power-grab-for-nhs-sparks-backlash-over-turf-war-wfbdn8f3m

[ix] https://www.bbc.co.uk/news/uk-politics-53297312