SO HERE we are again: another year, another government, another NHS reorganisation. However, Sir Keir Starmer’s announcement that he is to abolish NHS England, the largest quango in history, came as a bit of a surprise despite the number of resignations of its senior managers over the last week or so.
At this point I must admit that I have some skin in the game. When the National Health Service was inaugurated in 1946 my grandfather, after whom I am named, was appointed to the Executive Health Council for Dumfriesshire and served until he retired in 1952 due to ill-health. So, NHS management is clearly in my genes which is why I have a morbid interest in such things and indeed indulged in some local NHS management myself during my career (although I hope I proved to be a better doctor than manager).
When the NHS was established the Minister of Health was responsible for Regional Hospital Boards, Hospital Management Committees and Boards of Governors of teaching hospitals. During this period a hospital was run by an administrator, generally with a few supporting staff, dealing with the day-to-day functions. The clinical work was managed separately by the matron and the consultants, and there was no managerial input, although it must be accepted that the NHS and medicine in general was much more basic than today. This remained generally the same until the National Health Reorganisation Act (1973). The whole system was changed with the establishment of District Health Authorities, answerable to Area Health Authorities, answerable to Regional Health Authorities, answerable to the Department of Health and Social Security.
I will skip further details to avoid tedium, but you will get the drift. I once attempted to catalogue all the reorganisations since then but gave up in despair (I think I got to 43, which included both large and small changes). However, there were several ‘highlights’, for example in 1983 Margaret Thatcher, the grocer’s daughter, commissioned Roy Griffiths, the Deputy Chairman of Sainsbury’s, to report on the NHS. The result was the introduction of Griffiths managers to run the hospitals which were divided into Directorates. This change was badly received by the doctors as an unwanted intrusion by management into clinical issues, a feeling which remains to this day among many. Although this was, as usual, presented as a means to drive up the quality of clinical care, the real reason was to control costs, and the Griffiths managers generally succeeded by slashing expenditure in the Directorates, more benignly known as ‘cost improvement programmes’ (I know, I was there). Generally, we were set a target of 3-5 per cent each year.
Since that time each Secretary of State, determined to make his mark, has commissioned more reports leading to yet more reforms in both the hospitals and primary care. The list seems to be endless but includes ‘Working for Patients’ followed by the NHS and Community Care Bill (1989), NHS Trusts, GP Fundholders, ‘The Patient’s Charter’ (1991), ‘Care in the Community’, Payment by Results, PFI contracts, Primary Care Trusts, (PCTs 2002), Foundation Trusts and many more. The clear intention of these changes was to shift power from doctors to managers, and from specialist consultants to GPs, although it became increasingly clear that many GPs were ill-equipped to handle this responsibility, having little understanding of corporate governance, although some relished their new-found power.
In 2000 Tony Blair increased his control over the NHS by appointing Nigel Crisp as the CEO of the NHS but also as Permanent Secretary, thus combining the political and executive roles. In 2002 he introduced the system of Payment by Results which allowed PCTs to pay hospitals on the basis of the number of non-emergency cases they treated. However, this inevitably introduced opposing incentives: the hospital trusts wanting to maximise income, while the PCTs endeavoured to reduce expenditure. One such outcome was that, with a fixed tariff, if you were a frail elderly patient requiring a new hip or other complex surgery, and likely to incur a longer hospital stay with higher costs, you were unlikely to be selected for surgery, as opposed to a fitter younger individual. Blair, a Labour PM, also made it clear that 15 per cent of NHS work was to be carried out in the private sector, although this was not to be seen as ‘privatisation’ which only the wicked Tories could contemplate.
The system bumbled on until we come to the Health and Social Care Act (2012, Conservative) which established NHS England, set up as an organisation with statutory independence from the Department of Health and Social security. Its purpose was to oversee budget, planning, delivery and day-to-day operations of health commissioning. The idea was that this should be separate from political interference, after all what do politicians know about such matters (my comment)? Changes continued under NHS England, the latest being the introduction of Integrated Care Boards (2022) for ‘developing and co-ordinating work across their local system to reduce health inequalities and improve the health of their communities’.
The interesting thing is that if you compare the principles and aims of the Department of Health and NHS England you will find that, although the word salads used may be slightly different, they are, in principle, essentially identical. So we have ended up with two organisations with the same job, although NHS England clearly has the executive role. The last 14 years has also seen a massive expansion in national and regional bodies with associated bureaucracy and costs.
We have thus come to the announcement of Wes Streeting’s ‘bonfire of the quangos’, with more than 9,000 redundancies in NHS England, and perhaps up to 30,000 in the regional bodies. Hurrah! Let’s rid ourselves of thousands of the bungling bureaucrats, put the money saved into patient care, and bring back matron.
Now I need to don my sceptical cap, having worked at the front line for 40 years, and ask the obvious questions: the first being that, with all the money (£billions, time and resources) invested in all the multiple reorganisations over the years, where is the evidence that it has made any significant difference to the delivery of health care? Clinical outcomes have improved, the evidence being that as a nation we are living longer and more healthily. But this is largely due to advances in medical and surgical expertise and, let’s be honest, some good local managerial input and planning. But access to the service has never been worse. It is often impossible to see a GP face to face, there are months of waiting for outpatient appointments, huge delays in treatment, and as for the A&E departments – don’t go there! Literally! So given the history, what is the likelihood that these latest ‘reforms’ will fare any better?
I personally doubt it because of the glaring elephant in the room, which is that although Streeting has stated what he is going to abolish, he has been totally silent on what he will put in its place. For example, let us assume that the NHS needs a constant daily supply of thousands of widgets to keep the service going. This requires a robust tendering and procurement system, both nationally and locally. Since the widgets may be very complex the process will need to be well informed and robust. At present this is managed by NHS England, but the Department of Health will lack the necessary skills and will need to set up systems and staff to manage the process, a department for widget procurement. Equally the clinical service will need to be planned, commissioned and financed by someone, which to the present has been the function of NHS England, not the Department of Health. Who will fulfil these roles?
Consequently, there are two scenarios. The first is that thousands of current NHS England employees will take generous redundancy payments, book a five-star holiday in the Caribbean, and immediately start applying for the new posts which will inevitably become available in the refurbished Department of Health. Alternatively, to reduce redundancy costs, staff may simply transfer to the new system. Multiply this by many thousands, and the purported savings will quickly dissolve. The jobs will not creep back, they will gallop!
Politicians love fine words, but for the NHS to develop requires vision beyond the obvious, and clear strategic thinking, and a large dose of realism is required. Sadly, I have seen no evidence of this in the current government, and based on experience I have minimal hope that they will achieve anything. It is easy to pull things down, but infinitely harder to build.
