Some of our Great Wall is missing

The NHS is moving into another period of reform and reorganisation: but hardly anybody has noticed. Lyn Whitfield reports on NHS England’s proposals for legislative change and its effective merger with NHS Improvement.

The last reorganisation of the NHS was triggered by Andrew Lansley’s Health and Social Care Act 2012, and it was health service reform’s Great Wall of China. “A reorganisation so big you can see it from outer space,” as NHS chief executive Sir David Nicholson put it.

The current reorganisation, underway since last autumn, is attracting much less attention. Yet, in a couple of years, satellite monitoring will show sections of the Great Wall have been dismantled, and a new set of mandarins have taken charge of the palace.  

Proposals for possible changes to legislation

Two sets of developments are underway. The first is a set of legislative proposals put forward to support the NHS Long Term Plan. Over 130 pages, the plan laid out a remarkable number of projects and proposals, ranging from ‘digital first’ GPs to major investment projects in mental health and child cancer care.

However, at its core, the plan set out to reboot the agenda laid out by the Five Year Forward View, the 2014 plan to return the NHS to financial balance without undermining quality by moving toward population level planning and health management and integrated care delivery.

Following the Forward View, 44 sustainability and transformation partnerships were set up, a handful of which have become integrated care services (the current name for what were called accountable care organisations, because that’s what similar organisations are called in the US).

A raft of integrated care ‘vanguards’ were also established. Yet the Forward View struggled to gain traction, and a lack of legislation to put these new organisations onto a statutory footing was identified as one of the barriers to progress.

The 2017 election, which led to a minority government, and Brexit, which sucked-up Parliamentary time, ruled out a new health act. But after the government found a cash injection for the health service to mark NHS70, it asked for ‘helpful’ proposals as part of the long-term plan process.

Dismantling the Great Wall

In effect, the Proposals for Possible Changes to Legislation set out to reverse significant aspects of the Lansley reforms which, in retrospect, were the high-water mark for the ‘internal market’.

The internal market was propelled by the idea that competition is the best way to drive down costs and to drive up quality – at least in the sense of responsiveness to users. The Forward View, NHS Long Term Plan and legislative proposals are motivated by a different idea; that collaboration is the most efficient way to deliver services – and, perhaps, to wrap them around patients.

So, the proposals include removing the Competition and Markets Authority and NHS Improvement from merger decisions and relaxing the procurement rules that have led to the tender and privatisation of some community and screening services.

They follow through on the long-term plan’s determination to see ICSs rolled out across the country by 2021, by proposing the creation of clinical commissioning group / provider committees. These would be able to take joint decisions “in the interests of their local populations”.

They support the creation of integrated care providers (a new organisational vehicle through which a trust would run community and GP services). And they aim to rejig the NHS tariff so less ‘money follows the patient’ and ICSs have more flexibility to care out of hospitals without destabilising their emergency and critical care services.

Structural changes at local, regional and national level

If they are implemented, and then given time to take effect, these proposals would change the shape of the NHS at a local level. The number of CCGs will be reduced: NHS England has already said that one per STP or ICS area is likely to be plenty.

The number of trusts will also be reduced as stronger acute organisations take over weaker community and GP services. Mental health has already been through this kind of consolidation, so in some areas those joint CCG / provider committees could have as few as three strong members.

Shuffling the mandarins   

At the same time, a second set of developments is reshaping the NHS at national and regional level. The Lansley reforms envisaged that the Department of Health would decide policy and that NHS England would create the right commissioning environment to get it implemented.

Two regulators, Monitor and the NHS Trust Development Authority, were supposed to make sure that the providers commissioners had to work with were financially stable and operationally effective (while the Care Quality Commission marked them for safety and quality).

The steady shift towards population level planning and integrated care has rendered a lot of this dead letter. Monitor and the TDA have already merged in practice, if not in law, to form NHS Improvement; and NHS Improvement is now being absorbed by NHS England.

The Health Service Journal (£) reported recently that Simon Stevens, the chief executive of NHS England, is going to ‘lead’ NHS Improvement, whose chief executive, Ian Dalton, has agreed to depart. To maintain the legal niceties, NHS England will create a chief operating officer, who will also hold the title of chief executive of NHS Improvement.

But in practice, the two organisations will be led by Stevens and a deputy. It is not yet clear who this will be as, in the shake-up, the role of deputy chief executive of NHS England, which is held by Matthew Swindells, is likely to vanish.

The ‘new’ NHSE/I will operate through seven regions, led by regional directors who were announced just before Christmas.

Reaction reignites old battles: 

Where there has been reaction, it has generally been positive. From their very different political perspectives, both the Guardian and the Financial Times focused on how the proposed legislative changes would “scrap laws driving the privatisation of the health service” and “end rules forcing services to be tendered.”

The British Medical Association went further, saying competition rules wasted “time and money on tendering processes for contracts” that could be “better spent on the frontline” while “resulting in a fragmented NHS, driven by commercial motives rather than providing patients with seamless care.”

“NHS England’s ambitions are clear, and we strongly recommend Parliament to take forward these proposals and to push forward these legislative changes,” it concluded.  

However, there have been some dissenting voices. The Times (£) carried a leaked DHSC briefing document that, it claimed, “quietly warned” health and social care secretary Matt Hancock that the proposals would “undo” the internal market and with it “some 30 or so years’ worth of policy and legislation, including some of the checks and balances that a market-type approach allows.”

David Hare, the chief executive of the Independent Healthcare Providers Network, went further, complaining in City AM that the proposals to bring commissioners and providers together would “create huge conflicts of interest” and the changes to the procurement rules would “shield providers from pressures to improve.”

“Turning the clock back a generation, and reintroducing the unresponsive NHS monopolies of old, [means] patients will be the real losers, if the government chooses to push ahead,” he argued.

Health tech impact: changed priorities, new customers

The politicised nature of the reaction shows there is something at stake in all these legal and organisational manoeuvres; which should make health tech vendors sit up and take notice.

If the legislative proposals are implemented, and if they are seen through, then in a few years companies that are working with or wanting to sell into the NHS could find themselves facing a very different set of customers. That could mean powerful new regional organisations and effective ICSs run by bigger, better focused CCGs via the joint committees.

All that should open-up opportunities for suppliers with integrated care record, population health management, and digital patient products. But it may close-down a lot of the market that has been created around contracting and target monitoring.

At the same time, there could be far fewer provider trusts, and those that exist may be running chains of hospitals or integrated care provider set-ups of acute, community and GP services. That could open-up a market for cloud-based enterprise and electronic patient record systems.

But it may shake out incumbent suppliers and make it harder for new entrants to gain a toehold. Particularly if those procurement rule changes mean that fewer contracts go out to tender and more awards are made on the basis of ‘best value.’  

Interesting times

The legislative changes are only proposals. They could fall with a change of government. They could generate opposition and be amended. They could pass but make no difference, because the NHS Long Term Plan, like the Forward View before it, finds it impossible to get ahead of the curve on demand, finance and the looming workforce crisis.

On the other hand, the structures at the top of the NHS are being reshaped, and for the moment it is the NHSE/I agenda that has traction. Interesting times.