NHS reforms: plus ça change

The King’s Fund today released the first half of its verdict on how well the coalition has done on the NHS.  The second half – looking at NHS performance since 2010 – will be released in March, but today’s report focuses on the Lansley reforms.  Their verdict?  To put it bluntly, damning.  ‘Distracting and damaging’ were their words.

At my previous university I used to give a lecture on the history and structure of the NHS to first year medical undergraduates.  Given the continual revolution that is the NHS, this needed a certain amount of re-writing every year: editing the structure, and the history section getting longer and longer…  The introduction of the Lansley reforms required a bigger update than usual.

Prior to the Blair reforms of the early 2000s, most of the NHS budget was held by health authorities, although there had been experiments with GP fundholding in the preceding decade.  The Blair government decided that health authorities were too distant from the population they were intended to serve, run by managers not medics, and thus not responsive to the needs of their people.  They were therefore swept away in 2002 and replaced by 4-500 primary care groups (PCGs), later to become primary care trusts (PCTs) at which point they took over responsibility for around 85% of NHS expenditure in England.  All were to have Health IMProvement plans for their populations (known as HIMPs), overseen by the Commission for Health Improvement (disappointingly christened CHI, not CHIMP).  Crucially, they would be GP-led organisations: the GPs being gatekeepers to secondary care and also those closest to their respective populations.  In theory they could use their budgets to commission the most appropriate care for their populations.

In 2006, it was decided that the PCTs were too small, bureaucratic and inefficient, so they were merged down to 152, but with increasing quantities of ‘practice based commissioning’ (PBC), devolving budgets down to individual practices.

So along comes 2010, and the general election which no-one won.  Announcing the resulting coalition between the Conservatives and Liberal Democrats in the Rose Garden at number 10 on 12th May 2010 (picture), Cameron and Clegg launched the coalition document including a pledge to “stop the top-down reorganisations of the NHS that have got in the way of patient care.”

Two months later, Lansley launches his white paper, a major top-down reorganisation of the NHS, described by Lansley himself in the Commons as “a once in a generation opportunity to set the NHS on a sustainable course”.  A key aim of the reforms was to “[put] clinicians in the driving seat and [set] hospitals and providers free to innovate…” (page 8).  The implication being that PCTs were bureaucratic and unresponsive to their population needs.  They were therefore to be swept away and replaced by 4-500 Clinical Commissioning Groups (CCGs).  Crucially they would be GP-led organisations:  the GPs being gatekeepers to secondary care and also those closest to their respective populations.  In theory they could use their budgets to commission the most appropriate care for their populations.  Does this sound familiar?

I was updating my lecture at about this time.  I was very concerned to get a balanced view on the reforms so I searched the net high and low for supporters of the plans.  Unfortunately I found none: the Lib Dems were against them, the BMA were against them, the RCGP and the Health Select Committee expressed concerns.  Even the rapper, MC NxtGen was driven to write a rather memorable song about it.

In the end, after a break to “pause, listen and engage” we ended up with 211 CCGs across England, overseen by a body named NHS England (the NHS Commissioning Board), not that radically different a structure from the post-2006 PCTs (albeit with big changes at the next level up).

Learning to commission effectively is a skill that takes time.  Continual major structural change disrupts this and sets commissioners back.  The best thing the next government can do is to leave the structure as it is, and as the King’s Fund report says, let “evolutionary and bottom-up changes … reduce the complexity and confusion of the structures introduced by the coalition.”

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