The health policy challenges facing the NHS and government are enormous, but Hugh Alderwick and colleagues argue that a major reorganisation is not the solution
CREDIT: This is an edited version of an article that originally appeared on The BMJ
The proposals for a new NHS structure lack detail, so it is not possible to fully assess their likely effect, but several key issues can be identified from the proposals so far.
Benefits of integration risk being overstated
Overall, the emphasis on closer collaboration between the NHS, local government and other agencies makes sense, and goes with the grain of recent national policy initiatives, but the potential benefits of integrated care – efforts to co-ordinate services within the healthcare system, or between health and social care – have long been overestimated by policy makers.
Evidence suggests that integrated care may improve patient satisfaction, access to services and perceived quality of care, but evidence of effect on resource-use and health outcomes is limited; potential benefits may be modest, and take time to be realised. Despite the clear logic behind greater cross-sector collaboration to improve population health, there is limited evidence to suggest that partnerships between local healthcare and non-healthcare agencies improve population health.
Area health authorities are back—but how will they work?
Establishing a new regional tier of the NHS in England – integrated care systems (ICSs) – could improve the murky accountabilities of today’s health system. NHS leaders have a long history of reinventing the ‘intermediate’ tier of the health service – and most national public health care systems have some form of regional management layer.
Limited detail is provided on how ICSs will work, and interact, with other parts of the health system. For example, NHS providers are to sit on ICS boards, but how much power will the ICS have over its constituent providers? How will ICSs hold new provider collaboratives to account? And how will NHS providers balance their duty to collaborate with existing responsibilities as individual organisations – particularly foundation trusts, which are, technically, autonomous agencies with distinct local accountabilities?
The role of regulation in overseeing local systems is not clearly set out and there is a risk that unifying NHS and other agencies will affect patient choice and responsiveness.
With clinical commissioning groups (CCGs) abolished – or at least merged across larger areas – it is unclear how the ‘place’ level of the new NHS will be organised. The proposals suggest primary care networks – groups of general practices that collaborate to deliver defined services for populations of around 30 000-50 000 – will play a central role. But these networks are nascent, and small scale; redefining their functions risks derailing early progress.
Commissioning is dead; long live commissioning?
Formally establishing ICSs, and mandating provider collaboration, would further diminish – if not dissolve – the NHS internal market. The 2012 Act’s version of commissioning would be all but dead; CCGs gone or hollowed out, and compulsory competitive tendering abolished.
Changes to simplify procurement rules, and make joint purchasing decisions easier, should help reduce fragmentation and complexity in the current system, but commissioning would live on. ICSs would be responsible for ‘strategic commissioning’ – including assessing health needs, planning services and allocating funds to improve local health and healthcare. New payment models would be developed to help do this.
However, experience from the past 30 years suggests that NHS leaders should not expect too much from a renewed version of commissioning in the English NHS. Instead, greater attention needs to be given to developing the blend of policy levers to support improvement in complex systems – including by strengthening the NHS’s capabilities to identify, implement, evaluate and spread improvements in different contexts. Data and technology will need to be effectively harnessed to help staff and systems do this.
Past reorganisations have delivered little benefit
The new proposals should be understood in the context of a long line of NHS reorganisations. In its first 30 years, the NHS’s structure was relatively stable but, over the past 30 years, the NHS in England has been on an almost constant treadmill of reform and reorganisation. Standing back, the new proposals seem to mark the end of the NHS’s 30 year experiment of fostering competition within the healthcare system, with NHS policy more clearly reverting to its pre-1991 course.
Overall, evidence suggests that previous reorganisations have delivered little measurable benefit. Other policies to support NHS improvement – such as boosting investment, expanding the workforce and modernising services – are likely to have had a greater effect on performance. Reorganisations can also have negative effects, including additional costs, destabilising services and relationships, and delaying or detracting from care improvements. Even when one (more) restructure seems logical or desirable, the cumulative effect of regular reorganisation can drain the energy and confidence of staff.
NHS England states – perhaps pre-emptively – that it does not want to trigger a ‘distracting, top-down reorganisation’ of the NHS, but it is hard to see how their proposals to abolish CCGs, and create ICSs, would avoid this.
There is also a risk government will use the opportunity of new NHS legislation to introduce more widespread changes; this is hinted at by NHS England, which ‘envisage[s] parliament using the legislation to specify the secretary of state’s legal powers of direction in respect of NHS England’.
Changes to bring the NHS under closer ministerial control are likely to be rooted in short term political interests, not clear thinking about the right balance of national responsibilities.