NHS Reinstatement Bill – Back to the Future? Again?

NHS reorganisation

The NHS Reinstatement Bill removes the market and the purchaser provider split from the NHS and from 2018, effectively removes all private provision of services (GPs etc. aside).  It returns the NHS structures of the 1980s before there were Trusts and commissioning.

There was as much abuse and as many examples of poor care in the 80’s as there is now and the treatment then of the frail elderly, those with mental health issues and those with learning disabilities would now be seen as a disgrace.  There was no more accountability or public and patient involvement than now and the system was far from open and transparent.  The NHS was managed through a complex appointed bureaucracy, heavily skewed towards acute care.  But aside from this the world has changed especially around the use of information and others technologies, many developed and controlled in the private sector.

It is not clear why we need to reinvent the separate NHS of the 1980’s when what we require is a modern integrated care system.

Much of the difficult issues are avoided by saying that they will be resolved later by Regulations so analysis is not possible but the scale of change is obvious.  The reorganisation which ended the 80’s structure and brought in the “market” was hugely expensive (far more than the Lansley disturbance) so reversing it, even if this is actually possible, is also a huge task.

The Bill envisages a single Health Board for each area which both plans and provides all the necessary NHS services.  This does apply in Wales and Scotland (not without some issues) but England is sadly far more complex and fragmented in both its NHS and local authority structures. There are literally thousands of care providers all of which must be somehow restructured and managed differently.  Most NHS provider bodies are not coterminous with local authority areas so they would have to be broken up into the relevant pieces then bits pasted into the right place.  The tertiary providers have huge catchment populations for some services so don’t fit any natural boundaries. Contracts with the many private providers will have to be terminated and there may be penalties involved.

The Bill effectively makes impossible any provision of services to the NHS by private providers after 2017.  The scope of this is unclear but obviously it is intended to be limited to clinical services rather than services for IT or imaging or construction.  All kinds of managed services especially around diagnostics are now delivered only through the private sector and almost inextricably linked into the NHS.  The Bill clearly assumes all privately provided services are simply taken over in some way and absorbed into the NHS.  Paradoxically some accommodation is made for the anomalous position of GPs, Dentists, Ophthalmology and Pharmacy which rather blunts the central argument for a wholly publicly provided NHS.  Voluntary organisations are allowed which could be open to abuse.

It is argued by the Bill’s supporters that this cost and upheaval (albeit unknown!) is worth the objective of removing the market and the elimination of any private provision of services.  How this transition could take place has to be explained and at least tentatively assessed for cost and impact before the Bill can be taken seriously.

Removing market competition structures is necessary but it is just the start of the changes that are needed, not the end.  What has to be achieved is a structure that has proper democratic accountability for key decisions, which is genuinely open and transparent, that encourages and supports public and patient involvement at all levels and which is integrated into the wider family of public services.  The Bill makes this all harder not easier.

So the fundamental issue is that the Bill preserves a separate and unaccountable set of structures for the NHS and not integration. This separation of health from the rest of the public services is simply wrong, all public services for an area should be organised through the same local authority structures which are democratically accountable.

The scale of Regulations and so the scope for patronage is huge.  There is almost nothing about how we can elect people into key positions or how public and patient involvement has to be built into all decision making, and little about dealing with the power of vested interests endemic in the traditional NHS.

As Wales and Scotland have found removing the market and removing the split between planning and providing are not the same thing.  In England there is a case for leaving the NHS providers as separate entities allowing them to adapt to become integrated care providers.

There is much work still required about what must take place as the market structures are removed.  The Bill suggests the answer is a massive upheaval.  The alternative is to avoid the route of reorganisation, which has never worked, and to use and adapt the structures as they are.  Repeal of the H&SC Act has to be done in a way which does not just trigger more years of chaos.  It can be done but not by looking back to the 1980’s.