NHS Reinstatement – Back to the Future?

NHS reorganisation

The SHA has not discussed the proposed NHS Reinstatement Bill but established SHA policy as set out on the web site would appear to rule out full support.  However, much is still unknown and it would be helpful if the advocates of the Bill could give a lot more details than they have so far.  Little by way of supporting information has been provided that would allow for a proper discussion. Some important questions are unanswered.

The Bill effectively repeats the legislative background that applied 30 years ago.  Over the last 30 years there have been some positive developments into public and patient involvement and challenges to the medical model which underpinned the ‘old’ NHS.  How would this this important shift be accommodated?

How does the return to the old NHS structures facilitate the aim of integration into a care system? The Bill appears to enshrine the NHS as a separate island unconnected to other public services.

How in the proposed structures would decisions be made about funding flows to geographical areas, populations and services and what is the process for the setting of priorities?  Who decides, how they are accountable and how we can be involved in decision making are serious basic questions.  The Bill suggests there is reinstatement of the public accountability of the eighties but the old structures were very weak in terms of all forms of accountability, at least judged by current expectations.

Aside from stating that the implementation would take place at a pace determined by the Secretary of State there has been little explanation of how the changes would be made.  The SHA is opposed to yet another top down structural reorganisation given the convincing evidence of the damage and wastage these cause; far better to make existing structures work the way we wish them to.

There is no doubt implementation of the Bill would be hugely complex, expensive and time consuming.  It impacts on every fact of the system and would be a far greater set of changes than the H&SC Bill which made few if any changes to ‘providers’ which are the core of NHS service provision.  The 1990’s changes introduced the purchaser provider split and enshrined new management and organisational structures but this was done when the NHS was a far simpler ‘organisation’.  Things are far more complex now with thousands old organisational bodies involved which have to somehow be broken up and then fitted nto a new set of structures.  There are also many thousands of ‘contracts’ including many thousands with GP Practices, all of which would have to change.

So the Reinstatement would require a top down reorganisation that would be far more complex and expensive than the biggest reorganisation so far and three or four times as complex as Lansley’s effort. How would the change avoid years of disruption and lack of focus?  How much would the changes cost?  How long would the transitional arrangements (with double running costs) have to apply?

It may well be that these issues have been addressed and solutions found but if that is the case it would be helpful to have the details.  There has also been some claims that savings would be made but again no supporting evidence of any kind (the oft repeated claims of £10bn pa saving through abolishing the market have never been substantiated or even described).

The Bill addresses the issue of privatisation of the provision of services and removes the market like structures in the NHS.   It goes further in this area than the SHA and others have considered necessary by insisting on removal of any functional or organisational split between the planning of services and the provision of services. It is not clear how the ‘old’ 80’s structure would deal with the balance between vested interests something that plagued the NHS in the 70’s and 80’s.  It is not necessary to fully integrate planning and provision to remove the market.

This is clearly desirable but why is the solution of a major structural reorganisation the best way to do this?  On the limited information available it appears that the Bill would be an expensive and disruptive solution to a problem which could be addressed in other ways.

The SHA is clear that ending the era of market competition (in all forms of public service) is necessary but it is just the start of the changes that are needed and is not an end in itself.  Many of the other issues which confront moving to the kind of care system the SHA advocates would be far harder to address if years of structural redisorganisation had priority.