How To Reform The NHS? Leave It Alone

NHS reorganisation


The latest great reform for the NHS is now unveiled – the creation of Accountable Care Organisations. This sounds great doesn’t it?

  • bring commissioners and providers together
  • end contracting and the internal market
  • focus on community and service integration
  • improve efficiency with better data and innovation

I am not quite sure how this sounds to anyone outside the NHS. It may sound like a set of good ideas or just empty jargon. To those inside the NHS it promises yet another round of meaningless organisational change, personal confusion, management consultants, promotions for some and redundancies for others.

Of particular concern should be the first word in the name for this new structural innovation – Accountable.

The NHS is already accountable, because we own it and we hold the UK Government responsible for its performance. Although, in practice, how we hold it accountable has become increasingly confused:

Given this, an Accountable Care Organisation, a term borrowed from the United States, sounds like just what we need. But sadly you will have become another victim of Government Newspeak – using language to disguise and corrupt reality. For instance:

Accountable Care Organisations (ACOs) are being introduced to confuse accountability, and to make it even easier to sell off the NHS to private corporations. The first sign of this intention is in the use of the private corporation Capita to manage the introduction of an ACO to Nottingham. If all goes to plan then it will be clear that the NHS can be parcelled off and tendered out by geographical area. If Mrs May does achieve a US trade deal then US healthcare providers can queue up to buy big chunks of the NHS as if they were Premier Football Teams.

The Government claims that it will protect an NHS ‘free at the point of use’ (expect lots more reassurances on that front) but once private firms do get a hold then it will be natural for them to increase profits by extending preferential benefits to the wealthy wherever possible. Moreover, when the wealthy start to see they can buy better services for themselves then the long-term political consensus around the NHS will collapse.

Ambitious claims are made for the potential efficiencies created by Accountable Care Organisations, with reference to the US insurance company Kaiser Permanente (no, not Keyser Söze). But why should we model the NHS on a US system? As Melissa Hellmann of Time Magazine puts it:

“The US health care system has been subject to heated debate over the past decade, but one thing that has remained consistent is the level of performance, which has been ranked as the worst among industrialised nations for the fifth time, according to the 2014 Commonwealth Fund survey 2014. The UK ranked best with Switzerland following a close second.”

Promoting ACOs, by reference to organisations like Kaiser Permanente is a terrible example of cherry-picking. You take the best example of something and then pretend that you can easily replicate its benefits, despite the fact that it only provides cover to 3% of US citizens and has taken over 70 years to evolve. Innovation and efficiency in health care is not that easy.

I do not mean to suggest that the NHS could not be improved. There are lots of practical ways it could be improved and there is a real need to empower patients, work better with local communities and end internal markets. But this won’t happen because of another grand structural reform. What the NHS needs is constitutional protection to ensure that its basic structure is much harder to change.

It is political interference and ongoing structural reform that has undermined meaningful innovation in the NHS.

Changing structures at the whim of each incoming minister undermines leadership and the relationships of trust and security that enable more meaningful change and innovation. I would commend the position of the Socialist Health Association, the organisation who originally proposed the creation of the NHS in 1930. We need to get back to a strong national structure – and then bind Odysseus to the mast – make it really difficult for ministers to fiddle with that structure. Perhaps we could create a law that meant we need 75% of MPs to back any structural change to the NHS.

Do you remember the story of the boy who ‘cried wolf’? We have heard the claim that the NHS is threatened with privatisation many times; but the threat is real. The level of privatisation has increased and this next non-reform puts the NHS at even greater risk.

The Government will continue to claim that the NHS is ‘safe in their hands’. But if you did intend to privatise the NHS, then creating Accountable Care Organisations, bundling together all health services in large geographical areas, is exactly how you would begin.