2018 marks the seventieth anniversary of the founding of the NHS, but also the fiftieth anniversary of the 1968 Green Paper that marked the beginning of a series of attempts to reorganise the NHS that lasts up to today. What were these other reorganizations about, and did they work?
A most basic organisational challenge the NHS continues to face is the split between NHS, GP and community health services (including social care). This was the result of a political compromise in the founding of the NHS. The big idea in 1968 was bringing NHS organisational boundaries in line with those of local government. However, it did not succeed, failing again to due to political constraints. The split between the three areas of the NHS continues to cause us so many problems is testament to the force that past decisions about organisational forms can continue to hold over us, decades later.
Any discussion about the NHS inevitably takes us to the question of funding. In the 1950s there was a government inquiry examining why the NHS was costing so much more than anticipated. What it showed is that the NHS is, comparative to other health care systems, remarkably inexpensive. We still haven’t really learned that lesson. Apart from above-trend increases in funding in the 2000s, the NHS has continued to lag behind its neighbours in funding healthcare, year after year. This seems to get somewhat lost when politicians make lazy claims about how ‘unaffordable’ the NHS is.
Since the 1980s, the two big reorganizational ideas have been about management, and about markets. In the 1980s general managers were put in hospitals to try and make the NHS more ‘business-like’, and that didn’t seem to make much difference other than to increase management pay. This led to an ‘internal market’ for care, in which public providers competed with one another for care contracts to try and bring the discipline of competition into the NHS. Apart from some innovative changes the way GP practices worked, the internal market seemed to do little other than introduce new functions such as care purchasing which did little to improve services.
When they came to power in 1997, Labour promised to abolish the internal market on the grounds that it was wasteful and bureaucratic. Labour also embraced the Conservative ‘Private Finance Initiative’ (PFI), which allowed it embrace a radical building plan for new hospitals, but without breaching their own budgetary rules. However, PFI deals were often negotiated locally, and where poor bargains were struck, this left the hospitals involved with substantial funding deficits running over decades.
In January 2000, the Prime Minister committed to increasing NHS funding to the European average, taking his cabinet (and Chancellor) by surprise, but, for a short period in the NHS’s history, giving it sufficient resources to avoid winter crises and reduce waiting lists. Then devolution happened, and the paths of the home countries started going down different routes. In England, performance management and markets reigned. In Scotland, a more collaborative route was taken. At the end of the decade, evaluations suggested that there was actually little difference in reported health outcomes between the two, again asking questions about whether reorganisations actually improve things at all.
Labour’s performance management changes included hospitals and GP surgeries. The hospital system was widely gamed, and seemed to lead to managers ‘hitting the target but missing the point’ at best, and at worst was probably a causal factor in the horrific events at Mid-Staffordshire with staff becoming so driven to hit targets that they forgot about patients. The early years of the GP performance system appeared to show promise, with GPs being consulted upon and engaging strongly with the system, but policymakers then extending it and introducing more bureaucracy until it became deeply unpopular. It has already been abolished in Scotland.
Labour’s new market for care created greater scope for private providers to enter in England, and paved the way for an extended version of it appearing from the coalition government after 2010, leading to huge controversy and expense. What is remarkable is how little there was to show of this reorganization by the end of 2017 – much of the attempt at driving further competition in the NHS has been slowly abandoned in the face of budget pressures and high profile cases of private provision failure. Reductions in budgets, have, however, led the return of winter crises and budget overspends.
The NHS is all about its staff, but relationships between the government and clinicians have gone through cycles of antagonism and co-operation. In the 1970s industrial action and threats to the provision of services dominated, with governments fearful of challenging doctors. In the 1980s staff protests continued, but with the government taking a harder line, until they ignored the doctors completely in introducing the internal market in the 1990s. The doctors got their revenge though, teaching the government the lesson that it is one thing to make policy, and entirely another to implement it. Labour’s funding increases in the 2000s appear to have led to a period of co-operation, before the 2010 coalition government’s reorganisation leading to a groundswell of opposition. Since then relationships between Secretary of State Hunt and the doctors, in renegotiating employment contracts or in demanding a ‘7-day NHS’ at a time of reduced budget settlements, have seldom been friendly. The basic lesson of industrial relations in the NHS, again not learned by politicians, is that it unwise to introduce new policies unless you have the co-operation of those that you will need to implement them.
By 2018 we’ve had 50 years of NHS reorganization. Mostly, it hasn’t really made things better. Indeed it is hard to see what lots of it was actually for. We still haven’t managed to find a way of overcoming the tensions of the tripartite split. We know we need more collaboration between local government and the NHS, especially as the demands on social care services increase and the lack of funding for it has real consequences for services currently paid for by the NHS. However, for many of us the boundary between health and social care is an artificial one that does not serve our needs.
What does seem to have made a difference is increasing the funding for the NHS in real terms in the 2000s, with a range of measured improvements coming along soon after, but which are in danger of disappearing in the more austere environment of the 2010s. If there is a big lesson from the history of the last fifty years it is that health reorganizations often do as much bad as good, but increasing the funding of the NHS has a much better chance of improving healthcare for us all.
A version of this article was first published on the Social Policy Association website