Monday 8 February 2021

Reorgainsiing the NHS (again)


 The government's proposals, leaked over the weekend,  to re-reform the NHS raise some interesting questions.

First, credit where credit is due.  The proposals recognise that "in practice, the NHS has not operated as the market intended  by the 2012 Act. "

So, whereas the 2012 Act (aka the Lansley Reforms) built on earlier ones which tried to introduce market practices by talking about "purchasers" (roughly the the GPs) and "providers" (the hospitals and specialist services) by forcing different branches of the NHS to compete with each other, along with the private sector.

The new proposals intend to reduce the role of the private sector and enable the NHS to work more closely with local authorities.


The intriguing question is  that such a proposal has come from the present government, with its hitherto attachment to the neo-liberal ideology of the superiority of markets in allocating resources effectively, the greater efficiency  of the private over the public sector  (hence the eye-wateringly expensive contracts with Serco et al in running the Test, Trace and Isolate system) and has, until the vaccination programme began,  virtually sidelined local government  public health authorities in trying to combat the spread of coronavirus.

If this is conversion, then it is welcome.  Is it partly the resulte of the departure of Dominic Cummings?

Less welcome is the proposal to give the Health Secretary greater control of the NHS.  The tendency to concentrate power  in Westminster and Whitehall is sadly typical of both Labour and the Conservatives.  They seem incapable of trusting the locals bodies. 

 This is a long term problem. Maybe the success of local public bodies in the distribution the vaccine will put it to rest.  Let's hope so.

 Also worrying is whether yet another formal re-organization is the best way of going about things.  In other contexts we are told that NHS staff are exhausted by the demands of the pandemic, and that when it  passes its peak many will go on sick leave for both mental and physical rehabilitation, and quite a lot will actually leave. Do they need yet another  formal reorganisation on top of this?

Experience shows that the moment an organisation is to be re-organised , the principal pre-occupation of the employees, and particularly the managers, becomes securing their place, and preferably promotion, in the new regime, and doing what they are paid to do, in this case heal people, becomes of secondary importance.

 Cannot we just allow the unacceptable parts of the Lansley reforms to lapse (eg stop putting all contracts out to tender) and gradually introduce the new priorities? 


PS (added 9th February)


This article from 2018 puts supportive flesh and blood on my penultimate paragraph:



  1. Must admit I too am slightly surprised by this. I thought that it was almost universally agreed that the German healthcare system, which is a mix of public and private provision underpinned by compulsory health insurance, had coped with the demands of the pandemic much better than the NHS, at least in part because it isn't a single monolithic public body like the NHS () or inded PHEand therefore was able to respond more flexibly. And yet rather than reforming our health system to be more like the one which did better, they seem to be doubling down on the reasons it is worse.

    A cynic might suggest that what has actually happened is that the politicians have discovered that although the reforms gave more control to the individual bits of the health service, they — the politicians — still get blamed when things go wrong, even though the problems are with things they have given up control over so aren't really their fault. So they have decided that if they're going to get the blame anyway, they may as well have the control back — even if that leads to worse outcomes all around.

    1. I see you have selected a mixture of public and private provision of health care supported by insurance as the reasons for Germany's superior performance.

      I attribute it to the substantial devolution of power to the 16 Lander and their central government's willingness to work in co-operation with them, along with the fact that they spend 11.4% of GDP in health care compared to our 10%. That may not look much but 1.4% of a bigger GDP is a lot of money which enables them to have 4.25 doctors per1000 (UK 2.79) and 8.6 hospital beds per 1000 (UK 2.5).

    2. Devolution of power is only possible in Germany because of the mixture of public and private provision. Devolution of power is not politically possible within a totally state-run edifice because by definition if different areas have autonomy then they will make different choices, which will mean that different services will be prioritised and de-prioritised in different areas, which will be characterised as a 'postcode lottery'.

      If you have a single national system like the NHS, then people will expect the exact same provision in every area and will complain if they don't get it.

      I guess the point about higher spending depends on how likely you think the NHS is to spend any extra money it receives well, versus how likely it is to be wasted.

    3. Scotland and Wales make different choices but are still part of the NHS. The same could be said for greater devolution to regional or local health services.

    4. Scotland and Wales make different choices but are still part of the NHS

      In what sense, beyond branding, is the NHS in Scotland really 'part of the NHS'?

      (Though I suppose, given the national-religion aspect of the NHS which seems to count for certain politicians much more than how it actually performs, perhaps the branding is in fact all that matters).

    5. I presume they have some sort of flexibility about their priorities, but accept that they could probably do with more.

    6. From what I understand, the NHS in Scotland isn't 'part of the NHS' at all, in any real sense. It's a totally separate organisation to the NHS in England that just happens to use the same logo.

      It's no more 'part of the NHS' than the London Times and the New York Times are 'part of the Times'. They just happen to share a name, that's all.

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  3. According to Dr Google: "Following Scottish devolution in 1999, health and social care policy and funding became devolved to the Scottish Parliament. It is currently administered through the Health and Social Care Directorates of the Scottish Government" So it is one of those functions that was centrally administered and is now devolved: quite right too.

    1. Yes, and from what I gather (but I'm not an expert so am willing to be contradicted with facts) from that point the Scottish NHS has been, or at least has become, an entirely separate organisation to the English NHS, so in no real sense beyond branding is it 'part of the NHS'.

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