‘The worst winter ever.’ ‘A&E targets missed every month.’ ‘Record number of patients waiting for operations.’ February 2021? No – January 2020. Headlines have been the same every year for several years now. The Tory record on managing the NHS is awful, so let’s not entertain the argument that the coronavirus crisis has created this problem. The foundation upon which a recovery will need to be built looks shaky indeed. We now have an exhausted NHS workforce, frighteningly long waiting lists, routine care stopped or delayed, and a mental and physical wellbeing time bomb ticking away, as millions of people isolate themselves from the world. Does the government’s future vision, detailed in the new health white paper, offer solutions? Or is it a major distraction?
One of the problems we face in this discussion is that we are considering the unseen ‘wiring’ of the NHS. The vast majority of patients and professionals do not care about NHS bureaucracy and funding mechanisms. Like the driver of a car, they are interested in whether the engine starts and it goes where you want it to go, not the making of it. This wiring does affect us, however. Who makes the spending decisions, who is responsible for new and existing services and how organisations work together impacts directly on patients. The big problems – social care, waiting times, health inequality, mental health and more – need solutions and we await those eagerly, but this restructure is about how the NHS will go about delivering the answers to those issues.
The white paper published on February 11th is a bit of a ragbag of major and minor changes. On one level, it seeks to effectively retrofit legislation to support the direction of travel for the last few years, making integrated care systems (ICSs) the legal replacement of clinical commissioning groups (CCGs). This legislation has been repeatedly delayed during the Brexit wars. The changes made are ones that have gradually been unpicking the widely unpopular Lansley reforms. On another level, it does represent a significant restructuring in two ways, both of which could represent a move back towards centralisation in the NHS.
Firstly, the move away from local organisations to more regional-sized ones. ICSs will cover populations of around two to three million, compared to CCGs with around a few hundred thousand. They are likely to be more accountable to the centre than local people. Secondly, giving the Secretary of State more powers, including over hospital closures, and effectively making NHS England answer to them represents a reversal of the idea of an arm’s-length NHS and reintroduces more politics into the NHS (which, of course, never went away).
Leaving aside the legitimate argument of the wisdom of any major reorganisation and its timing (anyone heard there is a pandemic on?), the spin so far has been about ‘reducing bureaucracy’ and closer integration with social care. Working in the NHS for some time, I have seen several reorganisations. They do not reduce bureaucracy and they certainly distract managers and clinicians, who need to be focusing on the crisis. As for social care, there is a need for greater integration but the proposals don’t address the major reasons for which this has not happened. They introduce distant ICS partnerships with local authorities. They don’t address funding, low social carer pay, workforce or the conflicting funding models.
Closer local partnerships with local authorities and prioritising collaboration between NHS providers, not competition, would be progress. But distant, unaccountable and vague organisations making important decisions directed by Whitehall could represent the worst of all worlds. We shall see.
The implications for us in the Labour Party are significant. Labour opposes the timing, stands against ICSs, wants to reduce privatisation and does not like big waiting times either. At the moment, there are a number of questions that should be addressed. How would Labour organise the NHS without ICSs? Which elements of them do we not like specifically? How would we resolve the central versus local tension? Is the spin on reducing privatisation real, or is there a devil lurking in the detail that needs to be removed?
These aren’t easy to answer. But all of these questions are critical because the public will want to know that Labour has a story about how the NHS will be revived and thrive, and if Labour does form a government, all these problems will be on the desk on day one.
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