Rescuing the NHS from its recent history

Ways in which to think and act differently in health and social care if your political party has just won a landslide

From Radicalism to Managerialism

Wes Streeting took a radical stance in opposition in terms of asking the traditionally unaskable and intimating that he intended to do whatever might be necessary to sustain socialised medicine in the UK.

It was refreshing to hear a politician – particular from the Labour party – embracing the perspective that no idea could be cast as unthinkable. And, insofar as the topic was the NHS, it also felt clear that only a Labour politician could open up a dialogic space where it was permitted to challenge the status quo.

But four months into his tenure as Secretary of State for Health and Social Care, that radical edge has become decidedly blunted. He has launched what he considers to be a consultation exercise on people’s experiences in the NHS and their expectations in terms of health care.

Unfortunately, it is yet another limited online survey that channels respondents’ contributions down particular channels and fails to create a meaningful space where people could converse rather than just answer the questions set by those in power.

Bureaucratic Growth

Streeting has signally thus far failed to notice one crucial aspect of the contemporary NHS, namely that it is oppressively and constrainingly occupied by two large, extraordinarily costly, and competing bureaucratic excrescences.

One of these two has the potential to be redeemable and to thereby contribute positively to supporting the NHS with its challenges and ambitions; this is the 42 Integrated Care Boards that are charged with delivering a service that focuses on population health and ensuring that health and social meaningfully wraps around individuals when they feel the need to access these services.

The other is merely a top-heavy superstructure that weighs down on the service, a development that arose out of the need to balance aspects of the reforms to the NHS that Andrew Lansley introduced – yet NHS England persists despite the fact that those changes are now consigned to history.

In respect to the latter, this major shift was delivered out of the mess of the coalition government of 2010, despite the manifesto of the Conservative party offering no sense that the NHS needed to go through yet another top-down transformation. As Calum Paton observes in his book of 2022 on NHS reform and health politics:

‘The White Paper proposed the total abolition of all agencies below the level of the Department of Health – the PCTs, the Strategic Health Authorities and the Regional Offices. The Department of Health management group (the NHS executive) would be wound up and an NHS Board established outside the Department – something which had been trailed in a 2007 policy paper from the Conservatives (Conservative Party, 2007) and also in the Conservative manifesto. This was an attempt to take politics out of the management of the NHS, a perennial chestnut regularly proposed over the years by the King’s Fund and others, and of course tracing its pedigree back to the 1983 Griffiths Report.’ (p54)

Elsewhere, Rudolf Klein (2015) takes the view that Lansley was looking to deliver on a New Public Management agenda by engineering organisational change that was undergirded by ideas of ‘…competition, consumer choice, and provider plurality…Lansley’s legislation also introduced a new managerial structure designed to insulate the NHS from day-to-day political interference. As a result, a new body, NHS England, is now responsible for running the service. Whether the insulation is effective remains open to question.’ NHS England may not be party political…but, given its role in a significant area of social policy, it is inescapably political.

Battling Bureaucracies

This is very much to the fore in a speech that the overpaid boss of NHS England – who enjoys the grandiose yet faintly absurd title of Chief Executive of the NHS – delivered at the NHS Providers conference on 12 November 2024. Dipping below the surface of line upon line of anodyne corporate boilerplate, it is possible to see one bureaucracy manoeuvring against the other, with Matt Discombe filing a report in the Health Service Journal (HSJ) headlined “Performance management role stripped from ICBs”

In terms of a brazen allocation of roles, the speech offers the following proposed division of labour between the two presently static bureaucracies: ‘ICBs, focused on strategic commissioning, and creating the environment for more action on prevention and more care in the community. And NHS England, focused on planning, assurance and support, intervening quickly, and providing expertise, as well as using our regulatory levers where needed; but also doing those things which are best done once for the whole NHS.’

Meanwhile, while the introduction of Integrated Care Systems (which have since morphed into Integrated Care Boards and Integrated Care Partnerships) represented typical government and NHS thinking – they are statist, dominating, bureaucratic and managerialist – they are also rich with potential to abandon that provenance and step into a space wherein they might find different ways of thinking about and adapting to the challenges and ambitions that presently define how health and social care should be responding these days. But they will struggle to do that whilst trying to manage the compressing weight of NHS England sitting on top of them, contributing very little of use to the picture.

The circumstances with which we find ourselves confronted are, according to Stephen Bush in the Financial Times, as follows: ‘Streeting is opting to keep NHS England, the 2012 invention of then-health secretary Andrew Lansley, in its place. Is that the right call? Essentially, with the exception of Lansley, almost everyone involved in healthcare policy on the Conservative side thinks that the 2012 Health and Social Care Act was a mistake. Jeremy Hunt’s approach as secretary of state was to essentially ignore it, and had the pandemic not happened then Matt Hancock would have unpicked it. Another Conservative veteran of that time described it to me recently as “the biggest mistake” of David Cameron’s first term, while others have expressed their displeasure with it in fruitier terms. Darzi’s report was also highly critical of the changes.’

The Application of Reason

This is a prime instance of the Secretary of State’s radicalism melting away in the heat of the practicality of being responsible for such a large and significant part of UK welfare and social policy. And while no one has any appetite for yet another NHS reorganisation – activities that have tended merely to create disruption without benefit, leaving the fabric of the service largely unchanged and the lives of those working there adversely impacted – it is vitally important that thought and commitment is given to rationalisation in health and social care.

This needs to begin with chopping out one of the bureaucracies that currently hold the service back, so that the other one can find its wings and step up to the work that needs to happen to support the emergence of a socialised medicine system that genuinely takes into account and seeks to meaningfully address the needs and expectations of the nation, in contrast to other agenda that might be present in the domain.