Professor Alan Maynard once referred to successive governments’ health policies as ‘redisorganisation’. A leaked health white paper suggests that the latest episode of redisorganisation may be about to commence. Boris Johnson would be right to worry. The change that is needed is cultural not structural.
Since the 1960s, legislative change has been seen as the solution to the problems of the NHS. Eventually each change is unpicked. Centralisation appears the solution to the complexities of decentralisation, and vice versa. A step-change in public funding appears the solution to falling standards, then more measured spending growth appears the solution to falling productivity. The cycle of redisorganisation goes round and round, diverting resources and political capital as it does, and demoralising those on the front line.
I first met Andrew Lansley to discuss health policy almost 20 years before he became health secretary. Some readers may not believe this, but you would be hard pressed to find a bigger fan of the NHS in the Conservative Party, save perhaps for (my Department of Health boss) Virginia Bottomley. Caring for the NHS and listening to its experts is not enough to deliver effective change. Legislative reform eats political careers. Indeed, it pretty much ate a whole coalition government. Lansley was on a mission to ‘liberate the NHS’. Bottomley wanted to make the NHS so good that no-one felt the need to go private. The lesson from all of this is that a good diagnosis of the problems should not lead to fixation with shuffling around with structures and titles. Listening to NHS leaders does not make for effective policy. The NHS is too big and too complex for anything to work that is not organic. It is fundamentally, and mostly a (very large) group of people, not inanimate organisations and structures. Uniquely, the Blair government tried centralisation, decentralisation, and a rapid spending spree. The frustration was palpable.
The pandemic has shown that workarounds can deliver, given sufficient commitment and sufficient focus. Structures can be circumvented or put to good use. The same is true of any large organisation. You can either tinker or you can just find new ways to focus minds on results.
It is this lack of focus on people and results that lies at the heart of the perennial problems of the NHS. Logically, of course, a universal health system free at the point of use should not be one of the world’s worst systems for health promotion. But it is. A universal health system should not support dramatic health inequalities. But it does. Whatever structural changes have been made these core problems have persisted. The 2012 reforms sought to change this, putting ‘public health’, always a Cinderella service within the NHS, into local government. The cash, however, has gone to the treatment service. Year after year community services, social care, and public health have paid the price of stoking the hospital machine. In the end the problems of the health system are rooted in motivation and in money. Structural change is both an important source of frontline demotivation, and an important consumer of healthcare budgets.
Without a bold culture shift and funding shift no amount of structural ‘integration’ will achieve the necessary change. In our recent study of health charities’ work Alison Leary and I uncovered an incredible story of charities having to fill huge and growing gaps in health services. We also found a shocking story of relative neglect by the NHS: district nurse numbers had almost halved in the previous decade, leaving people at home or in care homes literally struggling to survive during the pandemic and with limited professional guidance. Similarly, as an afterthought in an otherwise successful vaccination strategy, the government had to resort to the introduction of a direct financial incentive for GPs to visit homes to deliver vaccinations. Some of the most vulnerable had to wait behind the more able elderly. The hospice movement had to go knocking on the door of the Treasury in order to meet the demand for its end-of-life services during COVID-19. This has happened whilst NHS leaders talked continuously about building patient-centred care.
No amount of structural change will fix this upside-down situation. There will be many lessons to learn from the pandemic response and from the spotlight it has cast on the historic failure to address health inequalities. Structural change will, however, distract from the core task. After decades of talking about creating a ‘national health service’ from the ‘national treatment service’, the imperative to do so could not be stronger or more urgent.
David Cameron woke up too late to the evolution of the Lansley proposals, from a collection of good ideas to a confusion of top-down structural changes. Boris Johnson may be about to repeat the mistake.
Tony Hockley is Director of the Policy Analysis Centre and a Visiting Senior Fellow in the LSE Department of Social Policy. His PhD thesis investigated health policy reform under Conservative governments. He is a past adviser to the former Labour health minister Dr David Owen (Lord Owen) and Special Adviser to two Secretaries of State for Health.