NHS reform requires fixing social care, too

Government bungling has left the UK with one of the world’s highest Covid-19 death tolls. Yet the NHS has overcome years of underfunding and administrative obstacles to emerge from the crisis with its public support burnished. Indeed, Britain’s vaccination programme has become the most successful of any large economy in large part because government entrusted the job to the NHS. Planned reforms that would shift away from enforced competition and encourage greater collaboration in the system recognise what is already happening in reality, and better suit today’s needs. But the government should wait until the coronavirus crisis is passed to implement them — and look again at plans to enhance the say of the health secretary in the running of the service.

The reforms mark the partial dismantling of three decades of attempts to create an internal market within the NHS. Specifically, they aim to reverse key elements of the 2012 restructuring by then health secretary Andrew Lansley. That created clinical commissioning groups, GP-led units that hold patients’ budgets and buy in services from other providers such as hospitals. It also brought in rigid procurement and competitive tendering rules.

Though well-intentioned, those changes went in the wrong direction. They increased fragmentation and “siloing” just when an ageing population suffering from a complex array of conditions required a more holistic approach. Under its chief executive, Sir Simon Stevens, NHS England has quietly encouraged development of local, integrated care systems, in which health and social care providers work together with local authorities. Yet these currently have no basis in law.

A white paper published last week would put such structures on a legal footing, while giving different parts of the system a duty to collaborate. It is also well-advised in proposing to loosen the procurement rules put in place in 2012, which have led to frequent retendering, even when they are repeatedly won by the same groups.

More controversial is the plan to give the health secretary more powers to intervene. The government wants to tighten its grip on the NHS as it strives to expand nurse numbers by 50,000 and open 40 hospitals. The autonomy of the self-confident Stevens has irked ministers. But giving NHS England operational independence was one of the more successful parts of the 2012 reforms. Creating a “clear line of accountability for service reconfigurations” back to the health secretary could lead to decisions on, say, hospital closures becoming politicised rather than based on operational needs.

While it is right to be looking now at how to improve the health system, moreover, the midst of a global health emergency is not the time to launch another sweeping reform. The government should also not seek to pre-empt the conclusions of the eventual public inquiry into its coronavirus response.

Most importantly, the reforms will come to little unless the government finds a way to plug the multibillion-pound shortfall in social care funding and integrate it with the health system. Prime Minister Boris Johnson promised to “fix the crisis” in social care on his arrival in July 2019, but no plan has emerged. The strains of the pandemic have also made clear that even the 3.4 per cent annual real-terms increase in NHS funding promised up to 2023/24 is inadequate. While the immediate focus is on crisis recovery, sooner rather than later the government needs to spell out a broader vision of how it plans to achieve, and fund, better health outcomes from cradle to grave in a post-pandemic world.