NHS reform, or rearranging the deck chairs

The NHS: much loved
but easier to reorganise than to fund properly

We trained hard, but it seemed that every time we were beginning to form up into teams we would be reorganized. Presumably the plans for our employment were being changed. I was to learn later in life that, perhaps because we are so good at organizing, we tend as a nation to meet any new situation by reorganizing; and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency, and demoralization. During our reorganizations, several commanding officers were tried out on us, which added to the discontinuity.

When I first came across these words, they were attributed to a Roman writer. But it seems they are far more recent, dating from 1957, and the pen of an American, Charlton Ogburn Jr.

It was back in the late eighties that I first came across them. It was the early days of my nearly 35 years working with, though never, in healthcare. And the reason a manager in the English NHS had dug them out, was because the service was in the throes of a major reorganisation.

Until 1983, local management in the NHS had all been by boards. The problem with this was that no single person could be held answerable for any decision. The boards were a wonderful hedge for individual executives to hide in.

The Griffiths reforms, that were still being implemented when I started work with the NHS, were introducing the notion of General Management, where a named General Manager would take top-level decisions and be held responsible for them. The report that led to the reform was by Roy Griffiths, formerly a director of supermarket chain Sainsbury’s. His selection, and indeed the notion of individual responsibility, reflected a Thatcherite belief that they order things better in private companies.

As the banks demonstrated in 2008.

In 1987, the same government decided to set up ‘NHS Trusts’. They would be bodies running one or more hospitals, but away from control by a geographical organisations, such as a district health authority. Essentially, it meant hospitals running hospitals. Which, like General Management, sounds like a good thing.

It wasn’t enough, though. In 1989, right at the end of the Thatcher era, it was announced that a provider-purchaser split would be introduced in the NHS. In other words, providers such as hospitals would deliver services to purchasers, organisations representing geographical areas or patients, in what came to be known as the internal market.

Again, note the ideological commitment to private sector concepts.

‘Fundholding GPs’ would hold finance with which to purchase services from hospitals or other healthcare providers. Non-fundholders would have their services purchased for them by geographical organisations. This process moved forward under Thatcher’s successor, John Major.

Note that there was nothing to stop GPs offering certain services themselves. They might do minor surgeries, for instance, such as ‘lumps and bumps’ or vasectomies. That meant some fundholders might buy services from themselves. Many felt this was an arrangement that was, at best, a little dodgy.

Then, in 1997, Labour came to power under Tony Blair. The internal market was all wrong, for ideological reasons, and had to go. But the provider-purchaser split would be maintained, but in a softer, kinder form. Two years later, GP fundholding was ended, and Primary Care Groups were introduced. These bodies represented large geographical groups of GPs and had the funds to purchase services on their behalf.

In 2000, the Blair government introduced the Private Finance Initiative. This enabled funds to be channelled to the NHS, but without appearing in government expenditure. It was a hopelessly expensive form of finance, for which we shall be paying for years.

In 2002, the Primary Care Trust was invented, as a more autonomous form of Primary Care Group.

But the most inspiring change in 2002 was the so-called Wanless review, which paved the way for colossal increases in healthcare expenditure. They took place over the remaining years of the Blair and Brown governments.

The next exciting reform was the launching of NHS Foundation Trusts from 2004. They would run hospitals, as NHS Trusts did, but with more autonomy, above all over their finances.

In 2010, the Tories came back to power, in coalition with the Liberal Democrats, and a programme of austerity was launched in the NHS. Budget increases were kept to around 1% annually. That was far below the level required to cover inflation, particularly high in healthcare where new and expensive treatments are constantly appearing, and the increasing cost of treating an ageing population.

In 2011, the Cameron government announced new changes, such as the creation of Public Health England. They also abolished Primary Care Trusts and set up successor organisations formed by merging groups of these PCTs.

In 2014, Simon Stevens was appointed NHS England Chief Executive (yes, General Managers went out long ago – terribly passé, don’t you know).

By 2018, the Theresa May government announced plans for significant increases in NHS funding, though still less than Stevens had been asking for – 3.4% annually as opposed to 4%.

Now, in 2020, we hear that Boris Johnson, or more likely Dominic Cummings, ostensibly his adviser, in reality the controlling power behind the government, is planning a further review. Unhappy with criticism of the handling of Coronavirus from Public Health England and Simon Stevens, it looks as though it will set out to bring the service far more under government control.

Control, indeed, seems the main concern. Certainly not the quality of service.

Again and again, I’ve watched reorganisation across the NHS.

Some of the ideas were good, some less so. None of them has really stood the test of time. Above all, I can’t point to a single one of them and confidently say it delivered a better service.

As Charlton Ogburn wrote, reorganisation is a “wonderful method… for creating the illusion of progress while producing confusion, inefficiency, and demoralization”.

Yes. Because it isn’t reorganisation that will improve the NHS. It’s spending sums of money adequate for the service we want. Reorganisation costs money, it doesn’t deliver any.

As Labour demonstrated after the 2002 Wanless review, when we really started turning the NHS into a world-leading service.

And as the Tories showed negatively by putting the process into reverse and starving the NHS of funds over years of austerity.

But it looks like we’re going to get reorganisation again.