While we all celebrate the NHS and bemoan the neglect of social care, we need also to look beyond the surface at the structural reforms that have contributed to an inadequate response.
Whilst people rightly applaud the hard work and risks taken by frontline health and care workers, there is mounting evidence that the UK’s handling of the Covid-19 crisis has been terrible.
At the time of writing, the ONS recorded over 40,000 deaths where Covid-19 was involved; with 64% of people dying in hospital and the rest dying in care homes, in private homes or hospices.
A future inquiry should determine what went wrong, and poor and slow decision-making are likely to loom large. However, there is another fundamental factor that has not been given the airing it deserves: the structural changes that have taken place within the NHS over the last decade.
This is a technical area that few commentators are aware of and hardly anyone is interested in, but which we must understand and question now if we are to reshape health and social care post Covid-19.
For the last 10 years, and particularly in the last three, the NHS has gone through major structural reforms, which has left it in a worse placed to handle a crisis like Covid-19.
The changes have little political mandate, have largely gone un-noticed and are still ongoing. While the NHS is now focused on dealing with the immediate and huge challenges of the pandemic, we must not avoid reflecting on the kind of healthcare sector we want if we are to stop further damaging, expensive and undemocratic structural changes.
The ‘Lansley’ reforms
While these structural changes are complex, I shall try to summarise.
Before 2010, funding allocated to the NHS in England (Scotland and Wales are devolved) was controlled by Primary Care Trusts (PCTs), who used it for commissioning healthcare for local areas, with planning and performance overseen by regional Strategic Health Authorities (SHAs). Overall policy and NHS funding is ultimately controlled by the Department of Health.
Since then, several major sets of reforms — initially intended to devolve decision-making — have in fact centralised power and control, taking away political accountability.
These reforms kicked off with the 2012 Health and Social Care Act, also known as the ‘Lansley reforms’ after the then Secretary of State for Health, Andrew Lansley, who sought to make the NHS more localised and driven by GPs.
These reforms removed Primary Care Trusts and SHAs altogether, replacing them with GP-led Clinical Commissioning Groups (which hold local areas’ health budgets) and the NHS Commissioning Board’, whose intended prime purpose was to commission specialised services.
These reforms were never fully realised as originally envisaged and had a number of unintended and unforeseen consequences, the biggest being at the centre, with transformation of the National Commissioning Board to NHS England.
This went hand-in-hand with power, resource and influence seeping away from the Department of Health (which has ministerial accountability and covers both health and social care) to NHS England, which only has influence over health (NHS) funding and has no link to social care, which is run by local government.
NHS England is not a government department, yet took on a performance management role far greater than anyone planned, and in effect also controls policy. Lack of ministerial accountability has two main implications. Firstly, big decisions are made without recourse to the scrutiny of normal policymaking and parliament; hence culture of strong performance management.
Secondly, without policy on statute, faced with other statutory demands and having to follow directives set by NHS England, local councils won’t necessarily comply, especially when they are struggling financially. Their own statutory duties will come first. This perpetuates the disaggregation of health from social care.
Integrated care systems?
More recently, there has been a move to ‘integrated care systems’, driven by NHS England.
These changes, despite not yet backed by legislation, are happening; the Health and Social Care parliamentary committee was reviewing potential legislative changes — described in NHS Long Term Plan — this has been stalled since the 2019 general election.
Clinical Commissioning Groups are already being grouped, along with NHS provider organisations — hospitals, community and mental health trusts — into integrated care systems with NHS England merging with the provider regulator, NHS Improvement.
In effect, the NHS in England is now run, with increasing centralisation, by NHS England and NHS Improvement’ (NHSE/I), which has far greater reach and exercises far more direct control than the central department ever did. NHS trusts in England are performance managed more closely than they have ever been and arguably the biggest drivers of local health authorities’ decisions and hospitals’ delivery plans are directives from NHSE/I.
Why does this matter and how has this affected the Covid-19 response?
On the face of it, one can argue that increasing centralisation will mean more control and consequently a better, more co-ordinated national response. In fact, the opposite has proved to be the case.
To begin with, whilst power is more centralised to a handful of people at the very top of NHSE/I, the health and care sector is more fragmented than ever. For example prior to the 2012 Health and Social Care Act a number of councils and primary care trusts had merged to form single health and social care commissioning organisations for a given area.
In London, Islington and Southwark were two examples. They used their joint budgets to commission health and care services that made sense for their local area. However, now, health commissioning is closely driven by NHS England, which does not have the statutory or performance leavers to compel councils to follow its lead.
Even though councils want to work closely with their local health commissioners, in the current financial climate, they will prioritise meeting their statutory duties.
The most damaging outcome of the changes, for both the long and the short term, has been the disconnect between health and social care in both policy and delivery. The re-branding of the Department of Health and Social Care in early 2018 masked the fact that, in reality, the department has always had accountability for both health and social care. The change of name brought with it no more power or control — which resides with NHSE/I — and, for all the talk of ‘integration’ there has never been a greater disconnect between health and social care.
As NHSE/I’s remit only covers NHS-funding, the first few weeks of reporting of death rates focused entirely on hospital deaths. Yet since the start of the pandemic around 15,000 deaths happened in care homes, a core part of social care provision, which sit outside the remit of NHSE/I.
Similarly care homes and home care agencies, not to mention self-employed care workers, were at the back of the queue when it came to protective personal equipment; they have simply never figured in NHSE/I’s planning.
Had control over the health sector in local areas remained with the Department of Health and Social Care, we would have seen much earlier involvement of local councils. In April, a letter from the Association of Directors of Adult Social Care to ministers mentioned a “significant imbalance between listening, hearing, and understanding NHS England as opposed to social care”
The lack of integration of NHSE/I with local councils also means they have no links to local public health leads employed by local authorities. Whilst Public Health England has been fronting up Covid-19 messages, there was no co-ordination and planning with local councils’ public health consultants until late May.
A third consequence of NHSE/I driving the Covid-19 response is that the under-utilisation of the thousands of volunteers who signed up to help with this national emergency. Had this been planned with councils, so much more could have been achieved.
Centralised planning
Centralised planning works if the planning is sound and everyone follows it.
The issue with NHSE/I approach to Covid-19 is that, not for the first time, it focuses on giving the government comfortable messages, at the expense of enabling locally-driven, clinically-led solutions. Consequently, individual hospitals, and even clinical leaders within individual hospitals, did their own planning, whilst giving NHSE/I the assurances it sought.
NHS England has, from the start, positioned itself at the top of the NHS, taking on that role when the Department of Health lost significant staff and influence. It drove an ambitious vision for a new healthcare system, but at a time when funding in real terms has not kept up with demand for core health services.
Consequently, the culture of performance reporting — which took off in the New Labour years, when politicians did put in more money and wanted to see results — became one where the reporting takes on a life of its own. This allows NHS senior leaders to square the circle of reporting success when successful transformation, and even basic service delivery, is difficult due to funding constraints.
Communication from the centre
Sadly, as the entire system is geared towards assuring the centre, there are not the mechanisms for communicating what is working and not working locally; essential when we are dealing with a new virus about which we know so little. What we then end up with is a situation where individual hospitals are trying their best through trial and error, with the veneer of following a national plan that came from an organisation that is focused on managing messages.
This is why we have seen so many abrupt changes and U-turns, with the centre issuing diktats determined by politics and then needing to be changed when they are exposed as unsafe or unworkable. One example of this was the changing advice from the centre on the types of personal protective equipment that is acceptable.
Poor, politically-driven messages from the centre too frequently hindered rather than helped hospitals in operational management of Covid-19.
For example, the initial message from NHSE/I to local hospital trusts was to not mark which wards were Covid-19 and which were free of the virus, as this would frighten patients. Wards were eventually labelled as it is essential to keep people in hospitals as safe possible; but this was despite rather than because of national planning. Although the delay is only short, in a pandemic every day matters.
Whilst NHSE/I has more power than the Department of Health and Social Care, it has no direct political accountability. In 2013 the NHS Commissioning Board was rebranded as NHS England and this was followed by moves towards merging the former regulatory organisation, Monitor, with NHS Improvement. If this merger goes ahead, then we will end up with a single organisation, which is not a government department, which holds a commissioning budgets (NHS England’s original purpose), directs national policy, controls local health systems, performance manages providers and does this on a statutory footing.
Finally, NHSE/I has brought about a deeply problematic management culture of top-down diktats, constant performance management and strict adherence to central messages. In a time of uncertainty, this leaves us with an NHS that is poorly placed to problem-solve and develop solutions. In a pandemic we need local hospitals, councils and community groups to work together and develop tactics and management plans that work for their local areas; all need to be able to adapt quickly and re-plan as we find out more about the virus. The NHSE/ Is’ top-down, assurance-led approach simply does not allow for this.
Learning from Covid-19
If we learn anything from the Covid-19 pandemic, it should be what constitutes a more resilient healthcare sector and how we bring this about.
First and foremost, we need measures that enable local planning and commissioning of services.
The concept of ‘integration’ in healthcare has been around for well over a decade but we have seen little practical difference and not even a clear understanding of what this means. The recent NHS England-driven changes towards ‘integration’ have been focused on bringing health and social care services together, with the purpose of facilitating hospital discharges and consequently managing costs.
Context is everything, and NHS England has only ever existed in the age of austerity, so it has focused on measures that control NHS funding and everything, including integration, is seen through the lens of minimising cost.
Local control and adaptation
The only way to have an integrated healthcare system that meets local needs is to give much greater control over health budgets to local councils and/or regional assemblies.
Giving budgets and greater responsibility to councils or regional democratic bodies allows us to take a broader view of integration, and enable joint planning of not only health and social care but also planning that involves schools, voluntary sector organisations, leisure services and businesses.
In a pandemic, this means hospitals and health workers working on the frontline can be supported by authorities which are better placed to draw on other local resources and access local lines of communication.
The shift to local authority-led healthcare planning and commissioning would also bring with it greater transparency and accountability, through democratically elected officials.
At the moment, most people do not understand how the NHS works, they do not know who can help them navigate the system and, whilst they can complain to individual providers, there is little opportunity for people to shape their local health services. With council services, any local resident can approach their councillors, who are obliged and incentivised ensure that local services work for local people.
A third significant benefit is that the health sector can build on lessons learned by social care in how to support people with long-term needs. Since the late 1990s, driven by the disability rights movement, the model of social care has transformed.
It is not perfect, but the culture change that social care has undergone is enormous, from one where service users are passive recipients of ‘care’ to one where people are enabled and supported to live their lives. Given that the biggest challenges for the healthcare sector are around supporting people with long-term, often complex, needs, the tools, approaches and mindset adopted in social care can help bring about a similar transformation in how we deliver healthcare.
At the moment, not only is commissioning and planning of health services highly centralised, we also have a command economy of health providers; the NHS behaves as a single, large employer whose prime purpose, as an employer, is to keep costs as low as possible. It not then surprising that pay has been one reason why there has been a workforce shortage building up in recent years, particularly in nursing.
This was made significantly worse by the removal of nursing bursaries, the ‘hostile environment’ for immigrants and the result of the EU referendum, which saw large numbers of EU residents return home; a record number of nurses and midwives from EU countries left the UK in 2017.
As most providers are state-funded and information about them centrally controlled, the nature of the nursing shortage did not figure in national Covid-19 planning. This shortage then played out in a number of different ways during the Covid-19 pandemic, for example, too few nurse to support high-quality ICU care and insufficient nurses carry out local testing.
Autonomous providers — those not directly controlled on a day-to-day basis by the centre — will not feel compelled to support political messages. They can be honest about major workforce issues and what is and is not feasible, so we are not caught short when there is a crisis.
In our current system, whilst we nominally have health providers and budget-holders, in reality there is little genuine commissioning-the same contracts are given to the same organisations, frequently with the same senior managers moving from commissioning to provider roles, and vice versa.
A mixed provider landscape, where providers are truly independent, will enable policymakers to support the development of not-for-profit providers.
In our current system, we play lip service to the ‘third sector’, muddling up the role of advocacy organisations and providers, the latter being on far from an equal footing (in terms of funding, access to resources and respect) to state-funded NHS providers. Enabling and sustaining not-for-profit, but independent providers will drive innovation, improve quality and allow providers to be great employers.
So, we need providers to be autonomous and greater transparency in the sector, and we also need budget-holders to be more commercially astute.
Some private healthcare organisations are amazing at providing quality solutions and taking a reasonable approach to profit. Other companies, and their investors, are driven far more by just maximising profit. At the moment, our healthcare planning, indeed the national discourse, is not set up to differentiate between the two.
As policymakers and commissioners, we need to be commercially smarter. If we are to foster excellence, we need to hold true that value, and support all organisations working in the sector to deliver excellence.
As well as healthcare workers, we need to support people to manage their own care. The greatest challenge to all developed healthcare systems comes from aging, lifestyle and related long-term conditions. The NHS has made attempts to transform itself to address this challenge, for example through the ‘personalisation agenda’, the website NHS Choices and now through Integrated Care Systems.
But actual, effective mechanisms for empowering people to manage their own health is very limited and, because it is coming from a system which is designed to deliver cheap acute care, not going to change without a concerted effort. Commissioning and planning organisations, such as councils or regional authorities (e.g. the Greater London Authority), need to put information and advice for the public at the centre of the healthcare system. In our current system, set up in the immediate post-war era, the culture is one where people need to be looked after, be grateful and be compliant. In a pandemic, we need people to be actively involved, alert and engaged.
A new national discourse
More fundamentally, we need a more open and better-informed national discourse about healthcare and the NHS. ‘Free at the point of use’ is an important principle but it should not be the only measure of success.
A strong healthcare sector is one that is also responsive, person-centred and transparent. These principles need to be held as closely as we hold the idea of not charging for healthcare at delivery.
We also need to de-couple the ideas of ‘free at the point of use’ from state-funded healthcare. A single-payer healthcare system can, and in other countries and healthcare systems does, pay for health and care to be delivered by multiple provider organisations.
In the UK, healthcare funding is already given to a range of private, profit-making companies. This extends beyond pharmaceutical companies and includes established health providers (for example, a significant proportion of acute mental health care), care homes and agencies and a new breed of providers set up in response to specific NHS needs (for example, reducing waiting lists for diagnostic procedures).
Moreover, since the inception of the NHS, general practice has been delivered by private organisations. Making profit may, or may not, be a significant issue in our healthcare sector. But a far more fundamental problem is not understanding how and when private companies are involved, who they are accountable to, how to commission them in a way that is fair, particularly given the often close relationship that exists between people who hold authority or budgets in the NHS.
Some people will find these ideas difficult, as they challenge closely held assumptions about the NHS. People who work in the healthcare sector — those with direct patient contact, managers, commissioners, and policymakers — have had an incredibly tough time in recent months. We should applaud their effort and support them as individuals. However, in recognising the effort of individuals, we should not shy away from honestly assessing systemic failures. Indeed, we owe it to the people working in the system as much as the people who have to use health and social care services, to recognise the structural deficits within the NHS and work towards a more open, responsive and resilient sector.
About the author
Smriti advises on strategy and delivers change programmes in the health and care sector. She has worked in health and care for 20 years, including as an NHS programme director for learning disabilities and autism. She is passionate about making healthcare more transparent and responsive.