As we approach the election, the prospect of yet more organisational restructuring for the NHS fills Kieran Walshe with dismay. The next government needs to focus more on changes which make a difference to patients, and which are founded on good evidence about what works.
The ability to hold two conflicting positions in your mind at the same time has its uses. George Orwell termed it doublethink” in 1984; academics call it “cognitive dissonance”. And it comes in handy when trying to make sense of both the government and the opposition’s plans for health reform.
On the one hand, there is a broad consensus that the Lansley health reforms of the last five years have been an unmitigated disaster – costing around £3 billion and untold political capital for little discernible benefit and leaving the NHS with a complex and fragmented organisational structure that few people understand. Sources close to Downing Street recently called the policy the worst mistake of the coalition, and the opposition have been unrelentingly critical of the reorganisation from the outset. Everyone agrees that the last thing the NHS needs now is any further reorganisation.
And yet, the government is now proposing a radical reorganisation to devolve powers over £6 billion of NHS spending to a Greater Manchester combined authority dealing with both health and social care, and bringing together the ten local authorities in the area with their Clinical Commissioning Groups, NHS trusts and so on. That looks like a pretty big reorganisation to me. Moreover, Labour seems to support the proposals for Manchester, and furthermore they say they would bring about the integration of health and social care throughout England, with a greater role for local authority-run Health and Wellbeing Boards. That too sounds like another wave of reorganisation.
Over the last two decades, the NHS has suffered (and that is the right word for it) some form of organisational structural change or reform about once every two years, all of which have been visited upon the NHS by the government of the day. Each time we learn the same three things: it costs a lot of money, it takes a lot of time and effort, and it adversely affects performance during the reorganisation and for at least two years afterwards. Of course you don’t need to be very clever to spot that NHS performance barely recovers from one reorganisation before it is hit by another. There is a deadly serious point here – that reorganising the NHS costs lives.
Of course we should not lock down the structure of the NHS and rule out any future changes. Apart from anything else, the Lansley reforms have left us with an organisational structure which is simply not fit for purpose. But politicians need to learn to engage in organisational change, not reorganisation. Changes should be demonstrably and plausibly linked to improvements in patient services and outcomes; they should be planned and enacted in and with the NHS, not dictated from the Department of Health or NHS England; and they should be independently evaluated to see if the intended benefits are realised in practice. Neither the government’s wham-bam speedy devolution plans for Manchester nor the opposition’s ideas on integrating health and social care throughout England yet meet these tests.
- This blog is based on an article published in The House magazine.