Sam Thurgood works with the NHS on hospital building projects, and is Deputy Chair, Political, for London South East. He was parliamentary candidate for Lewisham East in the 2019 general election.
Last week, and as covered on ConservativeHome yesterday, the draft White Paper on the NHS in England was leaked, showing the proposed future direction for the NHS. It contained a number of crucial proposals, including the formal merger of NHS England and Improvement – the oversight and regulatory bodies of the NHS – and the turning of integrated care systems into statutory bodies.
However, the White Paper includes much more, and many of the proposals look to increase the centre’s control over the NHS, replacing much of the Lansley proposals that led to more autonomy. As Conservatives, we often view more central control with suspicion and concern, the devolution of power being ultimately preferable. There is a case to be made however that with the NHS more central control is vital – particularly at the present time.
When looking at these plans we must, firstly, remember the role of the 2010 White Paper, the brainchild of Andrew Lansley. His proposals came at a time when the NHS needed to look more carefully at its overall spending.
Though the service was protected from spending cuts, it was undoubtedly going to have to be much more careful with its money, driving efficiencies through the system. Much was said of the Lansley proposals at the time: however, proponents would point out that at their heart was a central tenet of driving greater competition and accountability in the system, to ensure that greater financial savings could be delivered – which could then invested back into patient care.
So with that in mind, and looking at this leaked draft White Paper, what would they do to the NHS if implemented?
First, and as above, the proposals make changes to NHS England and Improvement. These two have been increasingly integrating for years now, and placing this merger on a statutory footing will help to formalise and further this process.
The would-be change that is likely to be noticed most by MPs in these plans is the right of the Secretary of State’s to intervene earlier in local NHS reconfigurations. This is a power that is absolutely needed. Though it is right that local bodies and interested parties should lead and input through the process, too many proposals spend millions in fees on development, only for these to get to the final stage of review by the Secretary of State, and to then be refused.
Earlier involvement and, crucially, the power for Ministers to be held to account in Parliament, is hugely significant. It does, however, have the potential to bring the Secretary of State much more into conflict with new Red Wall MPs, if service changes are proposed in their patches. The Government will probably be hoping that the massive investment in the new hospital building programme helps to ensure that this is unlikely, and may even be a driver of the need for greater and earlier influence in reconfigurations.
In a similar vein of increased control, the Department for Health and Social Care would gain greater controls over arms-length bodies, with the power to transfer roles and abolish them as they wished. As we have seen recently with the abolition of Public Health England, the need for a more flexible and adaptive NHS is vital, and this power should enable this to take place. For too long has Ministers deferred to the decisions of other bodies, rather than being held accountable for decisions.
Overall, these proposals arguably start to deliver what Simon Stevens has long been after: central control over NHS levers. It has often been said that, when taking over as NHS Chief Executive, Simon Stevens looked to his past in the American Insurance system. He saw the pro-active work that US insurers had done to promote healthy living, in order to reduce the chance of people needing interventions in a healthcare setting: surely the NHS, with its central control of the entire ecosystem would be even better at this.
However, he found that this was not so and, for much of his time in charge, has lacked the levers to make this a real possibility. Greater ability for intervention in the system could help to deliver change, and quicker.
Greater intervention is likely to also be vital as we emerge from Covid-19. The Integrated Care Systems (ICSs) have been used during this pandemic to ensure that resources are planned on a larger scale than a single trust or hospital – better managing backlogs, resource constraints, and outbreaks. As care backlogs and the results of delayed care become a real concern, the ICSs, and Government system control, will be vital to ensure that a postcode lottery of care is prevented.
But there are parts of these proposals that will cause concern. This includes the proposal for increased controls on Foundation Trusts (FTs). The freedom that was given to these organisations, first announced in 2002, has yielded some incredible results across the country – Sir Robert Naylor’s work at University College London Hospital being a good example.
Ensuring that these organisations retain their semi-autonomous nature and ability to adapt is key. Close scrutiny of any changes that reduce the autonomy of FTs should be undertaken – though over the last few years we have seen a creeping increase in control on FTs anyway. The formalisation of this in legislation may well be inevitable.
Most controversial of all is proposal for contracts to be awarded without competition. Many involved in the process of competitively awarding contracts would rightly observe that the process is unwieldy and cumbersome. The ability to award without going to competitive tender, though, is a big step in the opposite direction, and it will be interesting to see how the duty of collaboration to be given to Integrated Care Systems in the White Paper will ensure that the inherent focus on efficiency of the Lansley reforms is maintained.
And the White Paper both indicates a continued focus on some of the biggest challenges facing the NHS, including social care, while other big challenges are ignored – including estates.
Finally, and following the creation of NHS X, data continues to be an area that the NHS is pushing forward in. As the UK has shown its place as a life sciences powerhouse with the Covid vaccination development, the integration and accessibility of data will become even more vital. This is also an area in which the NHS can truly excel. Though the proposed White Paper doesn’t go as far as some have hoped – the creation of a new class of NHS Trust focused on the two aims of patient care and academic research – the breaking-down of data barriers is a step in the right direction.
In summary, the White Paper marks a dramatic change from the Lansley reforms of 2010, and it comes at a time of exceptional change. The result of Covid on services will be felt for many years to come. The NHS will need to be more integrated and adaptive for many years as it looks to deal with the results of the pandemic. These will include backlogs in care, the results of delayed interventions, and the effects of Long COVID. These proposals appear to deliver that, but we should look forward to seeing the final White Paper when it comes.