In defence of structural reform

There is rare unity among all three main political parties – don’t use the “R”-word in the context of the NHS when it comes to 2015 election manifestos.

Reconfiguration and structural reforms are almost certainly off the table for next year’s election, given the bitter experience of the recent top-down reorganisation of the NHS (though of course this one wasn’t in a manifesto either). What’s more, politicians are likely to go out of their way to stress that there won’t be any more structural changes if elected.

By some accounts, over £3bn will have been spent by the time the Health and Social Care Act 2012 is fully implemented, one of the largest NHS reforms ever conducted and, in the words of David Nicholson, the outgoing NHS’s chief executive, one that was ‘visible from space’. It has also been one of the most divisive. Everyone seems to agree – there should be no more of this.

However I beg to differ. Arguing that we have just reorganised and therefore shouldn’t do it again, even though many commentators, front line staff and commissioners have expressed concerns about the new system, is absurd. It is like operating on the wrong knee, just to rule out further surgery in fear of repeating the same mistake and reverting to homeopathic treatment instead.

If we genuinely think that there are challenges in the NHS which are at least partly driven by structure, we should act.

Take, for example, integration of services across providers which is a stated objective across political lines. The current system is hugely fragmented both on both the provider and commissioning side. This is of course not just a consequence of the most recent reforms, but also previous structural policy changes such as the introduction of autonomous Foundation Trusts, which may have improved services but potentially at the price of more introspection. Successful integration programmes – of which there are very few in the UK – have therefore worked despite, not because of, these structures. More often than not, they have relied on goodwill, incentives, and temporary suspension of organisational self-interests. That’s why even fewer will survive.

At the same time, in some parts of the country more radical structural changes are being explored locally to achieve the necessary improvements in care, some as far reaching as combining primary, community and secondary care into new healthcare organisations.

A sensible political strategy would therefore be to avoid the aversion to reorganisation, and instead embrace the plurality of local change, focusing on supporting and enabling where needed. This may include accepting that integration may require consolidation of organisations and revisiting our current competition rules. Competition and choice don’t exist in isolation and need to be balanced against other objectives such as quality and safety. Similarly, if it takes reversing the policy that will see all secondary providers become Foundation Trusts eventually, in the interest of better care coordination, then so be it. The point is, structure follows function. We had too little of the latter in recent reforms, but we risk having too little of the former going forward. One can’t exist without the other in a successful healthcare system.

Structural change is but one lever to help address the challenges the NHS is facing, and without a clear strategy and case for change, it is cosmetic and disruptive. However, as a policy tool, we ignore it at our peril.

Image source: