Richard Bourne discusses how past policy failings still haunt the current health policy debate, as he explores the changes proposed in Patricia Hewitt’s review of the integrated care system and the recently published paper by Chris Ham on the political failings in NHS policy – 2010-20


Even at the high point of 2010 the NHS and social care system faced severe challenges.  The basic NHS principles (universal, comprehensive, free at point of need and tax funded) were strongly supported and the NHS did well on international comparisons, but the much improved NHS had not adapted to the new reality that millions could live independent lives for many years with appropriate care and support – it was rooted heavily in curative care.

Whilst the NHS came near the top of health care systems in international comparisons, on some measures of quality of care the NHS performed badly.

The unspoken reality was that the NHS delivery model, loosely based on a pretend market, was dysfunctional and badly managed. The economy was being impacted by poor health.  The Treasury regarded healthcare as a cost to be cut, not as an investment.

It is all far worse now.

Years of austerity funding, and the worst thought-out reorganisation in NHS history has done huge damage.  The pretence of the Conservatives going into the 2010 government that it was now “the party of the NHS” never translated into anything serious. And after more than a decade of austerity, last year’s inept attempt to reverse the worst of the coalition government’s 2012 ‘reforms’ is already unpicking.

Moreover looming large over the issues in the NHS is the disgrace that is our social care system. After decades of failure to address the problems, it does not work for those that need care, for the staff that deliver care, or even for many of the organisations that provide care.  Multiple promises to “fix” social care have all been shown to be hollow. Many who need it most are denied any care, or receive inadequate care.

Two new perspectives  

Against this background we have had two significant publications.  Firstly, Prof Chris Ham’s synopsis of the woeful failures of the post-2010 governments to stem the severe decline in services.

That sets the context for the second publication, which is an attempt to address the issues around the “new” NHS of Integrated Care Systems (ICSs).  To be fair many of the 36 recommendations in the Hewitt Report are sensible although they are light on how things will be done.

In particular Hewitt argues for an approach that accepts the need for the NHS to adapt and to fit into a system designed to improve wellbeing, with more being spent on prevention and a shift to greater emphasis on community and primary care.

It argues for more stable funding, a longer term and more coherent way to use capital, and for better ways to use funding through pooling of budgets and for the proposed cuts to ICS management costs to be reconsidered.  It also puts the case for better use of data, and for employing more NHS staff capable of using that data to better manage and to improve outcomes. It supports a stronger role for patients and the public.

Critics might suggest it is an NHS solution to problems the NHS does not understand and, as ever, it is focused on the vested interests especially those of the large provider Trusts.  It also relies on opinions drawn from talking to ‘stakeholders’ (the usual suspects) rather than data and analysis, and little evidence of engagement with patients, carers, staff, service users or even voters.

There is no support for the minority view that ICSs are a trojan horse for planned Americanisation.  Hewitt argues that rather than disrupt yet another reorganisation, the ICB/ICP setup that has now been put in place should be adapted and made to work, reflecting at least a salute to devolution and localism.

However the Hewitt Review has not met with much enthusiasm, and looks like being shelved.  The Treasury is unlikely to move from its short term commitment, seeking cuts rather than investment to meet the rising cost pressures on the NHS. NHS England in turn will not relinquish its top-down culture of performance management and direction. Ministers will not accept localism, and will continue to try to micro manage; and the ICS’s will be made up of those who toe the line and look upwards.

More and more will be poured into hospitals, and the power and influence of community/primary care will continue to decline.  Desperately necessary capital investment will be as likely to arrive as the now mythical “40 new hospitals.”

And as a vehicle for real reform (whatever that means) Hewitt’s review does not go far enough. A new approach is vital.

The care system is in crisis.  It needs some short-term actions to resolve immediate problems, mostly around workforce.  It needs a government that believes in the founding principles, and will support them with funding.

But more money, more staff, or even more ambulances are not the solution – or at least not the whole of the solution.

The most important issue of all is the need to be honest about the NHS and its weaknesses as well as its strengths:

  • it cannot function effectively without a public health system to minimise the numbers developing avoidable health problems, along with proactive measures to improve the living standards and conditions of the poorest and reverse the recent downturn in healthy life expectancy.


  • hospitals and primary care services cannot function effectively without the development of a universal and accessible National Care Service in place of the current cash-starved, dysfunctional and largely privatised shambles.


  • despite the empty rhetoric about “integration,” hospital and community health services cannot function effectively when the NHS budget is carved up into contracts which allow the private sector to cherry pick the least demanding services in the quest for profit, while NHS trusts are left with all of the emergencies and most costly and demanding cases. The outsourcing of clinical and support services to private contractors undermines the viability of NHS providers, and should be halted and rolled back as contracts expire.

Only then can evidence based solutions allow some honesty about the expectations of the electorate on just how long they have to wait and how much they may have to pay in taxes!

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