For the first 26 years of its life after it was launched on July 5 1948 the NHS was hardly changed in structure. But since 1974 a regular churn of reorganisations and structural adjustments has consumed huge amounts of management time and energy, often with highly questionable results. Numbers of relatively local bodies running the NHS have up to now varied from over 700 to as few as 80.
By any measure the current proposals, expected to be spelled out in a Health and Care Bill before Parliament’s summer recess, will reduce England’s NHS to the lowest ever number of ‘local’ bodies, with no more than 42 Integrated Care Systems (ICSs) – and the possibility that some of these may merge.
Now, as campaigners nervously await the new Parliamentary Bill to legislate for this latest major reorganisation – and while the vast majority of the wider public remains blissfully unaware that anything is happening – it’s worth noting how the coming changes compare with those that have gone before.
In 1948, when the NHS in England and Wales was run jointly, there were 377 hospital management committees, and 36 teaching hospitals with their own board of governors, while health centres, ambulance services and other community services were run by 146 local authorities, and general practices, NHS dentistry, pharmacists and opticians were run by 140 executive councils.
The 1973 NHS Reorganisation Act was drawn up by Ted Heath’s Tory government and implemented by Harold Wilson’s Labour government.
It brought the first real focus on more local accountability and involvement of the public in the decisions on health care, and established a 3-tier system of Regional, 90 Area and 205 District Health Authorities (reducing to 199 by 1979). It also integrated ambulance services, and some community services, previously run by local government, into the NHS for the first time. Primary Care was to be run and financed separately through Family Practitioner Committees.
Concern over local accountability had been increased by the succession of controversial hospital mergers and closures linked to the building programme flowing from the 1962 Hospital Plan for England and Wales. In the stormy years that followed local concerns were to be increased by financial pressures forcing cutbacks in local services.
This pressure escalated from 1976 when a monetary crisis had forced Harold Wilson’s Labour government to seek support from the International Monetary Fund: one of the strings attached obliged ministers to cap NHS spending at local level. As a result hospital and mental health services (but not primary care) were to be subjected to formal “cash limits,” and Margaret Thatcher’s Tory government made these cash limits legally binding in 1980.
The next reorganisation followed in 1982, in which the Area Health Authorities were abolished, and district health authorities were restructured: shortly after this (1983) it was the 190 District Health Authorities that were tasked with putting non-clinical hospital support services out to competitive tender.
The following year saw the restructuring of NHS management along “business” principles as proposed by Sainsbury boss Roy Griffiths in a report for the Thatcher government. Out went consensus management and administrators, in came higher-paid general managers, soon rebranded as chief executives, and executive directors on short term contracts.
Also in 1983 Chancellor Nigel Lawson imposed hefty cuts in NHS spending, resulting in a wave of hospital closures and a rapidly worsening performance as waiting lists grew.
By 1987 the years of frozen or falling funding had forced widespread closures of beds and cuts in services, and – after Thatcher’s third election win in the summer – resulted in increasingly critical headlines in Tory newspapers complaining of waiting lists at crisis point and patients dying waiting for cancer and heart treatment.
This triggered a limited increase in spending – and a secretive “review” of the NHS by a hand-picked team of advisors, whose plans surfaced as the NHS and Community Care Act in 1990.
The Act, strongly opposed by the BMA and in parliament, split the NHS for the first time into purchasers (District Health Authorities, with cash-limited budgets based on local population, and 306 “GP Fundholders”, with their own budgets to “shop around” and purchase elective treatment for their patients) and providers (NHS Trusts, of which 57 were established in 1991, followed by several waves eventually creating 270, each with their boards). The Act also abolished Family Practitioner Committees and replaced them with Family Health Services Authorities (FHSAs).
The providers were required to compete with each other for contracts (and funding) from DHAs and GP Fundholders. The more complex system required tens of thousands more managers and administrative staff – but was still drastically under-funded.
The Act also included plans set out in another Griffiths Report in 1988, to remove long term care of the elderly from the NHS – where it was free at point of use – and switch it to social services, where it would be subject to means tested charges.
The Act slashed the number of DHAs from 190 to 145 by 1993, with plans to further reduce to 108 by April 1994 and eventually to as few as 80-90, raising questions over lost local accountability.
Five years later the Health Services Act reorganised the 14 regional health authorities into 8 – and scrapped the FHSAs that had just been established.
Tony Blair’s victory in 1997 was followed by a new policy statement “The New NHS, Modern, Dependable,” – but no new money. GP Fundholding, which had left a minority of GP practices holding substantial unspent funds, was scrapped in 1998, in place of which 481 Primary Care Groups were established as advisory bodies to District Health Authorities.
In 1999 the devolution of power to Scotland and Wales meant that the structures of the NHS increasingly began to diverge as both devolved administrations took their chance to progressively roll back the ‘internal market’ and reinstate the integrated model of the pre-1991 NHS.
In England from 2000 Primary Care Trusts (PCTs) began to be established, with up to 300 eventually agreed. As PCTs developed they replaced DHAs as hybrid bodies, commissioning local services, while also providing community health services.
New Labour’s NHS Plan also brought in the cash-limiting of GP services which had until that point been the only sector of the NHS not subject to spending constraints.
In 2002 28 Strategic Health Authorities were established, but 4 years later these were reduced back to 9, and numbers of PCTs were halved to 151 as a result of the controversial “Commissioning a Patient Led NHS” reorganisation which deepened the purchaser-provider split. It required PCTs to separate themselves from community services and contract them out, inviting tenders from “any willing provider” – until Andy Burnham as Health Secretary stepped in in 2009 and, under pressure from the unions, and triggering fury in the private sector, brought a temporary halt to the privatisation by insisting that NHS trusts should be the ‘preferred provider’.
A year later the Cameron coalition took office and immediately launched into the biggest-ever top-down reorganisation of the NHS
The last remaining community services were finally split from PCTs in 2011, in the midst of Health Secretary Andrew Lansley’s disastrous market-based reorganisation, which scrapped both PCTs and the remaining SHAs, and established 207 Clinical Commissioning Groups (CCGs) with no regional coordination, headed by NHS England. Regulations required the CCGs to put an increasing range of clinical services out to competitive tender.
The Health and Social Care Act was eventually implemented from April 2013 – but it was just over a year later that Simon Stevens, one of the movers of New Labour’s marketising “reforms” from 2000, was appointed CEO of NHS England.
He swiftly published the Five Year Forward View, which barely mentioned competition, and which first introduced the notion of Accountable Care Organisations (ACOs) to the lexicon of British health care reorganisation, coyly referencing its origins in the chaotic US health care system.
Stevens, who has never explicitly mentioned his prior role (while a leading executive in the giant US insurance corporation UnitedHealth) in leading discussions promoting concepts of “accountable” and “integrated” care at the World Economic Forum in 2012, eventually recognised that the terminology had become toxic, and NHS England began to rebrand ACOs as “Integrated Care”.
However ACOs were still in evidence when, at the very end of 2015, the emphasis switched from the Five Year Forward View to the establishment of “Sustainability and Transformation Plans,” which were to be drawn up across ‘local health economies’ at breakneck pace behind closed doors by NHS chiefs, where possible with token involvement of local government.
During 2016 England’s NHS was carved up into 44 STP areas, each of which set up extra-legal bodies to drive the implementation of plans that not only lacked any popular or political support, but which in several cases proved completely impractical.
Nonetheless the STP ‘footprint’ areas, with some adjustment in the north of England, have become the 42 areas now to be redesignated as Integrated Care Systems, with no real clarity over the extent to which the previous CCG areas (“places”) will continue to have any voice over policies decided by the most remote-ever “local” management bodies.
One obvious conclusion from this constant churn and redisorganisation is that there is no past golden age to which we can neatly restore the NHS. The period prior to 1974 gave little or no voice to local communities, with the NHS still not including ambulance or community services, and with primary care very much separately controlled. But as services have since been brought together, the competitive market has also split them up into contracts and brought rivalries rather than collaboration between NHS providers.
Changes have experimented with both many small (Primary Care Groups) and fewer large ‘local’ bodies (Area Health Authorities), and with health authorities, PCTs and CCGs of various sizes and composition – but none of these bodies have been elected, and none have adequately engaged with or won the confidence of local people.
To make matters worse, the underlying constraints on resources have limited options – with cash limits for the last 45 years that extended to cover all sectors of the NHS.
The fact is that while some damaging cuts and ill-conceived plans have been forced through, numerous attempts to force local NHS leaders to uphold cash limits and balanced budgets above delivering health care to those who need it most have proved unsuccessful. Most hospital management have proved themselves more willing to take their chances with rising deficits than to endure the hostile press coverage and public anger that would flow from turning patients away.
This has continued to this day – only last spring NHS England stepped in to convert £13.4 billion of accumulated trust borrowing to cover deficits into long-term Public Dividend Capital, recognising that it could never be paid off.
Time and again services have been saved or cuts and reconfiguration deferred or scaled back as a result of strong, focused local campaigns, sometimes backed by local newspapers, courageous local councils and MPs, and often supported by health unions and the wider trade union movement.
That’s why, for all the damage it has done, the Lansley Act has not resulted in the end or wholesale privatisation of the NHS, as some had feared. The reservoir of public support for the NHS at local level is still a major political constraint on senior NHS management and ministers at local and national level – and will also limit the extent to which ICSs can be used as local levers to force through cuts in spending and restrictions on access to services.
The stress on involvement of local government, links with social care, and even efforts to press gang council leaders into supporting NHS initiatives have markedly increased since 2015, with STPs and subsequent moves towards ICSs – but the extent to which councils have any resources to offer or any political influence has been drastically reduced by a decade of brutal cuts that have more than halved local authority budgets.
As we prepare to fight the warped Tory vision of “integrated care” it is obvious that we need a coherent alternative view of what we would like to see: however there is currently no common approach – and it’s clear that some campaigners will focus solely on opposing the coming Bill rather than seeking to mobilise the necessary political movement pressing to remove or blunt its offensive elements through amendments.
One common factor is all of us would much prefer not to be starting from here – an NHS disintegrated and fragmented by over 30 years of marketising ‘reforms’, crumbling after a decade of frozen funding and inadequate capital investment, wracked by chronic staff shortages, and its senior management largely lobotomised by decades of increased dependence on management consultants and their various quack theories that divert money and effort from patient care.
As the government faces internal wrangles over the scope and shape of the Bill, the challenge is for campaigners to find enough common cause to exploit these divisions and combine once more to defend the NHS against a major threat.
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