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Outsider gets lyrical about NHS England’s looming demise

Goodbye, NHSE

Though I never knew you at all

It’s nearly 15 years since the start of David Cameron’s coalition government with the Liberal Democrats. A government that promised “no top-down re-organisation of the NHS” yet delivered – arguably – the most divisive set of NHS reforms since the inception of the institution.

Andrew Lansley’s white paper on the forthcoming reforms was published with this gushing endorsement by Prime Minister Cameron: “It’s about getting rid of bureaucracy, putting the power in the hands of patients and GPs and cutting the cost of our bureaucracy by almost half over the next four years – and making sure money goes in to doctors and nurses and helping patients.”

Well, power and money certainly went to doctors. Check. Nurses, less so. Helping patients? Epic fail.

As for the cutting of bureaucracy… Hold on to your horses, for it’s a wild ride from 2010 to 2025.

They set you on the treadmill

And they made your change you name

Lansley got rid of Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) to replace them with NHS England (NHSE) and Clinical Commissioning Groups (CCGs).

Public Health would be handled by Local Authorities. NHSE would commission doctors, pharmacies, dentists and opticians. 

They would also authorise CCGs, which might also commission local services. As would NHSE and local authorities.

It started off a mess and it continued in that fashion. Even though the white paper was published very early in the life of the new government, none of the organisations were ready on 1 April 2012. A later report by Lord Darzi would describe these reforms as “a calamity without international precedent”.  

But this isn’t news; it was all known at the time. Lansley didn’t stand for re-election in 2015 for good reason, his subsequent elevation to the Lords representing the apotheosis of mediocrity.

And it seems to me you lived your life

Like a quango in the wind

In the 10 years since its architect’s departure, every passing health secretary has tried to minimise or undo the harms cause by Lansley – but typically ended up causing more.

It seems self-evident now but giving general practice what would amount to self-autonomy and self-commissioning in 2012 would not turn out to be the panacea Lansley predicted. PCTs and SHAs were great administrators. They were bean-counters, sure, but effective ones and they were experienced in using nuance and reason to manage deviations from the norm.

Suddenly giving all that power to general practice, which had only recently been introduced to the concepts of indicative budgets and shared gains, was a bold move.

CCGs were under-skilled and under-resourced. To think a PCT with hundreds of employees could be pared down to four or five CCGs, each with less than a couple of dozen employees was a pipe dream.

The flip side of the coin, NHSE, picked up the slack and grew to be an outsize version of Lansley’s vision.

Less bureaucracy just became different bureaucracy, with other organisations picking up the slack. Including, for a non-insignificant part – Local Pharmaceutical Committees (LPCs).

As headcount and skill sets drifted away from the new commissioning triumvirate, LPCs would step in to help design and manage services. 

The early 2010s saw PSNC endure endless internal debates about local provider companies, most of which went nowhere but cost a lot of time and money. All down to Lansley.

Then finally we see that the trajectory turns inward again, and Integrated Care Boards emerge. Placing the hospital trust back at the heart of the system. A hark back to health authority days, but still a long way off.

There is no political headspace to undo the 2012 reforms but workarounds can, and are, fudged. 

Sanity starts to raise its head. But is it too late? Water under the bridge is one thing, but the lost institutional memory of the last 15 years could have immeasurable costs. Here cometh the Labour Government, here cometh the salvation?

Community pharmacy’s decline can be directly linked to Lansley’s 2012 reforms. Pharmacy stopped being a function of a combined health authority and became merely a cost-line on someone else’s spreadsheet.

NHSE rarely defended pharmacy and general practice’s most egregious tendencies let loose.

Integrated Care Systems (ICSs) are still packed with the same self-interests that were unleashed by Lansley, though tethered now against their worst aggressions by the dominance of the Hospital Trust.

Yet there is hope. Government can’t expect to manage ICSs directly, there must be some return to the HAs of the past, only time will tell.

And if it’s time for again for NHS structures from 2002, perhaps it’s time to rock more songs from Elton’s Greatest Hits album? Goodbye Yellow Brick Road, or how about Saturday Night’s Alright for Fighting? 

Outsider is a community pharmacy commentator