British governments have, over the years, demonstrated a persistent and almost obsessive desire to re-engineer the NHS via politically driven, top-down reorganisation throughout its 73-year history – more so than most other comparable G7 countries do with their own healthcare systems. Arguably, the mis-characterisation of the NHS as a single unitary organism by politicians, rather than an ecosystem composed of differing constituent parts, ranks high on the list of basic errors of calculation which obstruct the success of such reforms.

Be that as it may, individuals who are prepared to stand up and proclaim that the 2012 Lansley reforms were a success are probably about as rare as live unicorns, or they’re living as hermits in remote mountain caves. The one consensus that binds the NHS commentariat together is that the Lansley reforms – no matter how well intentioned or imagined – were an unmitigated failure on most, if not all, counts. They also took place during a time of NHS funding surplus in technical terms, which is not where we find ourselves at this point in time with a depleted treasury and the pandemic-response costs of government spending high on the agenda.

And so, for any exhausted, burnt-out or depleted clinician or healthcare manager who’s spent the past year improvising, re-engineering, implementing social-distancing and testing protocols, re-designing care pathways, converting clinical spaces into hot and cold zones, deploying remote consulting capabilities from out of a hat – or latterly conjuring up mass-vaccination hubs in repurposed buildings up and down this country – they must be thinking, why now? Surely at this of all times, the NHS needs another top-down organisation about as much as Vladimir Putin needs a new set of gold bath taps or a bomb-proof underground billiard room.

The cynical money would point to the pandemic as being a perfect opportunity for the government to smuggle in contentious reform under the “COVID lessons learned” banner. Matt Hancock’s headline comments on the reform do appear to bear this out:

“The NHS and local government have long been calling for better integration and less burdensome bureaucracy, and this virus has made clear the time for change is now”.

Putting aside for the moment that many would argue the NHS has done what it does best during the pandemic – improvised, organised and adapted at ground level to meet the horrendous challenges of COVID – the DHSC web statement by Sir Simon Stevens makes the point that:

“Our legislative proposals go with the grain of what patients and staff across the health service all want to see – more joined-up care, less legal bureaucracy and a sharper focus on prevention, inequality and social care”.

So, in summary, the proposed bill will aim to enhance integration across health and social care, reduce burdensome bureaucracy and put technology at front and centre of these efforts. The first key point of the bill is to create Integrated Care Systems (ICS), 42 in number, aligning to local regional boundaries, comprising of “partnerships” between the NHS, local government and wider partners such as the voluntary sector. Crucially, ICS will supersede the existing 135 Clinical Commissioning Groups by April 2022 and take over their commissioning responsibilities.

But don’t expect to see the same merry-go-round of large redundancy pay-offs and seat shuffling that was so evident in 2012 and so widely commented on, and expect to see the proposed bill enacted through parliament by 2022.

Via ICS, the NHS and local authorities will have a statutory duty to collaborate across healthcare, public health and the social care system. There will be new powers for the Secretary of State for Health and Social Care over the NHS and other arm’s-length bodies. The Department of Health and Social Care (DHSC) will have the power to intervene in service reconfiguration changes at any point without the need for a referral from a local body. The Secretary of State will acquire new duties in respect of reporting on workforce planning across all areas of healthcare and social care. There will still be no statutory duty to provide services for all and there’s no mention of how to integrate ‘free at point of care’ healthcare with means-tested social care.

Crucially and significantly, the procurement process will change radically. Section 75 of the 2012 Health and Social Care Act will be repealed and replaced by a new procurement regime which will in effect do away with the need to go through a competitive tendering process. To put it mildly, this will not go unnoticed by anyone who’s had the slightest concern about the government’s widely scrutinised and criticised procurement arrangements throughout the pandemic, and would not in theory stop contracts being awarded to companies with little or no experience or expertise in healthcare-related activities.

The one aspect of the 2012 Lansley reforms that some might agree actually worked – the statutory independence of NHS England – is being removed and effectively replaced by centralised, ministerial control, which isn’t quite enough to make the average autocrat blush but certainly constitutes a major power grab in favour of central government. This is effectively a return to the days of central command and control, which historians could justifiably argue brings its own unique set of problems. Matt Hancock’s desk may risk becoming piled high with the day-to-day minutiae of running the NHS and, notably, Jeremy Hunt, Hancock’s long-serving predecessor, is on record as having stated he never felt that the independence of NHS England was an obstacle to him in carrying out his role and duties.

The Bill is widely being misperceived as an end to private competition for NHS contracts. This is not the case; it simply makes the process of procurement less subject to any checks and barriers from a competitive tendering process. Given some of the contracts that have been handed out during the pandemic, should we be concerned?

So, the checklist reads: reduce bureaucracy – always a popular sound bite. Increase collaboration between health and social care – makes perfect sense with an ageing population. Roll back the Lansley reforms – no one is going to argue with that. But no mention in the bill of an exhausted and depleted NHS workforce with a recruitment and retention crisis, a crumbling NHS infrastructure and the mountain of unmet routine and urgent patient clinical need that has been merely postponed by the pandemic. No mention in specific terms of the spending allocation from central government to make this all work.

The bill has as its backdrop the NHS improvement plan, at the centre of which stand Primary Care Networks (PCNs), which are now two years into their life cycle – the second year of which has been occupied pretty exclusively with the pandemic response. Led by relatively inexperienced clinical directors, who were originally funded to 0.25 whole-time equivalent, they have had to juggle a huge day-to-day clinical workload in their own practices. It’s unclear how the boards of ICS will be appointed; given the vastly differing size, scale and maturity of individual PCNs, from a primary care perspective, it has to be a valid concern that they will lose out in the competition for power and influence on ICS boards to more experienced and politically wily competitors comprising partners from secondary care, community healthcare, social services and the voluntary sector – or indeed, for example, representatives of the biggest American corporation to invest in NHS primary care, Centene, which now controls a huge swathe of GP surgeries and out-of-hours provision in North London. There is nothing in the bill to prevent this.

One of the few plus points arising from the pandemic response, most assuredly from the perspective of anyone involved at the sharp end of primary care, has been the effective side-lining of the Care Quality Commission in its normally inflexible, hostile and crushing regulation of general practice. There have been no on-site inspections and regulation has been a welcome light-touch regime, comprising a “Transitional Monitoring Approach” focussing on the pandemic response and carried out by telephone calls. With time on their hands, the CQC have been busy re-inventing themselves and information trickling out from Local Medical Committees (LMCs) appears to indicate that they plan to endow themselves with an expanded role which includes supporting change via a four-pronged strategy, which packages itself under categories labelled “People and Communities”, “Smarter Regulation”, “Safety Through Learning” and “Accelerating Improvement”. This should be alarming news given some of the language used in their strategy proposal which refers to statements such as “it will be unacceptable for services not to be working together”; this has a suitably oblique and essentially meaningless Orwellian overtone which anyone who’s had dealings with the CQC over the years will be very familiar with.

Unsurprisingly, opposition to and criticism of the bill are prominent in the British Medical Journal, which criticises the lack of detail around the “bespoke health services provider selection regime that will give commissioners greater flexibility in how they arrange services” and highlights issues around “Transparency, scrutiny and local accountability”.

The proposed bill seems to have gone down well on the Tory backbenches and in certain sections of the press. Others have taken at face value the pledges to reduce bureaucracy and increase integration of services without digging too deeply into the detail. Anyone who wants the PCN experiment to succeed should be paying close attention to what happens. With a solid parliamentary majority and the winds of a pandemic behind them, the government will not be feeling inclined to listen to dissenting voices on this bill, and with the new powers that the bill confers at his disposal, Matt Hancock (or his successor) will have the dice firmly loaded in his favour to act with relative impunity.

By @virverax (Forum Legend)