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Reform of the NHS – The Implications for C4PC – Author – Kim Ryley

  1. The Government’s recent announcement of a White Paper on (yet another) reorganisation of the NHS should come as no surprise. This is something that the NHS itself has been working on for the past few years. However, as is usually the case with such top-down driven change, this is a structural overhaul of the Health Service, rather than an attempt to tackle its perceived failings through improved frontline practice. It remains unclear how much it will contribute to the necessary “rebuilding” of health and care services in a post-pandemic Britain.
  2. The main shift desired by Sir Simon Stephens is to give Integrated Care Systems (ICSs) legal status, as statutory bodies from 1 April 2022. There will also be a move, by design, from competition and an internal market to greater collaboration. At the same time, as with other public services, the Government is centralising Health provision within Whitehall, as part of a move away from greater local devolution. (The role of Police and Crime Commissioners is likely to be next in line for such treatment). This greater political control is attractive to politicians given the command and control approach to the current pandemic, but it is a double-edged sword for the Government, who will need to “own” any future NHS failures.
  3. These changes might not arrive as a single “big bang”, but rather might come at a different pace in different parts of the country. There is also an unresolved tension between the language of “Place” and the language of “System”. The ICSs are very different in size and, through mergers, their number is likely to shrink from 40+ to 20-25 bigger bodies. They will, in effect, become the new regional tier of the NHS. However, their boundaries are not coterminous with those of upper tier local authorities, which will hamper integration with the Social Care system. In reality, ICSs are not about local delivery.
  4. At the same time, the key role of local councils, at Place level, makes Integrated Care Partnerships (ICPs) more crucial to delivery on the ground. However, how such a geographical approach will work remains unclear. The White Paper is short on important practical details like this. Localism looks increasingly like a fig leaf in this context, but in practice local collaboration cross-sector will be essential. The place and role of Health and Wellbeing Boards in this new structure is unclear and there are no new governance arrangements proposed, for example on who sits on ICS Boards. There is, however, meant to be a new emphasis on Patient Voice.
  5. There is no significant reference to Social Care in the White Paper. That provision remains within local authorities. There are no proposals for structural integration with Health and there is still no national Social Care Plan. Extra money for local councils in response to the Covid pandemic pressures will cease soon and there is no promise of extra funding in future, let alone for plugging the multi-billion pound funding gap in current care provision. Social Care will, however, be more regulated in future.
  6. A 2-year transition is envisaged to the new Health Service structure. In practice, this will be dominated by tackling the treatment backlog, with insufficient Government understanding of this being a task for a depleted and exhausted workforce, exacerbated by a predicted exodus as soon as the pandemic has passed its peak. In reality, this is likely to determine how the money for health will flow.
  7. However, there are opportunities in this new landscape for greater partnerships and collaboration, bottom-up, at local level, not least between councils and the VCS. The success of these initiatives will depend on the quality of local relationships. Although these are currently variable, many are working well and local coalitions have avoided silo-thinking and professional turf wars to innovate rapidly in ways that could become sustainable longer term.
  8. Such bottom-up approaches are more likely to be effective in tackling some aspects of inequality of health outcomes, though the wider social determinants of this needs cross-government action well beyond health and care services, such as on housing and income disparities. This dimension will not be solved by central command and control of medical operations and treatment within the NHS. Without genuine local public conversations about relative priorities, it is likely that only the most articulate will benefit from any improvements.
  9. The quality of Social Care and Child Care services will be pivotal, not merely to “saving” the NHS from demand pressures, but as an alternative to it. The greater use of Primary Care facilities will also be important at local level, which is more a landscape of what’s possible than is the case in Whitehall, not least in relation to effective support for frontline practitioners (which incidentally could also save the NHS a fortune it won’t get from internal “reforms”). An economic case needs to be made for adequate Social Care funding and attitudes need to change (in Whitehall about massive reliance on unpaid carers and amongst the public who wrongly believe that social care does not really matter to them, despite our rapidly ageing population).
  10. Covid will leave a lasting legacy-with those suffering long-term conditions and the significant number of the unvaccinated at risk of becoming a new “underclass”. Whatever the Government’s intentions, the public are likely to be unforgiving about future failures in ensuring their wellbeing in a hostile and uncertain world.

In conclusion, these changes and opportunities present opportunities for C4PC to influence frontline thinking and practice directly. They put greater emphasis on the principles of Personalised Care, not least in relation to the voice of lived experience, co-production, and community engagement and empowerment. Our planned Leadership and Culture Change Taskgroup would be best placed to explore the Coalition’s “repositioning” in this changing landscape, later this year.