Not Another NHS Reorganisation?

Dr Dan O'Carroll


July 17, 2020

In his State of the Union address in 1962 President John F Kennedy declared 'The time to repair the roof is when the sun is shining'.

It would seem reasonable to infer from this that it would be a really bad time to fix the roof during a huge typhoon, or perhaps during an unprecedented global pandemic if we were to be thinking about this in terms of the NHS.

Flexibility and Complexity

The NHS is a huge, complicated organisation and has shown itself to be remarkably resilient for dealing with the first acute phase of the COVID-19 pandemic. I think most commentators would praise how the NHS has coped with this, showing great flexibility, including being able to rapidly bring on-line huge increases in critical care capacity to ensure that this precious commodity was not overwhelmed by demand. There are rightly held concerns regarding the delays - which are becoming more evident - affecting cancer diagnosis and treatment and other elective waiting lists.

The complexity of the NHS and the trends of demand - particularly as the UK is dealing with an increasingly elderly population with multiple medical conditions - means that NHS planning needs to be considered over the medium to long-term. Unfortunately, it seems that our political leaders rarely think of such timescales and usually only consider actions over the terms of a parliament and their chances of re-election.

Multiple Reorganisations

Over the years the NHS has gone through multiple, and considerable, reorganisations, from the establishment of NHS foundation trusts under Tony Blair's government in The NHS Plan in 2000 - which gave much more autonomy to high performing hospitals - to the more recent and lamented Andrew Lansley reforms in the Health and Social Care Act 2012. Lansley's act was opposed by the BMA as it was felt that it would increase the amount of private provision within the NHS - this has proved unfounded. But it did result in massive organisational changes. Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs) were abolished and their £60-80 billion worth of commissioning was transferred to GP-led clinical commissioning groups. These changes were hugely costly, with projected redundancy costs of £1 billion for around 21,000 PCT and SHA staff, many of whom received large redundancy payments only to be re-employed in almost identical roles for the new groups.

Prior to the introduction of Lansley's reforms warnings were given that the abolition of SHAs - which were responsible for improving regional services and for co-ordinating responses to challenges posed - and the disruption to the speciality of public health with diminished funding, would disrupt our ability to respond to an emergency or epidemic situation. It is unfortunate to consider that if the COVID-19 pandemic had occurred 10 years earlier, the local authorities would have been in a much better position to cope and to mobilise far more quickly than happened this year, when the contact tracing was abandoned in early March.


As the death toll mounts in the UK, with the official overall number at more than 45,000, many feel that the Government should have done better in its response. It seems unable to acknowledge any mistakes and continues to make claims of 'world beating/leading' initiatives including a 'game-changing app' for track and trace that was abandoned at an apparent cost of more than £11 million, for 6 weeks work. The manual track and trace system, despite great fanfare and claims of great success, appears to be failing to contact approximately 1 in 5 confirmed COVID cases, and of those contacted around 70% of their close contacts were identified and asked to self-isolate. Although freely admitting limited knowledge about the epidemiology, the large percentage not being identified leaves me concerned about our ability to identify and limit any further local outbreaks.

Unfortunately, one area we appear to have been 'world leading' during this pandemic is with the number of health and social care workers that have sadly lost their lives. The UK, with at least 540 deaths, is second only to Russia (545).

'Radical Reorganisation'

With this background it is concerning to learn that the Prime Minister is planning a radical reorganisation of the NHS, and the thought of the incumbent government and its ministers gaining more direct control of the NHS does not fill me with any confidence following their continued apparent mismanagement of the current crisis. It is claimed that there is ministerial frustration with the role played by some agencies during the pandemic, particularly Public Health England (PHE), and with the independence of Simon Stevens, the Health Service's chief executive.

Any further major reorganisations will undoubtedly come at significant cost and would seem wasteful in the current climate of stretched NHS budgets. These will likely worsen rather than improve once the full economic cost of the COVID pandemic becomes clear and the Government's spending spree needs to be repaid. The cynics may suggest that this apparent desire to reform the NHS is merely one of the opening gambits for the inevitable 'blame game' that seems certain to follow, and highlighting problems within the NHS would help absolve or deflect blame from government.

The Lansley reforms that introduced competition between health care providers possibly had no place in a national health service, and many organisations are already working in closer partnerships at local levels to ensure that resources can be used more efficiently, for example, centralisation of acute stroke services, rather than each hospital delivering this 24/7.

The NHS is far from perfect, but it has shown incredible adaptability and resilience in its response to this unprecedented crisis. The last thing the NHS needs at this time is the distraction of another huge reorganisation which would possibly be motivated for short-term political gains rather than necessarily for the long-term future of the NHS. It is worth stating that some of the initiatives that were enforced by the pandemic need to be explored further and possibly maintained, for example, increased use of telephone and video consultations, and perhaps the introduction of A&E by appointment.

I'd even go as far to suggest that given the opportunity to make a sensible long-term plan, with appropriate funding and with limited political interference (I know this is unlikely to happen), the NHS could, indeed, get back to being 'world beating'.


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