Reorganising the NHS: why all may not be as it seems John KellHead of PolicyI said in the first of this series of posts that health and social care is a policy arena blighted by strong headwinds. The funding crisis is one (see last week's post); Brexit, even if only from the perspective of government capacity, is another. But there is a third: at a time when there is widespread consensus about the need to adapt and transform services to meet the changing patterns of demand thrown up by an ageing population, the work to do that could be halted by scaremongering and hysteria. In this respect, health and care policy are not merely facing strong headwinds: they are in an outright dangerous moment. The demographic shifts that are driving changing patterns of demand are not unique to England or even Britain. More people are living longer, but not necessarily in better health; rather, we have a growing population of people with two or more long term conditions, for whom being fixed up in hospital and sent on their way is not a viable approach. The essential response to this emerging pattern of need is to keep people as well as possible in their own homes, managing their conditions through high quality, multidisciplinary community services. This has been long forecast and long understood. Wales, Northern Ireland and Scotland all have plans to transform services to address this. Under successive governments, however, politically led plans have failed to tackle this looming challenge in England, instead concentrating (at the risk of a slightly, but only slightly, unfair simplification) on reordering the NHS’s internal market and trusting that once this was got right the services would come good. By the time NHS England was created by the Lansley reforms – formally as the NHS Commissioning Board – it was inevitable that it would be playing catch-up on meeting the challenge, after such a long delayed start. Almost as soon as it was able to set a course for itself, it published the Five Year Forward View, announced the development of new care models, created a new tier of management with footprints big enough to be workable (Sustainability and Transformation Partnerships, as they now are), and quietly set about dismantling the internal market. Back in 2008, former health secretary Ken Clarke commented: “If one day subsequent generations find you cannot make commissioning work, then we have been barking up the wrong tree for the last 20 years.” NHS England appears to have concluded that’s exactly what happened. You’d think all of this sounds like good news, particularly to those who were never convinced about the merits of the marketisation of the NHS. But it hasn’t been received as such in many quarters. In particular, the plan to replace the purchaser-provider split with single organisations responsible for arranging all healthcare within an area through collaborative arrangements, rather than commercial contracting, is being taken to judicial review. The litigators argue that these collaborative organisations will be American-style Accountable Care Organisations (which they were indeed modelled on), and that this represents the privatisation of the NHS. Unfortunately this takes us down the rabbit-hole of NHS privatisation conspiracy theories. I use the phrase deliberately: Jeremy Hunt has stated bluntly that his policy is that the NHS, “will remain a single–payer taxpayer-funded system free at the point of use – and should do forever as far as I’m concerned.” However much they may dislike the tag, those who theorise that Mr Hunt and others are conspiring to bring about something other than that stated intention are undeniably proposing a conspiracy theory. This is debunked comprehensively elsewhere, not least because no private sector organisation would be capable of taking on the proposed responsibilities of these collaborative NHS bodies. The ultimate aim appears to be that these will become statutory NHS bodies – indeed, the Conservative Party’s 2017 election manifesto committed to introducing legislation to facilitate these changes if necessary, including getting rid of the market-based structures established by Andrew Lansley and his predecessors. Unfortunately the hung parliament produced by the election made legislating on the NHS undeniably difficult. This has left the moves to new and more collaborative systems operating as ‘workarounds’ within the existing legal framework of market-based contracting, which renders the job harder but not impossible.However, mud sticks and scepticism (as well as misinformation) about the current plans for the NHS is now widespread. Turning it round will be a major challenge for NHS England: it will require a complete re-presentation of its plans. Re-branding the proposed Accountable Care Systems as Integrated Care Systems has been a start, as the new name at least gives an idea of what they are meant to do. But a sustained programme of communication and engagement is needed, including an unequivocal statement that the new organisations are ultimately intended to be statutory bodies, and cannot be contracted outside the NHS. For all the difficulty in legislating, it should ideally be attempted – unfortunately cross-party support will be hard to secure, with senior Opposition politicians openly advancing the privatisation conspiracy theory, but in a tight hung parliament it could just be possible to assemble a coalition of support. When Jeremy Hunt is eventually succeeded (by a member of whatever party), it is conceivable that the new incumbent may find it politically attractive to stamp on the Five Year Forward View and everything associated with it. But it would be a horrifying loss if the transformation of the NHS to meet the needs of an ageing population were to be struck down by ill-informed, conspiracy-fuelled politicking. Patients are suffering enough already because of the failure to plan for these foreseeable changes in need – this winter’s crisis bit much harder than it might have done because of the earlier failure to shift to new models of care that could keep more people well in their own homes, rather than sliding into crisis and a hospital admission. But I’ll close this series of posts with a caveat to the above. While the Five Year Forward View may be the only game in town where essential service transformation is concerned, it isn’t the entire answer. Even if fully implemented, it won’t produce a system that is able to care for people’s health and wellbeing at a population level. As an NHS initiative, it largely doesn’t address social care and public health. And integration between health and social care can’t really be achieved until the question of how the free-to-use NHS can be coupled to a social care system with some form of charging and means testing involved (assuming that continues to be the case). Even a convincing set of integrated care systems (with or without capital letters) will be at risk of ‘capture’ by non-patient interest groups if effective engagement cannot be baked into their design – and there is little sign of that emerging. And even if a major transformation is achieved, the introduction of a theoretically attractive set of institutions must not be mistaken for well co-ordinated care that integrates seamlessly around the patient (although they may enable it, just as their absence may stymie it) – that will remain the ultimate test. As if this wasn’t challenging enough, in truth the structural discussion needs to go wider even than these systems: where do housing, the welfare benefits system, education and other services fit into population health? Their importance is increasingly well understood, but how do we translate that into a coherent set of services – one that might even require a rebalancing in spending, away from the totemic NHS to one or more of those other systems? A glance at our struggles to agree adequate funding levels in the first place, and to reach a common understanding of what we want from Brexit, let alone how to implement it, leads inevitably to the conclusion that the UK as a polity is currently incapable of having the sort of ‘grown up discussion’ about these complex issues that so often gets called for. Attempting to do it might just cause more problems than it solves. Focusing, for now, on the money and the necessary transformation of NHS services is probably ambitious enough to be going on with.