Structural reform: can the next Secretary of State for Health avoid the legacy of his or her peers?

Emma Spencelayh, Senior Policy Fellow at the Health Foundation, reflects upon the history and development of health care commissioning.

When I was an NHS management trainee one of the competencies I needed to tick off was ‘managing and advising on an organisational change issue’. Was this a challenge? No: structural and administrative reform of the NHS has been a constant occurrence throughout its history.

One of my trainee placements was in a primary care trust in 2008, occurring just as its commissioning and provider roles were being separated under the Transforming community services programme. I remember being a bit confused by the whole thing. In practice, the same people were in the same roles, but providers and commissioners moved to separate floors in our building. Over time, the changes became more permanent and substantive, but at the time the changes seemed like an unnecessary distraction.

I was unaware of the history of reorganisation in the NHS and was not particularly sympathetic to those who had become weary of change.  The Policy Navigator is intended to provide an accessible overview of the development of the health and care system across a number of themes. I hope it will be useful to those working in NHS organisations as well as those with an interest in policy development. I would have benefited enormously from a tool like this when I was first starting out in the NHS and have learnt a lot through the process of producing the timelines some seven years later.

Our policy timeline on commissioning takes readers through the development of the system in the NHS from the Poor Laws of 1601 to the present day. Since the inception of the NHS, politicians of every political persuasion have found it difficult to avoid tinkering with the NHS’s structure of administration. We have had area health authorities, health authorities, regional health authorities, strategic health authorities, district health authorities, GP fundholders, primary care groups, primary care trusts and clinical commissioning groups. The centre has tried to organise the purchasing of care to cover various different levels of population size and has changed the number and powers of various bodies over time.

Initially at the conception of the NHS, the system was configured in a tripartite fashion based on hospital services, family practitioner services and local authority-run health services. Local authorities were an integral part of the NHS from its establishment providing ‘personal health’ services such as ambulance services, maternity services and vaccination programmes alongside other public health functions. The NHS Reorganisation Act 1973 changed this. The Act brought together the administration of hospital services, family practitioner services and the personal health services, which had been administered by local government into one, unified structure of NHS administration.

The NHS continued under this unified structure until the 1989 White Paper Working for Patients set out plans to create an internal market within the NHS by splitting the purchasing and provision of services. While there has always been a need to ‘buy’ services, it was really from this point that commissioning as we know it developed. This led to an ever increasing focus on identifying needs of a population and then securing services to meet those needs. While the system today has evolved from the structures set out in the 1989 White Paper, there has been considerable instability for those organisations involved on the purchaser or commissioning side of the NHS.

More recently, the Equity and Excellence White paper proposed considerable changes to the bodies undertaking commissioning with the creation of NHS England and the abolition and then replacement of the entire commissioning infrastructure. It is perhaps unsurprising therefore that these structural reforms met with such scepticism and opposition from NHS staff – particularly given they followed a commitment from the Coalition government not to pursue any top-down reorganisation of the NHS. 

The cyclical nature of reforms on commissioning is clear to see, we’ve seen GP or clinically-led commissioning go out and come back round again. However, what particularly struck me were the missed opportunities to truly tackle the more critical issue of transforming service provision. In 2002, Sir Derek Wanless outlined a vision for the health service for 2022, including more services outside of hospital and better joined-up working between health and social care. 

Over a decade on, these are all objectives that system leaders still talk about today. The difference is that today these objectives are set to be even harder to deliver against a backdrop of a major funding gap. The key question is what has stopped Wanless’ objectives being met? One contributing factor might be the constant focus on changing administrative structures.

Many permutations of commissioning structures have already been attempted – none of which have found the silver bullet. Rather the general consensus is that these structural changes have proved to be a major distraction from improving the provision of services.

The following quote from a Health Select Committee report in 2006  could easily relate to the latest set of reforms.

‘… despite the considerable attention these proposals have attracted in Parliament and elsewhere, debate has focused almost exclusively on the shape of future organisations, the morale of staff, and the consultation process, largely ignoring the critical issue of how commissioning can actually be improved ...’

While the quote relates specifically to commissioning, the principles apply more broadly. We hear a lot from the centre about what the system should do but very little about the ‘how’.

It remains to be seen whether those in charge over the next Parliament can resist the temptation to embark on structural reform. History suggests this won’t be easy.