Bishop, to curate: Young man, I perceive that your egg is bad!
Curate: Oh no, My Lord, I assure you, parts of it are excellent.
NHS England (NHSE) was a creature of the Cameron years, introduced through the Health and Social Care Act 2012. That Act ended years of steadily improving performance under Labour and brought with it all the ideological baggage of a party that does not, at its heart, believe in any motive other than profit, funded by shadowy think-tanks and largely US private health interests.
Nonetheless, while NHS spending doubled under Labour, quality of care did not. NHSE was supposed to close the gap, but instead, it presided over a dramatic worsening. Was the decline in NHS performance NHSE’s fault? Who can say? But they were the ones who were supposed to fix the problem and, by any objective measure, they failed.
But what does NHSE do?
Fragmentation of the NHS began in 1989–91 with the NHS “internal market”, cemented by the National Health Service and Community Care Act 1990, which established NHS Foundation Trusts. Ever since then, there has been a narrative of geographical inconsistency – the ‘postcode lottery’, in which areas with dense population and high economic performance generally seem to get better healthcare, at least in non-emergency cases.
NHSE was designed to address uneven standards, in part through the establishment of regional Integrated Care Boards (ICBs), coordinating primary (GP) and secondary (hospital) care, managing responses to acute pressures (Operational Pressures Escalation Levels [OPEL]) and applying and enforcing consistent targets. It also drove mergers of trusts, intended to deliver a “step change” in performance, but by 2022, this improvement goal had been abandoned.
It also gave politicians something more like the board of a corporation to talk to, while maintaining plausible deniability for ministers in the face of inevitable NHS failures.
Given its provenance, NHSE is rightly viewed by some with suspicion and as creeping corporatism. The fundamental conceit of Conservative health policy is, after all, that private organisations are more efficient, despite the evidence to the contrary. In 2010, the NHS was one of the most efficient health services in the world, but Tufton Street think-tanks sold the lie that it would be cheaper and more efficient if it were closer to the US for-profit model.
So, what went wrong?
Bluntly, NHSE was there to fix a problem that was caused by splitting the NHS into hundreds of arms-length bodies, driven by the same ideology that caused the problem in the first place. A body created to make the NHS look more like a company, by a party that doesn’t believe in public services and which is funded by for-profit health companies, would hardly be expected to make the NHS great again. Add the challenges of the worst health crisis in a century and the legacy of PFI contracts that leave hospitals saddled with huge costs for collapsing buildings and it’s easy to see why NHSE is not seen as delivering.
Some criticism is unquestionably legitimate. The old saying that “you don’t make a pig fatter by weighing it”, was never really internalised by the Conservatives – and NHSE was all about targets, many of which seemed arbitrary and perhaps driven by the news cycle more than by clinical need. Objectively, the NHS has gone consistently downhill since 2010. And NHSE is expensive: £3.2 bn.
Conservative dogma has it that competition always improves service. This is not necessarily wrong, but it also leads to duplication, which, in the context of a public service, is inefficient. Many view the NHS as a natural monopoly, where any competition is largely illusory anyway; the e-Referral Service (e-RS) or ‘choose and book’ purports to offer patients a choice when booking an appointment, but is meaningless when there is one local hospital and competing services are many miles away. And it’s notable that similar areas where Conservative policy led to segmentation and privatisation to introduce “competition” – water, electricity, gas – are dogged by increasing costs and poor performance.
Overall impact
Ultimately, NHSE was set up to centralise control while protecting Conservatives from accusations that they were interfering in the NHS for ideological reasons. All governments want to control the NHS given its cost and their ideological preferences, so it is politically expedient for Labour to dismantle NHSE and return control to the Secretary of State. What matters is not so much who controls the NHS, as the loss of expertise and vulnerability to large scale politically-motivated change at each change in government.
Alongside the winding up of NHSE, and largely unnoticed by comparison, there’s a 50% cut to Integrated Care Boards (ICB) and corporate staff budgets in NHS Foundation Trusts. The 42 ICBs coordinate care across geographical regions, replacing over 200 Clinical Commissioning Groups. They have had their budgets cut by 30% and now another 50%. The effect will be to displace large numbers of people whose obvious alternatives for employment will at the same time be shedding exactly the same kinds of people. This has already resulted in hiring freezes and open jobs not being offered.
There’s a narrative of “returning people to front-line care”, but sacking Band 7 staff is unlikely to help with shortages of Band 5 nurses: the idea of taking a £10,000 pay cut to return to frontline nursing is scarcely attractive, even if your skills are current.
Your health data is at risk
An aspect of genuine value offered by NHSE is the area of cybersecurity. Robust regional cyber leadership and targeted funding has helped trusts effect real change. If no equivalent national group is established when NHSE goes, then underfunded trusts will be on their own again, and cybersecurity is a specialised and expensive skill set.
Five years ago, NHS data security practices lagged far behind financial technology; and this is a big concern. As a country we do not seem to have learned from debacles like Palantir, and there’s a shocking failure to appreciate the difference between machine learning (which is of incomparable benefit in healthcare) and generative AI (which makes some stuff up and is a privacy nightmare).
And now the government is talking about selling health data to feed AI models. Last time this was on the table, many people opted out of data sharing – a fact the current government doesn’t seem to be taking into account. Rather, they appear convinced that somehow, AI will save the NHS.
We desperately need strong national leadership from people who understand the risks of data leakage through large language models. It seems unwise to ditch the one body that has a national brief and the technical know-how to help trusts navigate the largest privacy minefield that has ever existed, while cutting the budgets that would allow these high-cost skills to be brought in-house. Perhaps the National Cyber Security Centre will be brought in to help.
The end of NHSE: good or bad?
As with the curate’s egg, there is good and bad here. Good riddance to the additional layers of cost, fondness for large consultancy corporations and somewhat arbitrary goal setting. The worry, however, is how to provide centralised specialist oversight and assistance without a body like NHSE. The fact that the winding-up of NHSE was announced as a fait accompli, in advance of any consultation and with essentially no notice at all to affected staff, is deeply concerning.
What the NHS needs is more front-line staff, more funding for mental health, social and primary care. Winding up NHSE doesn’t achieve this.
Disclosure: I work for Dell Technologies. These views are my own and not those of my employer. I have been embedded in a large NHS Trust since 2020. Nothing here should be inferred as a reference to or criticism of any specific NHS Trust, and especially not the incredible professionals who work there.
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