Time for another “top down structural reorganisation” of the NHS?

14 November 2016

The NHS is leading the domestic news headlines again today. The Service really is entering a decisive phase, in which it faces up to the need for change in the way that other public services have done before.

Two weeks ago, the financial situation attracted media attention. Reform commented in a Times op-ed that more money might actually hold back change.

Today, the question is how to free up the NHS to make the change that is needed, together with a debate on what the Service should look like as a result.

There is no doubt at all that the NHS leadership is challenging the Service to change, and is impatient for it. Speaking for Reform in March 2015, soon after the publication of the Five Year Forward View, Simon Stevens said, “Just get on with it”, in so many words. We have caught the same vibe from the national leaders many times since. They, rightly, get frustrated by the historic divisions in the NHS that (say) prevent NHS money being spent on elderly people in social care, or stop NHS staff being trained or recruited into new roles.

At the same time, the experience of local leaders is that it is not so easy to “just get on with it”. One Chair of a Foundation Trust told me last week that the Care Quality Commission will send 40 inspectors, “on a coach”, to the hospital for a three day visit. This is not an environment for playing fast and loose with the rules, even a little bit. Equally Foundation Trusts can find it difficult to approve major changes in their services due to their governance which involves two boards (one of directors and another accountable to the whole membership of the trust, including staff and local people). Ignoring this framework would open any Trust to legal challenge.

It seems necessary, therefore, to look again at the structural questions that define how the NHS works: the number of commissioners, their role, the nature of providers, the role of competition, and of regulation, and so on. This is complicated by the fact that no politician has wanted to advocate a “top down structural reorganisation” since that was seen to be one of the failings of the 2012 reforms. (In fact the better criticism was that it was the wrong sort of reorganisation, weakening commissioning and confusing accountability between central and local government).

In its review today, the Kings Fund says that it is unlikely that Government will want to address these questions, and calls on the Service to find a way forward within the same structures. On a similar theme, others have suggested a radical scaling back of the size of the national regulators, such as NHS Improvement and the CQC, to give space for the Service to evolve. While these ideas would no doubt bring benefits, I wonder if it is time to grasp the nettle. The NHS has too many commissioners and is trying many different ways to hold itself accountable, from central regulation to patient choice to local democracy, often at the same time. Clarifying the Government’s position would greatly help local leaders. (In fact any review of the structures should not be “top down” because it should involve those local leaders directly.)


The Kings Fund may not be right to counsel against competition and autonomy as tools to improve NHS services going forward. Certainly the evolution of NHS services should make sense in their local areas, and organisations should be aware of their impact on each other. Still, monopolies in service provision are unlikely to drive the kind of change that the Service needs. Whatever happens, individual organisations need to be held to account for their performance, including financial performance. Each STP area will include around six hospital trusts and around 200 GP practices on average.


Some of the reporting of the Kings Fund paper focused on the fact that hospital beds may be closed as a result of the STPs. As the statistics show, more than half of all NHS beds have closed in the last thirty years, driven by advances in technology, changes in patient preference and so on. The shock would be if hospital bed numbers were expected to rise sharply, and the NHS return to an earlier model of care.


Number of NHS Beds Open Overnight



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