Lansley’s legacy

Since the coalition government was formed in the United Kingdom in May 2010, the secretary of state for health for England, Andrew Lansley, has dogmatically pursued a highly controversial health reform agenda in the face of widespread public and professional opposition. Lansley’s removal last week from the role, his demotion, and his replacement by Jeremy Hunt have provoked much media comment about his track record and the future of his health reforms. Lansley spent six years as shadow health secretary in opposition. During that time, he apparently gave much thought to how to achieve his vision of the NHS as a market based healthcare system in which private, not for profit, and public providers compete alongside each other, with general practitioners commissioning health services on behalf of their patients.1 However, the past two years have delivered a painful and costly demonstration of how not to do health reform.

Four main weaknesses undermined Lansley’s efforts to reform the English health service. Firstly, it was not clear what problem his “reforms” were designed to solve. Patient and public satisfaction with the NHS were at an all time high and the case for change was never properly articulated. Secondly, the reforms were very complex. The more the internal logic of the proposed market based system was pursued, the more complicated and obscure the necessary legal provisions, structures, and management arrangements became.2 As a result, the internal consistency of the reforms was often compromised. Thirdly, the reforms were launched at the start of a period of unparalleled reduction in government spending and soon became a mere distraction from the real problem: the need for the NHS to deliver unprecedented improvements in productivity.3 Fourthly, the reforms never secured much support from stakeholders who were key to their delivery, such as GPs, consultants, NHS managers, nurses, and patient groups. As time went on, levels of overt hostility to the reforms increased.4 The legislation was eventually forced through parliament at huge political cost.

Far from liberating the NHS, the reforms so far seem to have produced a profound centralisation of power in the new NHS Commissioning Board, as well as all the costs, traumas, and problems that usually accompany major reorganisations.5 They were much revised during the parliamentary process and have been further modified already in their implementation by the Department of Health and the NHS Commissioning Board. The pace of reform was slowed, the introduction of market competition was limited and qualified, the powers and freedoms of proposed GP commissioners were much reduced, and the new NHS Commissioning Board emerged as a hugely powerful national quango.

The new secretary of state for health, Jeremy Hunt, has little previous record of interest in health policy and faces the unenviable task of taking forward Lansley’s unfinished business. He will probably take a pragmatic approach of trying to rebuild damaged relationships with the health professions and seeking more favourable (or at least less negative) media attention to improve public opinion of the government’s handling of the NHS between now and the next election. Much of the business of implementing the reforms will probably be left to the department’s civil servants. We may see some of the rhetoric of Lansley’s reforms about the separation of the NHS and the Department of Health quietly dumped as the NHS Commissioning Board takes on its central responsibility for commissioning and the plan for all trusts to become NHS foundation trusts moves ahead. The future for proposed market reforms, such as the extension of “any qualified provider” and the role of Monitor as economic regulator, must surely hang in the balance because of their potential to destabilise NHS providers and lead to unwelcome headlines and public disapprobation.

In the short term, Lansley’s departure allows the Department of Health and the NHS to focus on what really matters: badly needed cost savings and improvements in productivity that can be secured only through major reconfigurations of service delivery.6 The new NHS Commissioning Board has, perhaps for the first time, the economic clout and organisational capacity to tackle this by challenging powerful sectional interests, particularly in the large acute hospital NHS foundation trusts, and driving large scale change. It will be interesting to see how commissioning works on a really large scale. The role of the new clinical commissioning groups is less clear. They could become vehicles for improving the organisation of primary care and its integration with secondary care, rather than just being the commissioning agencies that their name suggests. If a useful role is not found for clinical commissioning groups it will not be long before questions are asked about whether they are needed.

Policy makers, NHS managers, clinicians, trade unions, and other stakeholders now need to move on. Hunt and the Department of Health should take this opportunity to rebuild damaged relationships and to make improving health services for the people who use the NHS the main policy priority again.