Views And Reviews Acute Perspective

David Oliver: Let’s streamline NHS bureaucracy and then leave it well alone

BMJ 2017; 357 doi: (Published 23 May 2017) Cite this as: BMJ 2017;357:j2426
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

The House of Lords’ recent report, The Long-Term Sustainability of the NHS and Adult Social Care, is a considered document, full of prescient evidence.1 Its recommendations include increasing NHS and social care funding, ringfencing public health budgets, and establishing an independent Office for Health and Care Sustainability. Overall, the report is a fairly sound and depoliticised template for the future.

But I have no confidence that the recommendations will be heeded. No government has had the courage to take a tax funded NHS out of partisan politics in the way that decisions on interest rates were delegated to an independent Bank of England committee. So long as the NHS is subject to the electoral cycle, ministers will always be tempted to mess with it—what some have called “NHS re-disorganisation.” This ignores lessons on improving performance in health systems, that structure is secondary. It’s not organisational charts that count—it’s the people.2

The Lords committee was clear that the Health and Social Care Act 2012 has created a fragmented system that frustrates efforts to integrate and transform care. The Lords also recommended merging NHS England and NHS Improvement to achieve more consistency in efficiency and performance. Such changes might require further, time consuming legislation.

Commissioning, the internal market, and the purchaser-provider split have not conspicuously succeeded, and they have added considerable costs to the system.3 The creation of these national bodies was a consequence of Andrew Lansley’s rhetorical, grandstanding drive to “reduce bureaucracy”—despite the NHS needing good operational and financial managers and not being notably over-managed, compared with some systems.45

So long as the NHS is subject to the electoral cycle, ministers will always be tempted to mess with it

Lansley’s changes stripped out vital experience and institutional memory, gave the commissioning function to new bodies, and left the NHS without strong regional oversight.6 Yet the 2012 act led to increasingly complex and impenetrable bureaucracy understood by few frontline staff or people outside the health policy community.78 NHS England has drifted miles from its stated remit, NHS Improvement is involved in overlapping activities and sometimes conflicting messages or approaches, and the health secretary is far from the arm’s length figure, uninvolved in the system’s operation, originally envisaged by Lansley.910

There is real danger that people excited by re-drawing charts and creating new bodies think that this solves the NHS’s real and pressing problems. I would suggest that services need adequate funding and a sufficient workforce, as well as a long period of stability with no further reorganisations to distract healthcare staff from improving frontline care.

By all means, let’s merge a national body or two and streamline the NHS’s hull. But then could we please stop rearranging the deckchairs in an NHS that risks sinking like the Titanic?



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