David Oliver: Constant structural reorganisation won’t improve or transform healthcare

NHS leaders and politicians seem to have an endless obsession with organisational restructuring. The King’s Fund has produced narrated animations of the NHS “organogram,”12 showing the bewilderingly complex accountabilities created by the 2012 Health and Social Care Act3 and subsequent new organisational forms and workarounds, such as integrated care systems emerging from NHS England’s Five Year Forward View.4

In May 2018 a report presented at a meeting of the boards of NHS Improvement and NHS England set out why and how the two bodies should work more closely.5 In the same week the health policy analyst Nick Timmins, in The World’s Biggest Quango,6 reflected on how differently NHS England now operates from the then health secretary Andrew Lansley’s original vision when it was established in 2012.

Lansley moved public health to local government, created Health Education England and Public Health England, scrapped the 10 strategic health authorities that coordinated and oversaw care across natural geographical regions, and disbanded primary care trusts, replacing them with clinical commissioning groups (CCGs).

This plunged the system into entropy and uncertainty for several years, with most new posts being filled by existing NHS staff who had to reapply for roles.17 And Lansley’s populist rhetoric on “reducing bureaucracy”8 wasn’t realised, as the rapid change and added complexity ultimately led to a continuing need for good NHS managers and a reliance on consultancy,79 which is shown to add little to NHS efficiency in a recent London School of Economics report.10

Yet, around the 2010 general election, NHS performance was already improving steadily each year, the funding and workforce deficit was less severe than now, and public satisfaction was high.11 There was no need for this political vanity project of reorganisation for its own sake.

Lansley also stated that, in his new world, the health secretary should be far less involved in NHS operational issues and less accountable for its performance, which were for NHS England to resolve.38 Yet his successor, Jeremy Hunt, is intensely involved in NHS operational matters and finance, whatever the 2012 act set out to achieve.6

I’d bet big money that most frontline NHS staff, let alone the public, will have little understanding of the different roles of the national arm’s length bodies and where the Department of Health and ministers’ roles start and stop, as well as the new local structures that have undergone little consultation. The obsession with new structures can leave even seasoned policy watchers baffled.

There was no need for this political vanity project of reorganisation for its own sake

In essence, the proposals5 for NHS England and NHS Improvement’s civil partnership intend to recreate some of the pre-Lansley simplicity and single lines of accountability and the regional groupings of CCGs, vaguely akin to but smaller than the strategic health authorities his bill scrapped.

We need to end our fixation with restructuring. On reviewing the evidence, respected health policy analysts and think tanks have concluded that structural reorganisation, new form hierarchies, or mergers are not the way to deliver service improvement, transformation, or sustainability.12131415 They rarely deliver the benefits imagined, especially in a complex adaptive system such as the NHS, where all change brings unintended and unforeseen consequences.16

It is the behaviours, values, and actions of local teams of clinicians and managers, in a conducive environment of adequate workforce numbers and resources, that matter most in delivering improvement or subverting change.1217 Yet we still don’t learn.