Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Let’s end our fixation with structural reorganisation

BMJ 2019; 364 doi: (Published 05 February 2019) Cite this as: BMJ 2019;364:l422
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter: @mancunianmedic

From 2009 to 2013 I was on secondment to the Department of Health, as a clinical adviser and then a national clinical director, alongside my NHS day job. I had a ringside seat for the formation of the 2010 coalition government and the 2012 Health and Social Care Act,1 while also seeing its impact on the ground. After Andrew Lansley promised “no more top-down reorganisation,”2 the changes his act introduced were described by David Nicholson, then chief executive of the NHS, as “so big, you could probably see them from space.”3

The NHS in England is undergoing yet another mass restructuring—“redisorganisation,” as analysts called it some years ago.4 It has a new 10 year plan. Last October the Nuffield Trust published a series of essays, Doomed to Repeat,5 warning against making the same mistake of creating new organisational structures to “transform” or “reform” health services.

Since 2000 the NHS has had six national plans and 10 reorganisations: they’ve delivered few of the promised benefits, yet perhaps not all of the predicted harms.6 The 2012 act introduced several national leadership and regulatory bodies, removing or replacing others (notably, removing strategic health authorities and creating clinical commissioning groups). The complexity is outlined in a King’s Fund animation, “How does the NHS in England work?”7

Seven years on, where are we? Well, NHS England and NHS Improvement are set to work more closely together, if not quite merge, using more single leadership positions and closer collaboration in five co-located regional offices89 for just the kind of oversight that the (scrapped) strategic health authorities formerly gave.

It’s all starting to look eerily close to the chain of command that Andrew Lansley scrapped back in 2012

NHS England is clearly the dominant party. Health Education England has become “accountable to NHS Improvement.”10 NHS England is a statutory arm’s length body but, as communications around the 10 year plan showed (with ministers taking credit), there are big, blurred lines between it and the department of state.

It’s all starting to look eerily close to the chain of command that Lansley scrapped back in 2012, now dismantled. It would be nice to see some transparency, scrutiny, and open competition in appointments for new roles. We’ve had a terrible tendency to appoint the “usual suspects”—compounding the entrenched groupthink that redrawing the organogram will solve the NHS’s wicked problems and exert central “grip.”

Meanwhile, integrated care systems emerging from the 44 strategic transformation partnerships are being asked to deliver their own (one and 10 year) plans. These must contain all top-down elements of the national plan and are subject to financial control totals, so it’s not clear how much local control there really is. Although not statutory entities, they’re to be “accountable” for measures of population health. And now we have a requirement for GP networks covering populations of 30 000-50 000—and much uncertainty about them among GPs.

I’m an optimist who believes in the NHS and thinks that its national leadership is acting in good faith and making tough decisions. But I bet we’ll be back at this crossroads in a few years, having forgotten—again—that structural reorganisation isn’t the answer.



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