Intended for healthcare professionals

Rapid response to:


The challenges facing the NHS in England in 2021

BMJ 2020; 371 doi: (Published 31 December 2020) Cite this as: BMJ 2020;371:m4973

Read our latest coverage of the coronavirus outbreak

Rapid Response:

Re: The challenges facing the NHS in England in 2021

Dear Editor,

Chris Ham paints a dismal if possibly understated picture of the difficulties faced by an NHS struggling not only with chronic underfunding and understaffing but overwhelmed by COVID-19. A bold vision is certainly needed and the relevance of much of the Long Term Plan for the NHS must surely now be called into question.

It seems strange that during Christmas and in the midst of the pandemic NHS England launched a short consultation over major reorganisation around Integrated Care Systems (ICS). While purporting to seek the right foundation for the NHS over the next decade, the consultation document “puts forward substantial de-regulatory proposals which continue to ‘work-around’ the current statutory market based framework and undermine risk-pooling, even when proposing legislative change” (1).

Among the many criticisms levelled are that the proposals “give immense and barely-regulated power to monopoly providers and clinical networks; contain no controls on the composition of ‘provider collaboratives’, which could include, for example, large private hospitals, are silent on public accountability mechanisms at a system level, and at the non-statutory ‘place’ level” (1). In theory, partnership between local authorities and NHS bodies could among other things provide an effective approach to grappling with the social determinants of health. The Local Government Association, however, has pointed out that: “It is difficult to foresee how the relationship between national, regional, system, place and neighbourhood will play out in practice. It is not clear whether there will be genuine devolution of decision-making and resources to the most local appropriate level, or this will be limited to delegation from the national and regional tiers of NHSE and will stop at ICS level. It is also difficult to predict whether this represents true devolution of power and resources or whether it is simply delegation within a tightly controlled national framework” (2).

This is a response that reflects justified and deep scepticism of the proposals. Given the well documented challenges to the NHS, it is profoundly depressing that NHS England’s leadership has not been able to come up with something far better - such as a return to the NHS’s founding principles perhaps?

1. (last accessed 12/01/2021)
2. (last accessed 12/01/2021)

Competing interests: I am co-chair of 'Keep Our NHS Public'

12 January 2021
John Puntis
Consultant Paediatrician