Intended for healthcare professionals

Editor's Choice

NHS reorganisation: We don’t need a big bang

BMJ 2021; 372 doi: (Published 18 February 2021) Cite this as: BMJ 2021;372:n464
  1. Fiona Godlee, editor in chief
  1. The BMJ
  1. fgodlee{at}
    Follow Fiona on Twitter @fgodlee

“What do you call a government that embarks on the biggest upheaval of the NHS in its 63 year history, at breakneck speed, while simultaneously trying to make unprecedented financial savings? The politically correct answer has got to be: mad.” So began The BMJ’s response to Andrew Lansley’s proposed reforms in January 2011.1 Should we say the same about the government’s plans to reverse the Lansley reforms, coming as they do in the teeth of a pandemic, with hospitals at full stretch and a mass vaccination programme under way?2

The details are still emerging, but the key elements are clear: the abandonment of the 2012 Health and Social Care Act’s requirements for competitive tendering for services in England, the shift of control back to Whitehall, and the establishment of new intermediate structures, the “integrated care systems,” to manage healthcare at local level.3

While some see the changes as bringing a welcome end to 30 years of market driven policies, Peter Roderick and Allyson Pollock call foul.4 Far from reversing the market paradigm, the proposals consolidate it, they say. “These proposals are incoherent, de-regulatory, off-target, and badly timed. They will do next to nothing to remedy the serious shortcomings highlighted by the pandemic: a depleted NHS, a privatised social care system, with over-centralised, fragmented and part-privatised communicable disease control and public health systems.”

The proposals make more sense to Hugh Alderwick and colleagues, being not far off what is happening already across the health service as organisations have ignored or circumvented the rules to fit local circumstances.5 But they warn against overestimating the benefits of integrated care. Making collaboration work depends on culture, management, and resources as much as on rules and structures, they say, and major reorganisation carries risk. While there may be a need for change, “limited fixes” are better evolving over time than being introduced with a big bang.

Even if major reforms had ever worked in the past, now is not the right time, says the BMA,3 when staff are physically and emotionally exhausted and when resources are needed for national recovery and tackling the backlog of non-covid care.6 Also, what has been the consultation process? Are we ready to put our faith in the secretary of state for health?78 And where is the long awaited commitment to reform social care, which the pandemic has revealed to be the government’s Achilles heel?9

Lansley’s reforms were launched in the aftermath of a global financial crisis. They were hugely disruptive, costly, top down, rushed, ideologically driven, and ultimately deeply flawed. In seeking to reverse them, the government must not be allowed to make the same mistakes.


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