The coalition government’s plans for the NHS in England

The coalition government’s plans for the future of health care in England herald fundamental changes to both the anatomy and physiology of the NHS.1 These changes take forward reforms set out by the Labour government led by Tony Blair in 2002 and developed further by Ara Darzi in 2008, but they are much more ambitious and risky.2 3

The anatomy of the NHS will be affected by the setting up of an independent commissioning board, the abolition of strategic health authorities and primary care trusts, and a new role for local authorities in promoting public health. Its physiology will be altered by the use of markets instead of targets to drive improvements in performance.

On the provider side of the market, NHS foundation trusts will have greater autonomy, and independent sector providers will be encouraged to compete for patients. On the commissioner side, groups of general practices will take responsibility for most of the NHS budget and use their clinical expertise to bring about improvements in care. The operation of the market will be overseen by a new economic regulator. Its role will be to promote competition, regulate the prices paid to providers, and ensure continuity of service provision. The Care Quality Commission will work alongside the regulator to license providers and inspect services.

The government’s hope is that quality of care and responsiveness will be strengthened through patient choice and competition. Streamlining of the NHS structure and cutting management costs are intended to reduce bureaucratic controls on local action, thereby empowering frontline staff to deliver better patient outcomes. The reforms reflect a set of beliefs about public services centred on the argument that there should be a shift from big government to big society, with less reliance on state intervention and more emphasis on community engagement.4 Consistent with this argument, the government wants to encourage public providers to become social enterprises as the ownership of healthcare provision becomes increasingly mixed.

The impact of the reforms will depend crucially on answers to four questions. Firstly, how effective will general practitioners be in commissioning care, assuming they are willing to do so? Attempts to introduce market principles into the NHS in the past 20 years have foundered on the weaknesses of commissioning, and much hinges on general practitioners being more successful this time round. Although evidence suggests that primary care led commissioning can bring benefits,5 it is a triumph of hope over experience to expect all general practitioners to take complete responsibility for commissioning.

Secondly, will the government follow through the logic of its reforms and allow unsuccessful providers to fail? The impact of competition hinges on the possibility of market exit being real, but politicians have been reluctant in the past to accept a reduction in the public’s access to services. How they respond when hospitals run into difficulty will provide an early test of their resolve.

Thirdly, can changes to the anatomy of the NHS be implemented without taking attention away from the need to find up to £20bn (€24bn; $30bn) from the NHS budget through increased efficiency?6 Despite the promise in the Coalition Agreement published in May not to embark on top-down structural changes, that is precisely what is happening, and the effects of major organisational upheaval will be felt for three years.7 This creates a real danger that experienced leaders will be distracted from work on identifying ways to improve productivity just at the time when a single minded focus on this work is needed.8

Fourthly, will the government give priority to supporting collaboration and service integration as well as promoting competition? Collaboration is especially important in areas such as urgent care and the provision of high quality cancer and cardiac services, where better outcomes depend on services being planned and provided in networks. General practitioners must also work more closely with hospital based specialists in clinically integrated groups to improve care for people with long term conditions.9 Recent NHS reforms have neglected the need for organisations to collaborate across local systems of care, and the capacity to do so in the proposed arrangements must be strengthened.10

The government’s changes owe a great deal to the secretary of state for health, Andrew Lansley, and the ideas he developed in opposition.11 Unlike many of his predecessors, Lansley came into office as a man with a plan and has moved rapidly to turn his plan into proposals for legislation. The support of the prime minister has been sufficient to overcome concerns in the Treasury about how general practitioner commissioners will be held to account.12 The proposed abolition of strategic health authorities and primary care trusts will leave a vacuum in the organisation of the NHS, and it is questionable whether local authorities can fill the void. On this matter, the government’s visceral dislike of managers has trumped thoughtful analysis of what is needed and may yet prove to be an Achilles’ heel in the plan.

If coalition governments create rainbow politics, then in health policy the dominant colour is a clear Conservative blue. Much hinges on the consultation that will now take place and the opportunity this offers to fill the gaps in the design of the reforms. It is hard to disagree with the laudable aspiration to put patients at the heart of the NHS and to focus on improving outcomes and quality. But it is much more difficult to ensure that the means are put in place to achieve these results. Backing general practitioners to provide these means is both radical and risky, not least because no other country places so much responsibility for service provision and now commissioning on primary care.