The NHS White Paper: evolution or revolution?

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By Professor Judith Smith, Director of Health Services Management Centre and Professor Robin Miller, Head of Department, Social Work and Social Care, University of Birmingham. 

NHS White Papers seem to fall into two categories.  First, landmark ones that signal major change of direction and upheaval (can you remember where you were when you heard about the 1989 Thatcher reforms, the 1997 Blair post-election plan for the NHS, or the 2010 Lansley-Cameron debacle?) Second, the more bureaucratic and perhaps less exciting plans, such as the 1987 Promoting Better Health paper, or the 1996 Choice and Opportunity plans for GP, pharmacy and dental contracts.

Looking back, we would argue the former lead to major ‘redisorganisation’ of the NHS with much time lost in distracting reform and politically-charged debate, and promised changes only being partially realised.  The latter seem to lead to more sustainable and ‘under the radar’ change that arguably makes more of a real difference to patients, such as a greater range of services offered within local general practice, with an expanded team of health and social care professionals.

The publication of a new NHS White Paper in the midst of a global pandemic is puzzling to say the least, and begs the question: is this an attempt to distract from the Government’s poor initial handling of the COVID-19 crisis and a land-grab to exert (even more) central control over the NHS? Or are these reform proposals an evolutionary step for the NHS and social care who have been working hard for several years to circumvent many of the bureaucratic complexities of the 2010 reforms of the NHS?

Our answer to this conundrum is that the balance would seem to tip slightly in favour of the latter, with the new White Paper proposing (amongst many other things) to remove often unnecessary tendering of local health services, stop the Competition and Markets Authority having jurisdiction over NHS hospital mergers, mandate local health and social care collaboration, and make existing Integrated Care Systems formal and publicly accountable bodies. All of these are to be welcomed.

However, the White Paper announcement of sweeping away Clinical Commissioning Groups into new Integrated Care Systems (ICS), and the setting up of local Integrated Care NHS bodies (across hospital, mental health, community and ambulance trusts, and primary care) overseen by an ICS Health and Care Partnership (including local authority leaders alongside NHS peers), promise many months of turbulence and uncertainty. Structural reorganisations inevitably soak up considerable management time and energy as core staff apply for new roles amidst personal anxiety, whilst emergent bodies and existing structures try to understand their new responsibilities and realign working relationships.

For all this effort to be worth the pain, what needs to matter most as the White Paper proposals move into legislation is that the ‘integration and innovation’ of the title are truly at the heart of what happens next.  Over the past two decades, there have been countless pilot projects of ‘integrated care’, trying to better coordinate the myriad health and social care services available to say an older person living with multiple health conditions, or a young person with complex disabilities.

Evaluation of these integrated care schemes consistently points to the very positive impact they can have on people and their families, for example in knowing how to get advice 24/7, not having to keep repeating their story about their condition, and knowing they can get swift diagnostic tests, results and care when needed.

The same studies (see for example the long-term evaluation of the NHS Integrated Care and Support Pioneer Programme) also point to the sheer hard work and complexity of bringing about integrated care, and in particular tackling issues such as: data-sharing across services and organisations; resolving financial and budgetary complexity; involving frontline staff in planning new services (and not just senior managers); having really meaningful service user engagement; avoiding undue reliance on external management consultants offering easy solutions; and supporting quality improvement and service development work on a long-term basis.

This new White Paper will support evolution of integrated care at a local level.  There will not however be a revolution in how care is provided for people with complex needs.  For this, there are two gaping omissions in the White Paper that will have to be addressed. First, a comprehensive and sustainable reform of social care which is alluded to in this plan but with no specific details. Second, a fully funded plan to fill the 100,000 vacancies in the NHS, and the 112,000 vacancies in the social care workforce.

This White Paper is important, but not revolutionary.  It goes with the grain of policy and practice, but risks getting lost in the long grass of bureaucratic change.  We hope we are wrong, but time may prove this to be a major missed opportunity.

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