NHS shake-up finds Boris Johnson ready to ditch ideology

LONDON — The coronavirus pandemic is far from over and England’s National Health Service is not yet out of the woods — but its next big reform has already been set in motion. 

The obvious question being asked by some of the exhausted health care staff on the frontline is: Why now?

It’s the second time in a decade that the U.K. government has ordered a reorganization of the NHS — and the latest plan gives a hint at how the Conservative party under Boris Johnson is changing.

The last round of reforms, led by then-Health Secretary Andrew Lansley in 2012, proved deeply controversial. They had, at their heart, ideas firmly rooted in Thatcherite orthodoxy. Private-sector competition with state-run health services was an inherent good, and central government should be at one remove from public services on the ground.

The fresh proposals — set out by current Health Secretary Matt Hancock in a government white paper — represent a major about-face. They do away with the legal requirement for competitive tendering of health services in the NHS, and place significantly more power in the lap of the health secretary himself.

It’s a sign of how Johnson’s government is less driven by ideology than many of its Conservative predecessors, and far more opportunistic. Though founded by the Labour Party on principles contrary to Johnson’s espoused pro-market leanings, the prime minister has made the publicly-funded, free at the point of use NHS central to his political identity.

Much of what is in the white paper has been proposed by NHS England’s leading officials and has been in the works for some time. The previous Lansley reforms saw the establishment of GP-led clinical commissioning groups, which were handed public money and tasked with buying health care services for a local area from either NHS or private providers. The reforms were “only ever really understood” by Lansley himself, said Nigel Edwards, chief executive of the Nuffield Trust think tank. They were never warmly embraced by Lansley’s Conservative successors or the NHS.

“Politicians and the NHS go in cycles of falling in and out of love of different types of mechanisms,” said Edwards. “There has been a disenchantment with quasi-market mechanisms as a really major lever for change.”

The new “integrated care systems” that will now be responsible for the funding of health care are already up-and-running in some parts of the country.

That Johnson is willing to embrace changes drawn up by NHS leaders and casually sweep away pro-market thinking inherited from his Conservative predecessor David Cameron is characteristic of a prime minister who sees himself in the tradition of “Tory Democracy.” He is pro-market, but relaxed about state intervention where it seems to work and (crucially) is popular. And there are few areas of public life in which British governments stand to gain — or lose — as much popularity as on their handling of the NHS.

Eyes on 2024

But why now, in the teeth of a pandemic? The answer, said Richard Sloggett, founder of the Future Health think tank and a former adviser to Hancock, lies in the coming challenges for the NHS — and the Tories’ desire to address them in time for their public reckoning at the 2024 general election.

“The government wants to get this through now so it can be in place by April 2022. With the next election in 2024 that gives you a couple of years for these reforms to start delivering,” said Sloggett. “The big thing they’re going to have to deliver is the reduction in waiting times. We’ve got hundreds of thousands of people now waiting over a year for treatment after the significant disruption caused by COVID.”

Precisely how — or whether — the new structures can deliver remains to be seen. But Sloggett said the key reform to watch would be the additional powers accrued by the health secretary; an aspect of the overhaul that was not based on pre-existing NHS plans and came as a surprise to many observers. While the management body NHS England will retain “clinical and day-to-day operational” independence, Hancock has said reforms would empower him to “set direction for the NHS and intervene where necessary.”

In other words, Hancock wants to be able to pull a lever in Whitehall and for the NHS to respond on the ground. With a rapidly growing waiting list for treatment that could become a major election issue in three years’ time, you can see why he might want that.

But Edwards said it was “optimistic” to think the reforms could have any effect by the time of the 2024 election, and highlighted a chronic workforce shortage in the NHS as the real problem with the health service that needs fixing.

“What they will discover is that you can pull the levers all you like, if there’s no orthopaedic surgeons it doesn’t really matter,” said Edwards. “There’s a flawed theory about what the issues are … that somehow performance is a management problem or a lack of will; when actually the real problem there aren’t enough staff.”

There is another risk for Hancock and Johnson contained within the reforms.

“If the government wants to take more control of the health service, there is an opportunity for Labour to take a greater focus on the performance of the health service and to try to tie that more closely to Conservative ministers,” said Sloggett.

At the 2019 election, despite a range of NHS performance problems to highlight, Labour placed more emphasis on the claims that the U.K.’s post-Brexit trade deal with the U.S. would see parts of the health service sold off to American private healthcare; the kind of political attack that was par for the course when the Lansley reforms were being introduced.

“Now, they might now change tack a bit,” said Sloggett.

So while more ministerial control might (in theory) help drive down those ballooning waiting lists, as Hancock hopes, the risk is that the reforms do not deliver the boost he’s hoping for. And if the problems persist long after the pandemic has ended — the buck will now, indisputably, stop with him.