The NHS at 75 – what did we learn (or not) from the Lansley reforms?

10 years on – truly integrated care pathways and a re-think of the role of primary care (GPs) remain two of the missing ingredients in NHS reform

I listened with interest to Sajid Javid on BBC Radio 4 yesterday discussing the need for a root-and-branch rethink of the NHS (coming over 10 years after the Conservative-led Andrew Lansley reforms). Calls for a fundamental step-change have also been made by the chief executives of the Health Foundation, Nuffield Trust and The King’s Fund in a letter to Rishi Sunak, Sir Keir Starmer and Sir Ed Davey, imploring them to make the upcoming general election a decisive break point and end years of short-termism in NHS policymaking.

Given that today marks the 75th anniversary of the NHS, and having briefly worked back in 2013/14 in the “Competition and Cooperation Directorate” of Monitor and subsequently spent some time reviewing NHS Foundation Trust mergers at the CMA, I wanted to jot down some quick personal reflections of my experience of the Lansley reforms, what worked well (and not so well) and what the focus of future reform efforts might be.

Competition in the NHS was always an oxymoron

First off, Monitor’s attempts to encourage 'competition' between trusts (for example by publishing data on waiting times and care standards of different hospitals and encouraging patients to choose the best hospital), alongside its other functions as regulator of Foundation Trusts, were always going to sit awkwardly with the nature of public health free at the point of delivery (not least the practical issues associated with patients – often frail and elderly – travelling any significant distance for hospital care). 

It became clear at an early stage that patients - reasonably - wanted care in their community to be at a certain standard and had limited ability or incentive to 'shop around'. Whilst many Trusts entered 'special measures' (the 'stick' part of a failure to improve), and many more became Foundation Trusts (with greater freedom over strategic direction and budgeting - the 'carrot') the fact that the Government could never defensibly allow a hospital to actually fail / exit the market limited the impact of the regime to making mostly marginal improvements in already good or high-performing hospitals (and hospital networks).

Ultimately, competition could never (and did not) play a part in non-elective / emergency care, nor really in step-down, and this is where some of the greatest challenges were faced, and continue to be faced. It did help to some extent in more routine elective cases, for example in reducing waiting lists for knee operations (the most commonly ‘outsourced’ service).

Patient choice was an important tool and should be preserved wherever possible

One element that stayed with me from my time at Monitor was the power of ‘patient choice’. This idea - that a patient should be able to choose their care provider - tended to gain a lot more traction with clinicians, NHS managers and clinical commissioning groups (CCGs), than the idea of competition. Noone could really argue that the patient - for which the entire system works for - had a right to seek care from another provider if that would be quicker or better. In scenarios where people often rightly complain of a ‘postcode lottery’, any efforts to assist patients in accessing care more quickly at other hospitals should be welcomed. 

Where patient choice is valued, it should be wherever possible preserved (possibly the only remaining block to greater consolidation of hospital trusts).

Consolidation had a role in facilitating integration and improved efficiency

Consolidation was often seen by clinicians and NHS managers as essential to improving the overall standard of care.

For example:

• Mergers between trusts located in urban areas and those in rural areas allowed hospitals to pool consultant and staff rotas between both. This was incredibly important in staff recruitment and retention (since doctors and nurses would often have a preference for working in the city and less interest in the countryside) and became a key ‘relevant customer benefit’ in later CMA reviews. Thus, patients in rural areas could still be seen by some of the best clinicians in the region, who would rotate in and out periodically.
• Consolidation also allowed hospitals to pool waiting lists and maximise capacity utilisation, though this required monitoring (and there was always a risk that one set of patients previously served by the better-resourced / managed hospital pre-merger would be worse off post-merger).
• Consolidation gave some hospitals the essential ‘critical mass’ to improve highly specialised fields (such as radiology or neurology), allowing some to become ‘centres of excellence’. This could also allow regional hospitals to become part of a wider network and give a wider catchment of patients better access to specialist care.

Integrated care pathways were a fundamental – if often overlooked – element of the job

Monitor had a really important role working with CCGs to encourage greater integrated care pathways between NHS hospitals and, crucially, step-down facilities (such as community care, dialysis, nursing homes and other tertiary care centres). This sat alongside all functions and I saw some fantastic outcomes during my time there, including better engagement between, for example, ambulance trusts and the hospitals they worked with, resulting in clearer pathways for patients. This was also essential at the other end in 'freeing up' capacity in hospitals by having clear protocols between hospitals and care homes / primary care for step-down.

In reality, Monitor really struggled with integrating GPs into care pathways, which have very different practical and financial incentives to the rest of the NHS. Ideally, GPs should be the single point of contact for a patient, referring them for care and treatment at hospital and then reviewing next steps after that care and treatment has concluded. Often however, this was not possible or practicable and there was no one really at the apex of the patient’s care. This meant longer hospital stays and missed opportunities to return a patient either home with support or to an appropriate step-down / care home environment. The local NHS hospital - much like the police - became the 'carer of last resort', a position it simply did not have the resources to adequately fulfil.

Solving this conundrum remains essential to improving overall efficiencies in the NHS (and, I suspect, may require a review of the free-at-the-point-of-delivery model of primary care in the UK, or the further integration of primary care into NHS hospitals).

De-centralised decision-making reduced the level of overall system accountability.

The Lansley reforms pushed decision-making to NHS England (for non-elective care) and regional CCGs (for elective care). While in principle this could have allowed for nimbler / more focussed decision-making, in reality it clouded lines of authority and removed levers that were needed when top-down reform was required.

As the famous quote attributed to NHS founder Nye Bevan read “If a bedpan is dropped in a hospital corridor in Tredegar, the reverberations should echo around Whitehall.” And yet, increasingly, there was no one at the top to either hear or heed the growing calls for assistance and action from clinicians and managers on the ground (not least, as we are learning daily, during Covid).

The huge importance of the NHS must surely require the Health Secretary to take ultimate responsibility and accountability for system reform and failings.

The involvement of the private sector was largely a reaction to a lack of NHS capacity

My experience generally was that private sector care could augment but never replace NHS hospitals. It was often deployed to create capacity in a system that could not meet demand but was usually a stop-gap measure (for example, to reduce waiting times for routine operations such as knee and hip replacements). Ultimately, the private sector cannot replace specialist non-elective care (for example, in relation to oncology, neurology, complex surgery, and so on).

The CMA played its part well – by largely staying on the side-lines

The approach to NHS mergers showed that the CMA has the ability to flex its approach to new circumstances. After a shaky start in blocking Bournemouth and Poole, the CMA soon found its groove. While the policy had been for a long time that RCBs could never result in clearance at Phase 1 (or Phase 2 for that matter), the realpolitik of NHS consolidation soon overcame that hurdle. 

Having cleared Central Manchester / South Manchester NHS FT on RCBs at Phase 2, the CMA quickly moved to clear UHB / Heart of England at Phase 1. From there, the CMA's role became largely academic – it was not its place to block consolidation called for by NHS Foundation Trusts and CCGs. 

It was clear that merger control simply was not – and will likely never be – the right regime to review public hospital consolidation. Having said all of that, most NHS clinicians and managers I worked with reported that the 'patient benefits' piece (run predominantly by Monitor, with support from the CMA) helped focus minds in setting clear objectives for hospital mergers and helped ensure that the staff and patients had a fair share of the benefits of consolidation.

Conclusion

So, what did we learn from Lansley then?

Well, attempting to introduce competition into the NHS didn't compute, although championing 'patient choice' delivered benefits. The creation of Foundation Trusts - freer to make decisions about patient care and services - did improve local and regional outcomes. Consolidation did similarly give Foundation Trusts better ability to pool resources and reach critical scale in specialist services. And a third party undertaking objective assessments of the extent of patient benefits associated with consolidation was generally welcomed by the sector (even if the wider regime in which it operated was shunned). On the flipside, we learned the obvious – that simply throwing money at the problem might increase the availability of care, but will quickly be swallowed up and won't solve underlying issues. And the private sector has a distinct, but limited role to play (particularly to relieve short-term capacity constraints and reduce waiting lists).

I therefore have some sympathy with Mr Javid in the need for this to be a cross-party discussion (potentially through a commission) to gain consensus on the way forward. It is quite clear that this is not something that can be solved in a one or two UK parliamentary terms but requires a long-term, and settled, reform strategy. 

The thorniest issue remains how to align each level of the care system (the GPs, hospitals, care homes and private care providers) in a way that incentivises efficient care – “right care, right time, right place.” ‘Vertical’ consolidation (ie bringing hospitals, tertiary centres and care homes coming under common leadership) could prove an important key to unlocking this intractable problem. Similarly, a closer look at the role of primary care and GPs (largely spared under Lansley) might now be unavoidable.

And I utterly reject the suggestion by Steve Barclay that evolution, rather than revolution, is sufficient. Despite the best efforts of clinicians and managers, the system is not fit-for-purpose and is in urgent need of fundamental reform, and this must come from the top.