1 Title: Assessing proposals for a new NHS structure in England after the pandemic 2 Authors: 3 Hugh Alderwick, head of policy1 4 Phoebe Dunn, research fellow1 5 Tim Gardner, senior fellow1 6 Nicholas Mays, professor of health policy2 7 Jennifer Dixon, chief executive1 8 1 Health Foundation, London, UK 9 2 London School of Hygiene and Tropical Medicine, London, UK 10 Correspondence to: 11 Hugh Alderwick; Health Foundation, 8 Salisbury Square, London, EC4Y 8AP; 12 [email protected]; 020 7664 2083 13 Word count: 2153 14 References: 52 15 --------------------------------------------------------------------------------------------------------------------------- 16 Key messages: 17 - NHS leaders in England are calling for changes to health care system structures and legislation 18 - The changes are designed to support collaboration between organizations and services—and 19 could mean some NHS agencies being abolished and new area-based authorities created 20 - Encouraging collaboration to improve population health makes sense, but the potential benefits of 21 the new system proposed may be overstated and the risks of reorganization underplayed 22 - NHS leaders and government have a long list of policy priorities as the country recovers from the 23 pandemic. A major structural reorganization of the health care system should not be one of them 24 --------------------------------------------------------------------------------------------------------------------------- 25 Contributors and sources: All authors are researchers in health policy and public health in the UK 26 and have experience analysing health care system reforms in England and elsewhere. All authors 27 contributed to the intellectual content. HA and PD wrote the first draft of the article. PD, JD, TG and 28 NM commented and made revisions. All authors agreed the final manuscript. HA is the guarantor. 29 Patient involvement: No patients were involved in the analysis. 30 Conflicts of Interest: We have read and understood BMJ policy on declaration of interests and have 31 no relevant interests to declare. 32 Licence: The Corresponding Author has the right to grant on behalf of all authors and does grant on 33 behalf of all authors, an exclusive licence (or non exclusive for government employees) on a 34 worldwide basis to the BMJ Publishing Group Ltd ("BMJ"), and its Licensees to permit this article (if 35 accepted) to be published in The BMJ's editions and any other BMJ products and to exploit all 36 subsidiary rights, as set out in The BMJ's licence. 1 37 Assessing proposals for a new NHS structure in England after the pandemic 38 39 The health policy challenges facing the NHS and government are enormous. A major reorganization 40 of the NHS in England would not be the solution to fixing them 41 Introduction 42 The NHS has just faced the most difficult year in its history. The arrival of COVID-19 vaccines 43 provides hope that the UK may bring the pandemic under control in 2021. But the effects of COVID- 44 19 will be felt by the NHS for many years to come. Short-term challenges also remain significant: 45 hospitals are under extreme strain,1 the backlog of unmet health care needs is substantial,2 and the 46 NHS faces the mammoth task of vaccinating the population against COVID-19.3 47 Amid these challenges, NHS leaders are calling for changes to NHS structures and legislation. In 48 November 2020, NHS England published proposals for new legislation to change the way the NHS is 49 organised.4 The changes are designed to support local NHS organizations to collaborate to improve 50 care and manage resources as they recover from COVID-19—and could be implemented by 2022. 51 Here we analyse and assess these proposals. We briefly describe their aims and elements, put them in 52 context, and draw on evidence from the long history NHS reorganizations to help understand their 53 potential impact. We outline key questions for the NHS and government as they develop the plans. 54 Policy context 55 Before COVID-19, the national strategy guiding the development of the NHS in England was the 56 NHS long term plan.5 The plan—published in 2019—focused on developing more integrated services 57 within the NHS and between health and social care, boosting disease prevention, and improving 58 cancer, mental health, and other services.6 A mix of policy mechanisms was proposed to drive 59 progress, including new contracts for general practitioners, revised quality measurement, and greater 60 use of digital technology. The logic was that collaboration between local agencies would improve 61 services, contributing to better population health. 62 But the rules governing the NHS in England were not designed with this logic in mind. The Health 63 and Social Care Act 2012 sought to strengthen competition within the health care system and created 64 a complex and fragmented organizational structure. The aim of integrating services was supposed to 65 be balanced with competition among providers.7 NHS England has since established sustainability 66 and transformation partnerships (STPs) and integrated care systems (ICSs)—partnerships of NHS 67 commissioners, providers, and local government in 42 areas of England—to join up local services. 68 But these partnerships have no formal powers and must navigate the 2012 Act’s rules on competition. 69 As a result, NHS England first proposed new legislation to government back in 2019.8 The idea was 70 to bring the rules governing the NHS closer in line with the direction the system was heading in 71 practice. Proposals included removing requirements to competitively tender some NHS services, and 72 establishing local partnership committees with delegated powers to make decisions on local priorities 73 and spending. The proposals were designed to avoid a major reorganization but risked replacing one 74 set of workarounds with another.9 Then COVID-19 hit and the plans were shelved. But now 75 legislation is back on the agenda10 and NHS England has published expanded proposals for changes to 76 the NHS after the pandemic. 2 77 Proposed NHS structure 78 The proposals4 include a mix of aspirations, organizational changes, and policy and legislative fixes. 79 A new NHS structure is outlined involving four layers of NHS agencies and partnerships (box). 80 --------------------------------------------------------------------------------------------------------------------------- 81 Box: summary of proposals from national NHS bodies for a new health system structure in England 82 - Places: NHS organizations will work with local authorities and others to organize and deliver 83 health and social care services in ‘places’—defined by existing local authority boundaries. Joint 84 decision-making arrangements should be developed between local agencies, which may be given 85 responsibility to manage budgets for services. NHS organizations will be expected to collaborate 86 with non-medical services to address social, economic, and wider health needs of the population. 87 - Provider collaboratives: All NHS providers will need to join a provider collaborative. These may 88 be ‘vertical’—involving primary, community, mental health, and acute hospital services within a 89 ‘place’—or ‘horizontal’—which might include multiple hospitals providing specialist services 90 across larger areas. NHS England also calls for legislative changes to allow new NHS integrated 91 care providers to be established, able to hold single contracts for all NHS services in an area. 92 - Integrated care systems: ICSs will be established as collaborations between NHS providers, 93 commissioners, and local authorities—based on the 42 areas already identified by NHS leaders 94 (covering populations of around one to three million). ICSs will become a new intermediate tier 95 of the health system and control a ‘single pot’ of NHS resources. ICSs will make collective 96 decisions on use of resources and service changes, and can delegate funding and decisions to 97 ‘places’ within their boundaries. Clinical commissioning groups (CCGs) should merge to fit ICS 98 boundaries—and may be abolished depending on the structure chosen for ICSs. 99 - Two options for ICSs: NHS England outlines two options for enshrining ICSs in legislation— 100 though details on both are limited. The first is that ICSs are established as joint committees made 101 up of existing organizations, with mechanisms to make collective decisions between them. The 102 second—NHS England’s preferred option—is that ICSs are created as new NHS bodies, with a 103 duty to ‘secure the effective provision of health services to meet the needs of the system 104 population’. Each ICS would have a chief executive and board made up of NHS providers, local 105 authorities, and others. CCGs would be abolished, and their functions taken on by the ICS. 106 - National and regional NHS bodies: National NHS bodies will shift their focus to regulating and 107 overseeing these new systems of care. Legislation would be needed to formally merge NHS 108 England and Improvement, to provide a ‘single, clear voice’ to local NHS organizations. ICSs 109 would take on some of the functions of the regional arms of NHS England and Improvement. 110 --------------------------------------------------------------------------------------------------------------------------- 111 The centrepiece of the new NHS structure is ICSs: 42 area-based partnerships between the NHS and 112 local government that currently exist informally (some areas are not yet ICSs11) but—under NHS 113 England’s preferred plans—would be established in legislation as new NHS agencies, responsible for 114 controlling most health care resources and leading service changes. A further tier of organizational 115 partnerships between the NHS and local government—so called ‘places’, based on local authority 3 116 areas—and compulsory NHS provider collaborations would join ICSs in a new NHS landscape based 117 on collaboration rather than competition. NHS England want the changes implemented by 2022. 118 Analysis of the proposals 119 The proposals for a new NHS structure lack detail, so it is not possible to make a full assessment of 120 their likely impact.