There should be gains but do they go far enough and are they worth the risks?
The Government’s 10 Year Health Plan, is eagerly awaited. Even before it has been published, Wes Streeting, Secretary of State for Health and Social Care, has wielded his power by culling NHS England. The new, interim, and therefore last ever CEO of NHS England, Jim Mackey, has wielded his new axe, by telling Integrated Care Boards (ICBs), established in just July 2022, to slash the costs of running their systems by 50% and ‘prepare to merge’. It is a little sad, that they didn’t even make it to their 3rd birthday, but such is the pace of dynamic reorganisation within the NHS…
The proposed changes are undoubtedly dramatic and ambitious but are they realistic? Such cuts feel very dangerous, even more so because, the upheaval is required to be completed in just six months. Have any commercial companies have made such radical changes and survived? Is the NHS so bloated that it can sustain such slash and burn? If it is, then why is the previous leader still working for it, in any capacity?
Slash and burn is terrible in rainforests so why do it to the NHS? The uncertainty is hampering key, normal activity because it’s hard to motivate people facing mass redundancies and whose bosses are trying to fundamentally review what Integrated Care Systems will be able to still do. The national blueprint still includes, what ought to be redundant: regional offices. This suggests the usual Soviet style command and control will continue. One day there will be a true revolution.
The Guardian has reported NHS bosses describing the scrapping of so many managers as “vandalism”[i]. Andy Burnham, Labour Mayor of Greater Manchester, and co-chair of the Greater Manchester Integrated Care Partnership told the Health Service Journal the Government and NHS England should step back from a reorganisation that has come out of nowhere and risks taking peoples’ focus away from the big challenges the NHS faces[ii]. His words were prescient. It can’t be a coincidence that waiting lists have, for the first time in seven months, crept back up.
The NHS, contrary to uninformed yet popular opinion, is not awash with swathes of capable management. As is the case in many organisations, there always are some expensive senior managers whose value to their employer is debatable. A cull of ICBs should definitely cull some of that cost and, with it, the harm they inflict. But sadly the NHS readily suffers fools gladly. HR processes are abysmal and so the useless managers will likely linger. Has anyone ever been performance managed out of the NHS? I doubt it, but part of the explanation may be because HR are perpetually swamped with reorganisation processes, recruitment freezes and banding challenges.
Staff who drift from one bit of the NHS to another maintain their continuous service, and the growing benefits / costs that go with it. It’s understandable that HR are terrified of financial impact of losing employment tribunals where compensation payments divert resources away from the front line. The end result of this approach is ineffective people stay in the NHS for years. The commercial sector manages performance, or lack of it, much better and where needed is prepared to give ‘some money’ to those who underperform, to sign away their rights and move on. This is surely a better solution than paying wages to people who are ineffective, fail to make a positive contribution and drag down the colleagues around them. It is not unknown for senior NHS staff to enjoy paid ‘gardening’ leave for extended periods of time, as, if they take the NHS to an employment tribunal and are successful the NHS could be left with an eye-watering bill.
ICBs do not manage their contracts or analyse the vast amounts of available data at all well, though there are some brilliant NHS analysts. They don’t challenge providers as recently demonstrated by the reports on independent eye providers operating unnecessarily on patients. Contract management is hard, particularly with toothless contracts – in the GP one there are virtually no levers for any performance management and whilst it’s hard being mean to a hospital when they’re already in a deep financial hole. Such things have to be left to coroners or the Health and Safety Executive as even public inquiries don’t lead to fines, until years later once the patients’ very patient lawyers have followed due process. Whilst contracts and their management is so poor this will likely only get worse.
There are undoubtedly opportunities. There is no doubt that the duplication of effort since the creation of the current 42 ICBs is unbelievable. Each one has been busy creating the postcode lottery ‘Commissioning Thresholds’, Shared Care Agreements, Local Enhanced Services and Prescribing Formularies. The public expect to have a national health service, not 42 local ones. In truth duplication is a scourge on the NHS that Simon Stevens’ failed experiment with ICBs only helped a little. Previously the duplication was worse, undertaken, before Covid, by hundreds of Clinical Commissioning Groups (CCGs). Sadly, even now, the ‘harmonisation’ of all this work is not complete. Policies are still being merged from the previous constituent CCGs, to sit under ICB logos. Oh heck, they’ll have to all be looked at and changed again as we head to somewhere between 25 or so new bigger and better ICBs! Alas if only we could get down to one set of all the above, we would save a lot of time and money, the postcode lottery would go, and we’d finally get closer to a genuinely national health service.
As the cull looms and uncertainty prevails there is a grave danger of good staff jumping ship and leaving the commissioning environment. Opportunities are not aplenty, but the good ones will get the few there are. Whilst you may not be aware of it NHS commissioning is vital. Without good commissioning, euphemistically known as ‘system integration’, (as if we lived in a communist utopia), providers will be completely unchallenged. GP practices already are, and hospitals have, for years, believed themselves to be untouchable. Who will challenge the productivity levels? Who will challenge poor care: high infection rates, prolonged trolley waits and ‘hospital flow’ that resembles cooling lava?
The war on drug costs is a different matter. The NHS in England spends £19 billion on medicines annually. Who will watch the prescribing costs grow if the medicines optimisation teams within ICBs are smashed? Mackey might as well give the keys to the Treasury vaults to the prescribers, who because of their professionalism, are independent a.k.a. often conflicted, ignorant and immoral in their willingness to not give a stuff about the unnecessary cost they place on the public purse.
Medicines Optimisations teams alone save the NHS millions every year by finding financial efficiencies, influencing prescribers and optimising safe prescribing. That protects patients and saves an awful lot more money. Losing them would be criminal neglect. Just watch the prescribing costs for proof – they will sky rocket.
Some ICS staff will no doubt welcome the opportunity for early retirement. Working for the NHS is a thankless task, particularly if you feel loathed as one of the mythical legions of penpushers. In truth, like the front line, NHS management is not terribly well resourced and would benefit from more, capable staff who are not reinventing the wheel, up and down the country. Losing years of experience will being a heavy to cost the service. High performing experienced staff should be incentivized to stay albeit that’s a tough sell without the confidence of a coherent structure in which to achieve productive work. Inevitably the mediocre staff who haven’t been performance managed out, will likely hold on for redundancy payments, albeit that is a better outcome than them staying in the NHS for years to come.
Achieving all of this change in six months might be politically expedient but it is seriously risky for the public and its purse. Time will tell whether Streeting and Mackey can achieve what no commercial company would dream of risking. In a Department of Health and Social Care, this rush feels careless.
[i] The Guardian Ministers admit failing to assess impact of thousands of NHS job cuts in England, Denis Campbell, 6/5/25 17.31 BST
[ii] HSJ Ex-health secretary attacks ‘drastic’ ICB shake-up Caitlin Tilley 1/5/25
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