With the government’s record on healthcare reform coming into sharp focus, and following five years at the helm, have its legislative and structural changes left the service in a better or worse shape than when it arrived?

As we head towards the general election, the government’s record on the NHS will come under intense scrutiny, not least by a King’s Fund assessment.

This will be delivered in two parts: in March we will publish an analysis of how the NHS has performed since 2010, while last week we launched a review of the government’s record on reform.

‘Damage is evident in the serious fragmentation of commissioning’

Our review of NHS reform argues that this has been a parliament of two halves. The first half was dominated by Andrew Lansley’s plans to extend competition and choice, and to devolve decisions to GPs and frontline staff.

The second half has seen the focus shift to patient safety and the quality of care as Jeremy Hunt responded to the Francis Inquiry report into Mid Staffordshire Foundation Trust.

Debate on Lansley’s plans generated strong feelings on all sides, with critics claiming that the Health and Social Care Act 2012 would not only extend competition, but also lead to much greater privatisation of provision.

In fact, our assessment shows that the private provision of care to NHS patients has changed little, with over 90 per cent of services still delivered by NHS providers.

Unintended complexity

Far more important have been the massive organisational changes resulting from the act.

These changes have created a system of considerable complexity and confused accountabilities. Reforms that were intended to simplify and streamline the organisation of the NHS have had the opposite effect and resulted in a vacuum in system leadership at a local as well as national level.

‘Competition and choice have gone on the back burner’

The organisational changes contained in the act have been both damaging and distracting.

Damage is evident in the serious fragmentation of commissioning, the bewildering complexity of regulation (to use the words of the Berwick review into patient safety), and the loss of continuity as leaders have been replaced and organisations have been restructured.

And distraction has resulted from a requirement to undertake fundamental restructuring when there ought to have been a focus on improving patient care and delivering greater efficiency at a time of constrained budgets.

A new transparency

Since his appointment in September 2012, Mr Hunt has turned away from the technocratic changes contained in Lansley’s act by placing patient safety and quality of care at the heart of the NHS agenda. He has also worked with Norman Lamb to give greater emphasis to integrated care.

‘There is growing evidence of financial distress and widespread problems in delivering key targets’

Competition and choice have gone on the back burner to be replaced by regulation and transparent reporting of information as the means by which ministers have sought to improve performance. These developments are very much to be welcomed.

There have been other positive developments, including progress on integrated care, the establishment of health and wellbeing boards to link councils and clinical commissioning groups, and the provisions of the Care Act 2014, which are an important step towards the fairer system of funding long term care called for by the Commission on the Future of Health and Social Care in England.

In reality, most of these developments could have come about without the 2012 act, and we shall never know how much more could have been achieved if ministers had opted for evolutionary, rather than revolutionary, reforms.

Public favour

What is not in doubt is that the government has had to use a lot of political capital to overcome opposition to the Lansley reforms and assure the public of its true intentions towards the NHS.

It is a tribute to the 1.4 million staff working in the NHS that, as the Parliament nears its end, public satisfaction remains high and productivity has increased at a faster rate than in recent years.

‘The government has to use a lot of political capital to overcome opposition to the Lansley reforms’

On the other hand, there is growing evidence of financial distress and widespread problems in delivering key targets.

Our assessment of performance over the period since 2010 – published next month – will set out in detail what the balance sheet looks like, to help inform debate on the public service that matters most to the public.

Chris Ham is chief executive of the King’s Fund

This piece was originally published on the King’s Fund blog

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