The NHS Reform That Solved Accountability by Abolishing It
In July 2010, a white paper landed in NHS trust post-rooms with the title Equity and Excellence: Liberating the NHS, Command Paper 7881, seventy-odd pages of the driest prose since the last white paper, and the Daily Telegraph, not usually given to hyperbole about command papers, called it "the biggest revolution in the NHS since its foundation." Andrew Lansley had been planning it since opposition. It had appeared, briefly, in the Conservative manifesto. It did not appear in the coalition agreement, which mentioned the NHS only to promise a real-terms funding increase every year — a document two parties had spent five days negotiating line by line, and somehow missed the biggest thing either of them was about to do to it.
The Act that followed did what its title promised and abolished the middle. Primary Care Trusts, which had commissioned and provided services under one roof, were split by March 2011 so that commissioning and provision sat in separate hands — the theory being that a purchaser who also ran the shop could never negotiate honestly with itself. GPs, rebranded as commissioning consortia, were handed roughly £60 billion of the NHS budget and told to buy care on patients' behalf, in competition, from "any qualified provider," a phrase carefully agnostic about whether that provider wore an NHS badge or a shareholder's. The bill went into the Commons on 19 January 2011. The Guardian reported it rested on 20,900 NHS redundancies. Nobody had voted for any of this eight months earlier.
The reaction was not the usual grumble of a profession defending its patch. The Royal College of General Practitioners denounced it. Nurses, physiotherapists, the British Medical Association queued up. And then, in a detail that deserves to be better remembered than it is, the government appointed Steve Field, a GP, to run a "listening exercise" meant to calm everyone down — and by 14 May 2011, the Guardian reported that Field himself had dismissed the plans as unworkable, his own review undermining the bill he had been hired to rescue. It is worth pausing on that: the official chosen to reassure the public that the government was listening concluded, in public, that the thing being listened to was correct.
There was a steelman, and it should not be waved away. A cohort of GPs wrote to the Telegraph in May 2011 to say the reforms were "a natural conclusion" of fundholding begun in the 1990s and practice-based commissioning under the last Labour government — not a Tory rupture but the next stage of something both parties had already been doing. Commissioners closer to patients, the argument ran, would spend more wisely than a regional bureaucracy ever could; competition between providers would sharpen services that monopoly had let go slack. This is not a stupid argument. It is the argument for markets generally, and in narrow places — elective surgery waiting times, for one — it has evidence behind it.
The pause that wasn't one
The "listening exercise" ran from April to the end of May 2011, timed, with a precision that should embarrass nobody involved because everybody involved has stopped being embarrassed by this sort of thing, to halt the bill's progress until after the May local elections and then resume it once the voters had been safely thanked and dismissed. Whitehall does not call this cynicism. It calls it "pause, reflect and improve," which translates, reliably, as: we will wait for the news cycle to move, then proceed. The bill received Royal Assent on 27 March 2012, thirteen months after it entered the Commons, its architecture essentially intact. The listening had produced amendments. It had not produced a different Act.
What the amendments obscured was the Act's real achievement, which was not efficiency or patient choice but distance. NHS England was created as an arm's-length body precisely so that health, that most electorally lethal of portfolios, could be handed to commissioners and quangos the Secretary of State no longer had to answer for day to day. If your local trust closed a maternity unit, that was now a decision by a clinical commissioning group, accountable in the loosest sense to a national board, accountable in turn to nobody you could find on a ballot paper. Lansley's genuinely stated aim — take politics out of the NHS — has a name when it succeeds, and the name is accountability laundering. You cannot take the politics out of who lives near a maternity unit that closes. You can only take out the person who used to have to explain it.
Fourteen years on, the current government has begun dismantling the thing Lansley built, folding NHS England back into the Department of Health and Social Care and restoring direct ministerial control over the machinery the 2012 Act spent a year and a Parliament's patience prising loose. That reversal is being sold, this time, as ending duplication and waste. It might even do that. But notice what it concedes without saying so: that the arm's-length model, sold to the country as modernisation, produced thirteen years in which nobody occupying the Secretary of State's chair could be made to answer for the system he nominally ran, and that this was eventually recognised, quietly, as a bug rather than the feature it was marketed as.
The lesson of 2012 was never really about competition or privatisation, though both made good headlines. It was about the difference between reforming a system and relocating the desk where its failures get explained. Attlee's government built the NHS from nothing in three years with the country bankrupt, and every minister who ran it from 1948 onward answered for it in the Commons, badly sometimes, but in person. The 2012 Act took sixty years of that arrangement and dispersed it across boards, consortia and an arm's-length body with a chief executive nobody elected, and called the dispersal liberation. The people rebuilding it now are not wrong to try. They should just be honest that what they are rebuilding is the thing 2012 was designed to remove: a name to blame.