Ahead of the publication of his report on the government’s NHS reforms, Nicholas Timmins gives HSJ an exclusive angle on his inside story.

Two years ago this week, Andrew Lansley published Liberating the NHS. His white paper – launched after repeated Tory and coalition promises of no more “top down” reorganisations – set out arguably the biggest structural upheaval the service has ever seen and certainly the biggest transfer of power and accountability in its 63-year history.

What resulted is widely seen as one of the biggest “car crashes” ever in terms of both politics and policy making – one to which the service must never again be subjected.

  • Scroll to the end to download a PDF of Never Again? The story of the Health and Social Care Act 2012.

Over the past few months, the Institute for Government and the King’s Fund have jointly tried to piece together how and why this happened and what lessons might be learned.

The lessons might seem obvious. Don’t do anything so radical to one of Britain’s best-loved institutions when you haven’t told the staff or public what you are planning. And certainly don’t do it this way.

But there is another view, and it is Andrew Lansley’s. To understand that, you have to grasp precisely what it was that the health secretary was seeking to do, however badly he explained it. Essentially he wanted to take “market-like” NHS reforms that both Labour and the previous Conservative administration had introduced, complete them, and entrench them, permanently, in legislation.

These had, of course, been subject over the previous two decades to repeated two steps forward, one step back and often a step right off the road before the route was rejoined.

NHS trusts were set up to be “self-governing” hospitals but gradually lost most of their nominal freedoms. GP fundholding was established, then abolished, then partially reinvented through practice-based commissioning. Alan Milburn reintroduced choice and competition, only for Andy Burnham to declare that the NHS was to be its own “preferred provider”. And so on.

What Lansley wanted to do was nail down in legislation all the incentives, penalties and accountabilities in this more market-like approach, to produce what Labour used to call a “self improving” organisation – one that would produce improving results while running more or less on auto-pilot without the need for repeated ministerial intervention. New legislation would be required. Lansley’s hope and belief was that once this was through then never again – or at least not for many years – would the service need to go through another structural upheaval.

On the way he has answered a couple of questions that had been lying around unanswered for 20 years or so. Who in the long run was meant to be the chief commissioner of local healthcare – GPs or some form of health authority? The answer has turned out to be something of an amalgam of the two through the clinical commissioning groups. And he has produced in the commissioning board a statutory answer to the administrative arrangement that again has attempted over two decades to separate the running of the service from the policy-making machine in the department. And if this does prove to be the last major restructuring for many years, plenty of people will welcome that.

To put it another way, there is huge continuity here with what Labour had been up to. As Simon Stevens pointed out at one point, what was so radical about Lansley’s proposals was not that he was tearing up what the Blairites were doing, but that he was moving so decisively towards fulfilling it.

Most of the obvious “lessons” from the past two years – appalling communication, the huge financial and opportunity costs in the face of a massive financial challenge, too great an obsession with defining and driving a public service market while somehow taking politicians out of it – depend on the received wisdom that these reforms will fail.

If in practice they work reasonably well, the decision to drive them through may come to be seen as somewhat heroic. The completion of an evolution, rather than the revolution that Lansley so often painted his plans as being.

If, however, they largely fail it is also indisputably true that this will have been the fifth or sixth attempt in two decades to get commissioning genuinely to “work”. Which will raise the question of what to do instead.

Take it yet further, with patients choosing between competing integrated care organisations, either virtual or actual? A choice, so to speak, between a set of NHS Kaiser Permanentes, still tax funded and largely free at the point of use? Or abandon all this choice and competition and join the Scots in trying to demonstrate that the pre-1991 NHS can be made to work really well? In England, one somehow doubts that it will be the latter.