Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by senior bureau chief Dave West.

Is this week a landmark in the history of the NHS? Simon Stevens (who has to be referenced at least once a week in this column) says the nation has to renew its vows, reignite its love affair, with the NHS once a decade, and suggests this is that moment. That indicates a degree of historical significance – though a decade does happen once every 10 years, which isn’t that long, is it?

His words elsewhere speak less of turning point and more a very welcome change of scenery: “It’s not the land of milk and honey but we are leaving the desert.”

If the nation is renewing its vows, it’s as an earnest but ultimately flawed gesture which close friends know will give way to stand up rows in the not-too-distant future, probably within five years (note the likely general election in spring 2022 is sandwiched between the thin 3.1 per cent years).

But at the current time the signatories of the deal really need to signal that a change has happened – repudiation of what went before plays its part in that.

Some political commentators have pointed out that Mr Stevens’ comments on coming out of the desert (or “a clear gear change… compared to what we have had over the last five years”) are a clear statement of what desperate austerity the NHS is emerging from (well – still stuck in till April next year, in the absence of a winter bung) – effectively a dissing of recent government policy.

Personally I thought the NHS England chief (and health and social care secretary) had been pretty clear about that already in recent months – leaving little left for them to repudiate – certainly within NHS leadership circles.

A stronger repudiation symbolically for NHS leadership, and a more risky one, is that of the Health and Social Care Act 2012, which the prime minister this week effectively said she was very willing to change, something Mr Stevens seems reasonably enthusiastic about.

It’s true that the Lansley Act is widely trashed in health policy circles and has been since before it even reached the statute book. It’s going has been a long time coming.

But it was a very bitter battle back in 2010-13 and the reforms, in one of their many endearing features, sewed deep divisions, resentments and rivalries that some people are still living with.

The death of clinical commissioning groups has been slow, giving time for the message to propagate that change is coming, allowing people to get accustomed to their demise.

Frustrations with the current system are very tangible and widely shared, but the arguments for specific legal changes to address them are not. 

The signs are that policymakers have no list of law changes ready to roll out, although privately proposals were developed before the 2016 general election when legislation also looked possible. Politicians would surely be more comfortable with removing barriers, modest adjustments, rather than sweeping restructure and invention.

Even so, the potential implications for jobs, roles and organisations are clear. Some strong organisational identities, relationships and local attachments are at stake. 

Thousands of people work in jobs related to internal market transactions, and linked to the status of current organisations, both on the provider and commissioner side (curse those 200 contracts per clinical commissioning group – many with small businesses, charities and GPs I assume); then there are those in Health Education England, overseeing competition, and other parts of regulation which face potential demise.

Maybe there is an attraction to the powerful message of making a mark, and bidding for a place in NHS history, by repudiating the HSCA and the internal market. But maybe simply the clear offer to legislate will achieve the desired effect. Ministers could honestly say then that they have asked the NHS and it has nothing to put forward.

The deal on the money is unifying, within the NHS at least. Although everyone will compete for a piece of it, they are as one on the desired destination – milk and honey. On the legislation, less so.

  • We have renamed The Commissioner to The Integrator. It will continue to cover integration, system working, commissioning, and primary and community care.