The drive to merge independent NHS organisations might have potential benefits but could end up making the health service less responsive to patient needs, opine Bill Morgan, Andrew Taylor and John Bennett

Jigsaw puzzle

Few would disagree with NHS leaders when they demand that the next stage of NHS reform must address our fragmented system of care. As Simon Stevens declared at the NHS Confederation conference earlier in the year, we need to end a system which passes people from pillar to post.

But there is more potential to disagree over the means being pursued to achieve this. Because what Simon Stevens described as “the biggest national move to integrating care of any western country” runs the risk of being little more than a nationally dictated drive to merge and consolidate independent NHS organisations and GP practices.

Double edged sword

There is no guarantee that this will result in any greater degree of care coordination than now. And there is little prospect of it delivering integration between health and social care. Local authorities are creatures of statute, and can be expected to look after social care alone until a law tells them to do otherwise.

We seem to be heading down a road that leads towards 1970s era regional health authorities, divorced from social care. We can attach a US label to these and describe them as ‘Accountable Care Systems’, but apart from the label, are we really trying to do something that has not been tried before and found wanting?

In a system that can already find it difficult to put the interests of patients ahead of producers (or to be able to differentiate between the two), we are moving away from mechanisms, like patient choice, which give scope for making the health service more responsive to those who use it.

Recent moves to allow waiting times to deteriorate, or to deliberately impose minimum waiting times on patients only seem to reinforce this.

We seem to be heading down a road that leads towards 1970s era regional health authorities, divorced from social care.

Yes, there is the potential for gains from consolidation that offset these losses. The taxpayer may gain an efficiency benefit in the short term. Back offices could be merged. Management tiers could be streamlined. Purchasing power might be deployed a little more effectively.

The Treasury may sleep a little more comfortably with the illusion of more control. On the clinical side, consolidation of certain specialties has the potential to improve service delivery, particularly where clinicians are in short supply, or changes in treatment approaches place a greater emphasis on 24/7 delivery of services.

But, there is no guarantee of the greater care coordination which is ostensibly the purpose. And in the process a key right for patients – the chance of going somewhere else when they are not happy – may be denuded to the point of complete ineffectiveness.

Moreover, the challenge that the NHS continues to have in identifying, spreading and adopting innovative ways of improving care is unlikely to be helped either.

Small, nimble organisations

The NHS has to continue to have space for small organisations, and new providers, that have the nimbleness to challenge the status quo. It is in these kinds of organisations that the challenges facing today’s NHS are most likely to be met.

These organisations may frequently be the ones that are best placed to harness the power of data, to make use of wearable technologies to help the NHS target and time its interventions, and to adopt cutting edge diagnostics to make use of precision medicine.

Put simply, having different kinds of organisations will permit and encourage different people to do different things.

It is in small organisations that the challenges facing today’s NHS are most likely to be met.

And, with an ageing population, characterised by a growing burden of comorbidities, this change is sorely needed throughout the NHS – and particularly so in primary care.

It is therefore one of the tragedies of current policymaking that it is general practice which is now affected by the latest wave of mergers and consolidations.

GPs not spared

For decades, general practice has sat independently of the wider NHS. It has been able to escape most of the wilder swings in political philosophy, and much of the recent trend towards more intrusive healthcare regulation which seeks to preserve in aspic whatever model of healthcare delivery is deemed safe by today’s standards.

But now – through the alphabet soup of ACSs, ACOs, MCPs and PACSs – we are sleepwalking into a situation where GP practices are being folded, by merger and acquisition, into larger, corporate bodies either in the NHS or in private sector corporate chains.

In some cases, these new GP practice operators are swallowing up whole swathes of the country, leaving few choices for the public.

This may not be something that concerns us now, as the light of the new care model shines on the hill, but the potential for serious regret in the coming years looms large.

But maybe there is a solution. Maybe instead of bluntly ordering organisations to merge into giant regional monopolies in blind faith, we can take a pragmatic view.

Maybe we can preserve the potential for innovation by protecting the independence of standalone organisations in the NHS, unless those seeking to merge can prove that they will deliver the greater coordination of care, and benefits to patients, that they promise.

And if that sounds like a sensible principle, then wait for the punchline. It is the same principle which underpins competition law.