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Overdue questions for the NHS

Great Western Hospital, Swindon. Photo Pegasus Pics/shutterstock.com.

Change is in the air in the NHS, with its most senior managers reportedly pressing for repeal of the destructive Health and Social Care Act. And there are new calls to stop looting doctors and nurses from abroad…

In recent months those in leadership roles in the NHS have broached two big questions which have needed tackling for some time. All those involved in the service need to take part in providing the answers.

The first question dates back to the Thatcher era and the division of the NHS funds between those who “purchase care” and those who “provide care”. This is known as the purchaser/provider split or internal market. Andrew Lansley’s disastrous Health and Social Care Act 2012 made this worse by introducing further institutionalised fragmentation.

The second big question dates back even longer. Why has the NHS relied on overseas trained staff since its inception and what are the ethical and practical implications?


Professional bodies, trade unions and providers of the service have been unanimous in their rejection of Andrew Lansley’s Health and Social Care Act 2012. And no one involved can explain how it was in any way helpful in providing NHS services.

That act destroyed the strategic health authorities responsible for NHS planning. It also replaced the primary care trusts (PCTs), which had coordinated local NHS services. In their place clinical commissioning groups (CCGs) were supposed to be the vehicles for GPs to run the NHS.

But CCGs rapidly became nothing more than irrelevant shells, although the better elements have constantly sought to merge themselves into the old PCT boundaries.

The NHS is an unusual organism. It is entirely composed of workers and there is a history of its workers combining to take control of the service. It has taken some time for rejection of Lansley’s act to manifest itself. But even at its most senior levels, the service has tried to bring together those parts of the NHS that Lansley sundered.

‘Even at its most senior levels, the NHS has tried to bring together those parts that Lansley sundered.’

As local CCGs began forming federations and clusters, something similar was happening at a national level. NHS England, NHS Improvement and Health Education England are the organisations in overall control of the service in England. They have been drawing steadily closer together. There are limits on how far this integration can go without repealing the 2012 Act. Everyone is clear about that. But it looks as if the time has come to press the point.

The chief executives of NHS England and NHS Improvement are reportedly ready to push the current Secretary of State for Health and Social Care, Matt Hancock, to repeal the Health and Social Care Act. This unprecedented move would lift the legislative constraints on integration and open up new, positive opportunities.

If successful, repeal would be a momentous step. For example, existing Sustainability and Transformation Partnerships could develop fully into integrated care systems. This has already started to happen in several parts of the country.

The prospect of single NHS organisations re-emerging raises other possibilities. In 1991 Kenneth Clarke, health secretary in the Thatcher government, introduced the internal market and the purchaser-provider split that accompanied it. These measures undermined clinical responsibility and were the principal organisational mechanisms for doing away with planning in the NHS.

The Chief Executive of NHS England has already mooted that this new move could herald the end of the internal market. There is even now a long-term plan for the NHS that followed on from a five-year forward view. These are the seeds from which regrowth of the NHS becomes a possibility.

In 2008 Kenneth Clarke said on the occasion of the 60th anniversary of the NHS, “if one day subsequent generations find you cannot make commissioning work, then we have been barking up the wrong tree for the last 20 years”. He was barking up the wrong tree then, as he is now about remaining in the EU. It’s time to lay those ghosts.

The need to resolve the errors of the internal market is becoming urgent. The end point of the purchaser-provider split, amplified by differing regulations brought about by devolution, has led to ridiculous and damaging events.

On 5 April the Countess of Chester NHS Foundation Trust announced that it would no longer treat patients from Wales except for emergencies, due to a row over funding.

The hospital was built as part of the NHS to serve the people of Chester and the wider area of Deeside in Wales. One in five of its current patients lives in Wales, as do many of its staff.

Susan Gilby, the trust’s chief executive said: “This is a national issue related to the highly complex NHS internal market”. That’s true, but she could have added that the fragmentation is further exacerbated because the NHS in Wales is devolved to the Welsh government.

Cross-border protocols are in place to govern how patients who live in Wales but require treatment in England should be dealt with. But payment arrangements are not always the same between the English and Welsh systems! So the end point of the internal market is a refusal to treat patients: its end can’t come too soon.


Since its inception the NHS has had an unhealthy reliance on overseas trained staff. In June 2018, 13 per cent of hospital and community sector staff in England reported a non-British nationality. At some times the reliance on overseas staff waned, but at others– such as the early 2000s – it has increased.

More recently, the bursary for nursing students was abolished as a cost saving measure by the Treasury. The then chancellor George Osborne faced down opposition from unions and professional bodies, knowing that the NHS could more cheaply rely on other countries to pay the training costs and the NHS could continue to import nurses.

‘Since its inception the NHS has had an unhealthy reliance on overseas-trained staff.’

Questioning this reliance over the years tended to be drowned out by sweeping statements that migration is a huge benefit to the NHS. Questions about the impact on countries who were deprived of qualified staff they had trained at great expense were rarely heard in the public domain.

However, speaking at a conference in March this year, Simon Stevens, head of NHS England, said the NHS “must stop denuding low-income countries of health professionals they need”. Professor J Meirion Thomas, a cancer surgeon speaking at the same conference, put it plainly: “...there is a moral issue here. We are poaching doctors from abroad and have done for decades.”

It’s vital to address the ethical issue head on as the question is often avoided or side-lined. For example the King’s Fund, an independent health policy think tank, recently produced a report on the NHS Workforce.

This report devotes a whole chapter to international recruitment, which it advocates as a key solution to resolve NHS staffing shortages in the short term. The ethical implications get only a brief mention in the final paragraph! And there’s no recognition that addressing our short-term shortage could leave other nations with a long-term problem.

Other chapters in the report, written by different authors, focus on home grown solutions for workforce development. They document the negative impact of the removal of the nursing bursary in England. The number of placed applicants for undergraduate nursing was 4 per cent lower in 2018 than in 2016.

Progress in expanding the quicker, postgraduate training route, which leads to registration, within a two-year period has also stalled. Given that overseas recruitment often takes a year, then more investment in the post graduate route could provide a homegrown sustainable solution nearly as quickly.

We are still awaiting the first NHS workforce strategy in 25 years as Workers goes to press. But the recent King’s Fund report has shown there is a range of homegrown solutions waiting to be coordinated, implemented and funded.