Photo: Echoes in the void from @ Rodney Campbell Flickr photo stream

The year 2022 marks the 10th anniversary of this blog. I know it does not seem like 10 years since the Liberal Democrats (remember them?) were reneging on their election pledge on university fees in David Cameron’s coalition government. We were railing against the vagaries of Lansley’s Health and Social Care Act reforms, with the dissolution of Primary Care Trusts and the looming arrival of Clinical Commissioning Groups (CCGs) . Now, 10 years later, what has changed? Lots, is the short answer, but still we find ourselves facing a piece of NHS legislation which promises profound changes to the ways in which health care services are provided in England. This blog was in part borne of a frustration with the timescale of academic publishing. Once the reasoned and considered peer reviewed papers critiquing Lansley’s reforms were published, it would be too late, the reform would already be through. The blog format presented a forum for reasoned academic debate in a much more timely fashion. The questions as to whether either approach have had any real impact upon the processes they critiqued is another question that we cannot answer here.

The newest innovation is Integrated Care Systems (ICSs), comprised of two parts; Integrated Care Boards (ICBs) and Integrated Care Partnerships (ICPs). The ICBs will take on the primary commissioning role, and will be accountable to NHS England. There will be 42 of these ICBs across England, and they will be responsible for commissioning most health services within their board area. The ICPs will bring together a wider range of partners to address braoder health, public health and social care needs to their local populations. Across the ICBs and the ICPs there will be opportunities for private healthcare providers such as UnitedHealth, as well as insurers such as Bupa, to sit on these organisations.

This has been the main thrust of the criticism of the Health and Care Bill, that it represents bonanza time for the private sector. The Chancellor Rishi Sunak was chastised for missing COVID-19 crisis meetings in mid-December 2021, as he was reported to be meeting with US healthcare interests in California. Critics argue the bill will ensure more private funding of NHS care, ICB’s will be less accountable to parliament or local authorities, and ICB’s will mark a shift from place based healthcare to membership based healthcare. This last point seems a long way from the commitment to universal coverage so embedded in the public imaginary of the NHS. Furthermore, the commitment to a comprehensive service appears under threat, as lists of funded and unfunded services (expedited on back of COVID-19 austerity) begin appear.

So again we face an assault on the principles of universal comprehensive healthcare based on need. Does this mean that Lansley’s attempts failed, that an effective rearguard action protected the NHS from the worst vagaries of the last round of reorganisation? Whilst impossible to answer in a short blog, I actually think this is asking the wrong question. I think the more interesting question is how do we keep coming here, to this point, where a right wing conservative government develops far reaching reform intended to undermine the statutory obligation on the state to provide a comprehensive healthcare service, free at the point of need? How is the issue that keeps coming back, like a zombie policy frame which refuses to die. Perhaps it is because successive conservative governments are ideologically opposed to principles and sentiments of universal healthcare. But I don’t think it is even that. I think the reason we keep ending up here, successive government after successive government, is because there is money to be made from healthcare provision. In the English context, it represents a largely untapped oasis of profit, and this is the goal of successive re-organisations and reforms.

Much has changed in those 10 years. We did not have Brexit in 2012, and universal credit was still a glint in Ian Duncan Smith’s eye. We had a welfare state that was not characterised by conditionality and sanctioning, where people on benefits were not having to work 2 and 3 zero hour contract jobs to keep food on the table and money on the meter. Where foodbanks were not yet a feature of every town and city. Austerity has had a wicked impact on these communities and people, and the current context suggests this is not going to get any better soon. I am left wondering what state we might be in another 10 years? We can but hope it is a better place than we currently are…