A Sliding Doors moment for the NHS?

Image from Sliding Doors

Sliding Doors is a film that strikes a chord with many people.

It alternates between two parallel universes based on the two paths the central character's life could take depending on whether or not she catches a train.

In chaos theory this is known as the butterfly effect, in which a small change at one place can result in large differences in a later state.

Life - as it was for Gwyneth Paltrow in the 1998 movie - is full of these "what if?" moments. The same is true for the NHS.

Take the debate about integrated care - or joined-up care as it is sometimes called. This is an unexciting word for what everyone agrees is one of the most pressing issues of our time.

As medicine has advanced and led to more life-saving treatment, an increasing amount of the NHS budget has come to be spent on long-term conditions.

Many of these are related to old age and involve managing illnesses such as diabetes, heart disease and respiratory problems.

This often requires coordinated care between the health and care sectors.

Start Quote

The current structures with local authorities, clinical commissioning groups and NHS England are so complex and fragmented that they will have to change”

End Quote Richard Humphries King's Fund

The problem is that one is free and provided by the NHS, while the other is means-tested and overseen by councils.

It means vulnerable people fall through the cracks as they are passed between the two.

'No big bang'

Both the government and Labour want this addressed.

Ministers are planning to launch the £3.8bn-a-year Better Care Fund next year off the back of 14 pilot schemes running this year looking at different ways of getting the two sectors to work together.

But that is small change - it doesn't even amount to 3% of the combined budgets for the two sectors.

This week saw the publication of the recommendations from a Labour-created independent commission led by Sir John Oldham, a GP and former Department of Health official.

Nye Bevan in 1948 Aneurin Bevan insisted local government should not be given responsibility for the NHS

But they attracted little attention, proposing even less - £10bn from the NHS over the course of the next Parliament - be set aside. Although to be fair to Sir John, he was working under tight parameters - no reorganisation and no extra money.

Yet behind the scenes all the main political parties have talked about biting the bullet and merging the budgets to ensure integrated care becomes a reality. So why has none gone further?

People from both sides of the political divide say there is simply no appetite for another major shake-up of the NHS. Or as one person put it to me: "Andrew Lansley's reforms have poisoned the well."

But this wasn't even integrated care's first Sliding Doors moment.

Prior to the creation of the NHS in 1948, three-quarters of hospital beds were run by councils.

But when Aneurin Bevan started drawing up plans for a national health service after World War Two, he decided they could not be trusted to run a system on such a grand scale. So he proposed the giant central structure that still largely exists today.

The decision prompted a series of rows with Deputy Prime Minister Herbert Morrison, but Bevan won the argument and the rest, as they say is, history.

The combination of the two moments means today the plans being put forward are arguably just tinkering around the edges.

Richard Humphries, the King's Fund's expert on integrated care, believes this is unsustainable.

"The current structures with local authorities, clinical commissioning groups and NHS England are so complex and fragmented that they will have to change," he says.

"This is the elephant in the room, but the changes will be evolutionary now. There will be no big bang."

Nick Triggle Article written by Nick Triggle Nick Triggle Health correspondent

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  • rate this

    Comment number 141.

    18.p_richard stroker
    efficiency and consumer focus it has demonstrated with the railways and energy supply

    I take it this is irony (did anyone else think so?)

  • rate this

    Comment number 140.

    Free at the point of delivery means that people don't value the care they get, don't bother to cancel unneeded appointments and use A&E inappropriately. If we had to pay a fee, recovered from mandatory insurance (not NI) then we might care a bit more and the NHS might be better funded. NB I was a health worker in Scotland from 1972 to last year.

  • rate this

    Comment number 139.

    Would it not be simpler, to shoot people dead at age 65. How else is anyone goung to make a profit. All that is needed is broad availability of very cheap pain killers, large numbers of very poorly trained doctors and nurses to expand the current rubbish and the pensions crisis is solved. A young, fit healthy population will result and taxes are no longer needed. We can do away with taxes.

  • rate this

    Comment number 138.

    Call me dave and obnoxious hunt are out to destroy the NHS so that their mates can move in and make a tidy profit for the companies that will makes these 2 wastes of space non exec directors when they get kicked out in May 2015

  • rate this

    Comment number 137.

    We need to build modern hospitals and change the footprint of Primary Care and integrate, through the same management channels, health and social care. We also need better school buildings, new social housing, newer prisons, better transport infrastructure...and many other things besides. But it costs.......

  • rate this

    Comment number 136.

    130.MaddestMax - "%14 of all tory party donations come from private healthcare companies.
    Rather alot isn't it.
    But obviously very good value for money."

    To be honest I am all but surprised it isn't more.....

    .....not good value for the tax payer though, clearly....


  • rate this

    Comment number 135.

    All the things I thought were essential to proper care of my patients, informed consent, confidentiality, openness, proper pain and anxiety control, are now, seemingly new concepts.
    And yes, though we need managers we don't need the plethora of management posts which have been burgeoning since that first reorganisation, many of which are simply makeweight jobs. Don't get me started on accountants

  • rate this

    Comment number 134.

    from the early 70's until recently. And yes, managers are required ... to ensure that the system works smoothly and efficiently for the patients (not customers) and for the staff whose job it is to ensure compassionate and effective care.
    For those who celebrate the involvement of the private sector (in an non ironic way), I can only assume that you have vested interests of your own.

  • rate this

    Comment number 133.

    ...is still employed, at enormous cost, to destabilise the organisation. Blair and his coterie of 'right pretending to be left' self servers managed to do what even Thatcher dared not. Aided by people like Nicholson and like minded 'managers', whose job it was to implement the changes we now see, the scene was set for all the vultures now circling.
    How do I know this? I served as a clinician ...

  • rate this

    Comment number 132.

    To anyone who cares to follow the doings of the politicians it should be clear that too many of them, across the spectrum, have vested interests in privatising the NHS. The rot started in the 70's with the employment of McKinsey in the first of the big reorganisations. Almost 40 years on and this company ...

  • rate this

    Comment number 131.

    If they close hospitals they need more paramedics on motorbikes and more speradic across the UK. They need a computer system like no other with a back up system encase the computers go down.

    The Government are however are closing hospitals with less paramedics and the population is higher putting too much pressure on the NHS.

  • rate this

    Comment number 130.

    %14 of all tory party donations come from private healthcare companies.
    Rather alot isn't it.
    But obviously very good value for money.

  • rate this

    Comment number 129.

    107.Lemslip - "......focus on outcomes then does it matter is the private or public sector provides"

    Let us see what happened when water, electric, phones, railways et al were privatised....

    ....erm..... costs to us up......any improvements paid for by us through our taxes........service levels down......profit for already obscenely rich individuals up......


  • rate this

    Comment number 128.

    64. Peter_Sym
    "If we pay more tax, spend 12.5% of GDP we'll get Dutch level of care."

    I wish.

    Managerial aspirations and political vanity projects will find far more "important" things to do with an extra 3.5% than actually provide (not just talk about) an integrated service.

    Ban the ability to sue for compensation, as New Zealand did. Ought to save a few bob. And a lot of nurses' time.

  • rate this

    Comment number 127.


    "Working in A&E" you think you "make no profit", but someone runs risks (career & bonus, profit & loss) from decisions made on service funding, from year-end out-turn.

    In a world of perverse incentivisation, basic inequality made worse by bonuses, liberation logic is only most reluctantly 'seen' by leaders themselves beneficiaries.

    We need all to be equal shareholders in all.

  • rate this

    Comment number 126.

    @124 All for All. Errrmm - not sure I understand your point.
    One thing I am sure off is that in the NHS, decison makers don't take account of free advice -but they do seek out and take notice off advice they pay for. Hence the huge boom in external management consultants examining every aspect of the NHS - ultimately paid for out of the public purse!!

  • rate this

    Comment number 125.

    121(c) Working in A&E I see completely the wrong end of this competitive market. There is no profit to be made in A&E so little resources go to it. "Marginal penalities" are in place (put in by Labour!) which penalise Trusts for each A&E attendance over 2008 levels - as if we have any control over this! We also have some well meaning but potentially harmful targets which can distort clinical care.

  • rate this

    Comment number 124.

    "choice of advisors"

    Sadly, ill-advice has been long embedded, four decades at least

    Maybe never the advocacy genuine of such as 'Cash Releasing Efficiency Savings', they have proved their worth essentially as hidden daggers, wielded by frontline bonus-dependent managers, deceits never to be spoken of above senior manager level, except no doubt in amused asides in the right company.

  • rate this

    Comment number 123.

    121 (cont) But sadly I fear that the present government is looking towards the USA (certainly in the choice of some of it's advisors) for advice over the future direction of the NHS.
    The competative healthcare market isn't working!!! Increasing use of the private sector risks lessening resources for those of us at the sharp end. Government -please listen to the front line of the NHS!

  • rate this

    Comment number 122.


    No harm in philosophy the pursuit. Problems in start-points, twists, turns & rests. In a society neglectful of democratic equality, curses of insecurity rule: fear, greed, corruption. From observation of almost every level & branch of the NHS: hobbled from start.

    That founding spirit - next with an economy more true - will return. Let us hope not again post-war, or too late


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