NHS: Does it make sense to slim down the health service?

Would a reorganisation of the NHS in Scotland deliver better value for money for taxpayers and improved outcomes for patients?

The idea of "cutting bureaucracy" in the health service is a recurring theme which has been resurrected once again by Scottish Labour proposals to cut the number of territorial health boards from 14 to three.

The party's deputy spokesman for mental health, Paul Sweeney, told the BBC that the current system is "way too cluttered" for a population of 5.5 million people with "way too much duplication".

How did we get here?

The current system was shaped by devolution. Previously, the NHS was run by an even more complicated structure of 43 separate boards and trusts.

In 2001, the 'Rebuilding Our National Health Service' plan promised – among other things – to "streamline bureaucracy" and foster "greater collaboration" by replacing this with 15 territorial health boards (the 15th – Argyll and Clyde – was later broken up, with the Clyde part absorbed by NHS Glasgow and NHS Highland taking on responsibility for Argyll and Bute).

In 2004, NHS trusts were finally dissolved as Scotland diverged from England by removing the so-called "internal market" in the NHS, first introduced in 1990. England retains this system whereby trusts can compete for financial rewards by meeting specific targets, such as cutting waiting times, but it has been repeatedly criticised for increasing administration costs.

'Radical surgery'

Scottish Labour is not the first to suggest that NHS Scotland could cope with fewer health boards.

In April 2018, former SNP health secretary Alex Neil set out his own blueprint for a slimmed-down NHS Scotland. He proposed scrapping all 14 territorial boards plus the Golden Jubilee National Waiting Times Centre as a standalone special health board, and replacing them with three north, east, and west super-boards.

"It’s time for radical surgery on the bureaucracy," he said at the time, adding that there were "far too many layers of management".

Once organisations such as NHS 24 and the Scottish Ambulance Service are included, Scotland currently has 22 health boards in total plus 31 integrated joint boards (IJBs) linking councils with territorial health boards to provide social care.

Former SNP health secretary Alex Neil said in 2018 that the NHS had 'far too many layers of management' (Image: Newsquest)

Bloated bureaucracy?

There is certainly an argument to be made that Scotland's health and social care structures could be simplified. Maree Todd, minister for social care, said that an amalgamation of boards is an idea "being bounced around".  

Reducing the overall number of chief executives and directors on six-figure salaries might seem like common sense, but there is a counter-argument that the NHS is actually under-managed overall.

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A recent study reported by the King's Fund think tank found that managers made up just 2% of the NHS workforce compared to 9.5% of the overall UK workforce. In the UK, just 1.9% of health spending goes into administration costs compared to 8.9% in the United States and 5.5% in France, which both operate under more cumbersome insurance-based systems.

There is also a risk that the upheaval involved in re-organisation can end up costing more than it achieves in savings.

Other reforms – such as updating the formulae used to allocate funding to health boards – might be a quicker and easier fix to ease postcode lotteries in waiting lists and treatments.

Likewise, more accurate patient record-sharing between GP surgeries and hospitals – a long-running bugbear – would remain unresolved by merging health boards, and might do more to improve efficiency and outcomes. 

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Additionally, when it comes to management, accountability is probably as big a priority for patients as value for money. The case of the serial killer nurse, Lucy Letby, highlighted the ways in which failing NHS managers can escape the kind of scrutiny and sanctions meted out to doctors, nurses, and other healthcare professionals. This has led to calls for managers to be subject to their own regulator with the goal of improving patient safety and NHS culture.

Simply cutting the number of health boards without more fundamental changes risks becoming a facelift rather than the "radical surgery" intended.