Where does the power lie in the new NHS reforms?

Anna Reilly, Kacey Cogle and Ben Jones

Patients, providers, pharma: where does the power lie in the new NHS reforms?

In the days since it was published, the MHP Health team have been considering what the NHS White Paper really means for patients, for providers, and for pharma. Anna Reilly, Kacey Cogle and Ben Jones dive a little deeper into the reforms.

Collaboration, partnership, and integration have all been NHS buzzwords for a number of years now, so it’s fitting that the NHS White Paper recommends that these ways of working are now made into law. Across the board, the White Paper has been broadly welcomed with support from government backbenchers, industry experts, while Labour, who were critical of the White Paper’s timing said they would interrogate the detail before passing judgement. However, while the White Paper shaves the edges off the 2012 Lansley Reforms, it’s not a silver bullet and many questions and challenges remain. Requests for further clarity are set against a backdrop of challenges: COVID-19 and the recovery period; an exhausted workforce; and the dependence on this workforce to make collaboration work. We take a look at what these changes mean for patients, providers and the pharmaceutical industry.


For patients, this White Paper represents a legal solidification of collaboration and devolved decision making. At the very heart of a successful Integrated Care System (ICS) is the understanding of the needs of a local population and how best to serve those needs. ICSs are designed not only to provide healthcare, but also to provide other services within a community that robustly support the local health economy and indirectly enhance day-to-day health, by improving local skills and employment, or by ensuring high quality housing. For patients, ICSs are touted as the holy grail of healthy communities.

Further, these changes acknowledge the importance of the patient voice in the development of care for the community. As highlighted by Healthwatch, this White Paper is a “real chance to strengthen and assess patient voice at place and system levels, not just as a commentary on services but as a source of genuine co-production”. However, no detail about how the patient voice will be championed has been provided. Without such detail, this seems like just a tip of the hat but nothing more. Patients and their representative groups are still very much at the mercy of an invitation to engage, an invitation which often comes too late.


Without a statutory footing, an ICS is simply an informal partnership of senior executives of local organisations, including providers, local government, primary care networks, and others. This presents some risk for those involved, as accountability for decisions made by the ICS would sit with the governance structures of those constituent organisations, not the ICS itself. This means that the partners of the ICS would have had a greater sway over how the decisions were made, given they would have ultimately borne the risk for them.

With a statutory footing, as proposed by the White Paper, an ICS will be accountable for its own decisions, which is entirely appropriate and long overdue. However, this now puts the partners at a level footing and brings the role of the independent Chair into greater focus. Each partner will have their own drum to beat (social care from local authorities, the resourcing of primary care from PCNs, funding and workforce from secondary providers, and so on). These drums will reach a crescendo if we then overlay the relationships and history between partners and with the community, their populations, geography, budgets and turnover. Partners can make their case in the ICS Partnership Board Meetings, which do not have to meet in public, but ultimately the ICS is the decision maker. Trusts and Foundation Trusts may no longer be the big kids in the playground who call the shots.

What then, of the power of the Health Secretary to have the power to intervene in traditionally local decisions, such as service reconfiguration? As outlined by the King’s Fund, one of the great successes of the 2012 reforms was the independence of NHS England, so while it is right to clarify who is accountable, it is contrary for the government to be able to intervene when it deems appropriate. If the Health Secretary can intervene directly, what is the purpose of the eight regional directors that straddle national and regional priorities?

Pharmaceutical industry

It’s clear that the spirit of these reforms is about giving local organisations the power to make local decisions based on the needs of their local populations, even if the detail isn’t yet clear. There has been a shift in the goals of ‘integrated care’ which, up until recently, overlooked the strategy behind how medicines can be used in relation to population health management. The new reforms may encourage local NHS leadership to be truly mindful of the broader needs of the population covered by the ICS, rather than displaying a loyalty to their own organisation.

To get a seat at the table, industry will need to move away from a product-centric view and embrace this broader, population and outcomes-based system. Willingness to share data with NHS decision makers, and an openness to work in partnerships, while managing the perhaps competing priorities of the different players within those partnerships, will be key to influencing within this new structure.

The changes in the White Paper are, as Nigel Edwards, Chief Executive of the Nuffield Trust, noted, ‘a re-wiring behind the dashboard’, with the Government itself saying that this is not a comprehensive set of reforms. While there are some notable things to be aware of, especially about how decisions are made and by whom, we may not see a drastic impact on the day to day running of the NHS. When it comes to who really has power under these new reforms, it may not be patients, providers, or the pharmaceutical industry at all. The new ability for the Health Secretary to intervene directly in local decision making and to dissolve arms lengths bodies at any point, will undoubtedly undermine the independence of the NHS with no clear rationale apart from the whims of politicians. As ever, they will be the ones who hold the power.