Lets Rethink HealthCare: Reforms, Fragmentation and a Paradox.

So to be totally honest – before, during and after university I worked for several NHS organisations. I worked for 24 Months at one on a one month contract, eventually getting a permanent role.

Eventually I left direct employ with the NHS and went to forge a career in the private sector – starting with the Leisure and Recreational sector (Ok Pubs and Hotels), via Telecommunications, Food Services, Financial Services, Online Retail, I was even a Civil Servant at a Government Regulator, IT services before setting myself up as an independent business providing Business Services.

I have since then, as a Business Owner and Director provided services for RCN, several business’s that provide services to the NHS, Several Government Departments, A couple of Oversea Governments, and even a Mental Health Trust, amongst others.

So I may not be totally unbiased with regards to the NHS, but I wished to be open up front.

Ok onto my look at the NHS.

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HOW WE GOT HERE

There’s a line often attributed to the Roman army:
“The only constant is change.”

If that doesn’t describe the NHS, nothing does.

And during the 1990s, when yet another restructure rolled in, someone in a Birmingham hospital taped a follow-up note to the management accounts department wall: (this was in a time before email – yes ask your historians there was such a time)

“Due to further cuts, the light at the end of the tunnel has been switched off.”

Dark humour, yes — but also a quiet acknowledgement that the NHS experiences more structural churn than almost any other health system on earth.

To understand why the NHS looks the way it does today, and why Birmingham is a perfect case study, we have to go back to the beginning of the internal market era.

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1. Before the Upheaval: Regional Stability in the West Midlands

Through the 1970s and 1980s, the NHS in the West Midlands operated under a structure that, while imperfect, was recognisable and coherent.

At the top sat the West Midlands Regional Health Authority (WMRHA).
Below it were the District Health Authorities (DHAs):

• North Birmingham
• East Birmingham
• South Birmingham
• West Birmingham
• Central Birmingham
• (and neighbouring DHAs such as Sandwell, Solihull, Wolverhampton, Walsall, Coventry)

Strong regional planning allowed:

• coordinated specialist services
• sensible distribution of hospital functions
• economies of scale
• system-wide workforce planning

It wasn’t glamorous, but it worked.

Then came the redesign that changed everything.

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2. Bevan’s Original Compromise — and the Hidden Fault Line It Created

One crucial misunderstanding in Britain is the belief that GPs are “part of the NHS workforce.”

They aren’t.

When Aneurin Bevan created the NHS in 1948, he faced a revolt from doctors. His compromise guaranteed that:

• GPs remain private independent contractors, not NHS employees
• Consultants retain private practice rights, even while working in NHS hospitals

This bargain allowed the NHS to be born — but it also baked in a structural divide between:

• a publicly funded system
• and privately owned primary care businesses

It rarely caused problems in the early decades…

…but when the internal market arrived in the 1990s, it became a defining constraint.

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3. The Early 1990s: Enter the Internal Market

The 1990 NHS and Community Care Act split the health system into:

• Purchasers: GP fundholding groups and district authorities
• Providers: newly created NHS Trusts

This was meant to introduce competition.

Trusts gained boards, chief executives, financial reporting obligations, and autonomy.
Commissioners “purchased” services through contracts.

On paper it resembled a market.

In practice, it was a market with none of the preconditions for competition.

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4. Why the NHS Couldn’t Behave Like a Market

Economics tells us that competition needs:

1. Choice
2. Mobility

Without both, you don’t have a functioning market — you have a paperwork-intensive simulation of a market.

The NHS had neither:

• Patients rarely have meaningful choice for A&E, maternity, cancer care, strokes, major surgery
• Geography and safety determine hospital use
• Specialist services are natural monopolies
• GPs (private businesses) could not redirect demand freely
• Trusts could not enter or exit the market

The purchaser–provider split therefore created a market veneer, while the underlying structure remained immobile.

Birmingham experienced this more clearly than most.

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5. Birmingham: Fragmentation Followed by… Reassembly

In Birmingham, DHAs became Trusts. South Birmingham carried heavy deficits, scrutinised in Parliament. Market testing took hold across non-clinical departments. Instability became ambient.

But then something interesting happened.

Over the next two decades:

• Trusts merged
• Specialist services centralised
• University Hospitals Birmingham (UHB) became the dominant regional provider
• The 2018 merger with Heart of England NHS Foundation Trust reassembled much of the original regional configuration

By the 2020s, the NHS introduced Integrated Care Systems (ICSs) — effectively Regional Health Authorities 2.0, but renamed.

After 30 years of fragmentation, Birmingham returned to something close to its starting point — only more expensive.

Rome would call this a “reform cycle.”

In England, we call it Tuesday.

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6. Why Part I Matters

Part I isn’t about blame.
It’s about recognising that the NHS didn’t fail to reform.
If anything, it reformed too much, too often, in too many directions.

To understand why the internal market didn’t work — and why Birmingham ended up where it began — we need to examine the economics and incentives behind the system.

That is where Part II takes us.

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