Lets Rethink HealthCare: Another Broken Promise.

Ok so I ended the last post saying I wasn’t going to do this –

But I then got interested in investigating a few possibilities – so here we are.

WHAT A STABLE, MODERN, NON-FRAGMENTED NHS SHOULD LOOK LIKE FOR THE NEXT 30 YEARS

For 75 years, the NHS has never been given the one thing every high-performing health system relies on: structural stability.

Systems like those in France, Denmark, Canada, Sweden and the Netherlands have reformed slowly, predictably, and purposefully.

England has reformed dramatically, repeatedly, and often pointlessly. As the old Roman saying goes, “The only constant is change.” But in the NHS, change has become a substitute for improvement.

If we want the NHS to thrive over the next 30 years, we need to stop reorganising and start designing.

Here is what a stable, modern NHS would look like.

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1. A Clear, Simple, Regional Structure — and No More Rewrites

The UK should adopt a governance structure that remains in place for at least a generation — 20 to 30 years.

It should have:

📌 One national service standard

Clear entitlements.
Clear performance expectations.
Clear accountability.

📌 Around 30–35 regional authorities

Not 42 ICSs one year, 100 PCTs five years earlier, 28 SHAs before that, or 300+ GP groups as “commissioners.”

France has 17 regions.
Denmark has 5.
Sweden has 21.

Thirty for England is reasonable and would replace the Cycle of

These Regional Care Authorities (RCAs) should:

This mirrors the most successful elements of the French, Danish and Swedish models, where regional planning, not perpetual reorganisation, underpins success.

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2. End the Purchaser–Provider Split — Replace It with Planning + Accountability

Competition hasn’t worked because it cannot work under NHS constraints. Markets only function when mobility and choice exist. Healthcare is neither mobile nor choice-rich, and competition is structurally impossible for trauma, cancer, maternity, or emergency care.

Instead, we should:

• abolish internal contracting
• fund RCAs by population need
• fund providers directly through multi-year budgets
• hold them accountable through outcomes and transparency, not internal invoices

📌 Population-based planning

Each RCA receives a budget based on weighted population need.
No market fiction.
No billing flows.
No “internal contracts.”

📌 Direct funding to provider networks

Hospitals, primary care, community and mental health services form provider collaboratives, funded directly by RCAs.

📌 Accountability via transparent metrics

France’s mobility, Sweden’s transparency, Denmark’s political accountability — combined.

Outcomes should drive change, not theoretical market forces. This restores the logic that exists in every high-performing public health system: plan services around population needs, not theoretical market signals.

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3. Integrate Primary Care Into the NHS: sort off reverse Bevan’s Compromise.

GPs must remain independent to a degree — that autonomy is valuable, especially in clinical matters.

But the current model cannot support long-term integrated care.

A modern system should:

📌 Bring GP practices into regional NHS networks

GPs would remain contracted professionals — not salaried civil servants — but part of integrated care teams.

📌 Consolidate practices into larger Primary Care Groups (PCGs)

This follows the New Zealand, Dutch and Danish model:
larger practices = more resilience, extended hours, better diagnostics, more prevention and team based care.

📌 End single-handed GP business risk

If a GP practice collapses financially, patients suffer.

This should never depend on the commercial viability, or management style, or possibly asset stripping of a small partnership.

We need a 21st-century model, not a 1948 compromise.

📌 Build shared digital tools and common clinical pathways

A prerequisite for 21st-century care.

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4. Invest Properly in Capacity — Hospitals, GPs, Community, Digital

What the NHS Needs After 30 Years of Underinvestment

“Efficiency” alone won’t fix a system starved of capital and workforce.

A realistic 5-year investment programme requires:

Area	Estimated Investment
Hospital capital backlog	£10–12 billion
Digital infrastructure upgrade	£5–7 billion
Primary care expansion & estate modernisation	£3–4 billion
Mental health parity uplift	£2–3 billion
Public health & prevention restoration	£2–3 billion
Community & social care integration	£2 billion

Total: £22–27 billion (one-off investment over 5 years)

This is not “Nordic luxury money.”
This is the minimum required to stop multi-generational decline.

Let me repeat that:-

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5. Where the Money Really Went — the True Cost of Perpetual Reform

When people hear that the NHS has “wasted £50–70 billion on structural churn,” it is natural to ask:

Where did that money actually go?
Who benefited?

The answer is clear — and well-documented by the NAO, Public Accounts Committee, and academic research:

Most of the money spent on NHS restructuring went to management consultancies, accountancy firms, legal advisers, interim executives, IT contractors, and duplicated administrative bodies — not patient care.

Across the 1990s, 2000s and 2010s, waves of structural reform consumed tens of billions through:

🔹 Management consultancies

McKinsey, KPMG, Deloitte, PwC, Accenture, Boston Consulting Group — hired for:

🔹 Accountancy & audit firms

Paid to:

🔹 Legal firms

Handling:

🔹 IT and systems contractors

Every restructuring required new:

Often replacing systems built only a few years earlier.

🔹 Interim managers and turnaround specialists

Paid at £800–£1,600 per day to steady organisations destabilised by the reforms themselves.

🔹 Redundancy and re-employment cycles

The 2012 reforms alone cost £600m in redundancy payments, many of whom were rehired into equivalent roles.

Put simply:

The NHS did not lack money.

The money existed — it was burned by the engine of reform.

And the beneficiaries were not patients or clinicians, but the consultancy and professional-services industries that thrive whenever the NHS is broken apart and stitched back together again.

Had the NHS simply avoided this cycle of dismantling and rebuilding, England could have easily afforded the £22–27 billion needed to modernise its hospitals, digital systems, primary care, and prevention infrastructure.

Twice over. Yep Twice Over

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6. Prevention Must Move From Slogan to System Logic

Successful health systems shift spending upstream — preventing illness rather than only treating it.

A stable NHS should:

The UK spends among the lowest in the OECD on prevention.
This is both costly and irrational.

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7. End the Political Pendulum — Electoral Reform as Health Policy

The NHS cannot be structurally stable while the political system rewards instability.

Under First Past the Post:

• each government can rewrite the NHS with 40% of the vote
• reforms reflect ministerial branding, not system need
• every change lasts only until the next government
• no party has incentive to defend a predecessor’s reforms
• churn becomes structural

By contrast, proportional democracies (Denmark, Sweden, Netherlands):

• require consensus to enact major reforms
• produce stable health architecture
• avoid radical oscillations
• allow long-term planning
• embed system ownership across parties

You cannot build a stable NHS on an unstable constitutional foundation.

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8. What the Next 30 Years Should Look Like

A modernised NHS doesn’t need reinvention.

It needs consistency.

📌 One long-lasting governance structure

Regional authorities with statutory stability.

📌 Integrated care pathways, not markets

Abolish the purchaser–provider split.

📌 £22–27b capital investment

Paid for twice over by avoiding structural churn.

📌 Primary care modernisation

Stronger groups, digital integration, extended care teams.

📌 Prevention as a system pillar

Not a budget line to be raided.

📌 Cross-party protection

A constitutional guarantee that the NHS cannot be restructured at ministerial whim.

Conclusion

The NHS does not need more dramatic reform.
It needs long-term engineering, not short-term renovation.

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