Plans for “academies-style” reform of the NHS set up prospect of effectively private control of state-funded hospitals

Plans, reported today, for an “academy-style” model for the National Health Service would appear to pave the way for what would effectively be private control of state-funded hospitals.

Under proposals reported as being designed to “improve patchy NHS leadership” – by a government which its many critics will say has leadership problems of its own – the academies model is being billed as a solution to NHS problems including “post-pandemic waiting lists”.

The Times reported that Sajid Javid, the health secretary, is “formulating the reorganisation to give well-run hospitals more freedom as well as forcing failing trusts to improve”. This description certainly fits with the way the academies policy is billed by ministers as operating.

The piece added: “A new class of ‘reform trust’ will be established as Javid signals an appetite for wide-ranging changes to deal with a ‘huge’ variation in performance across the health service.

“Modelling reforms on the Blairite academies programme could lead to failing hospitals being forcibly turned into reform trusts, as happens with schools that are rated inadequate. It is possible that chains of hospitals will be run by leading NHS managers, or even outside sponsors, although this is yet to be decided.”

Handing such influence to “outside sponsors” sets up an obvious echo of the academies scheme, which would lead to effective control going to such “sponsors”, without any local democratic accountability.

Top-down control inherent in academy “sponsorship”

The academies model has seen individual “sponsors”, who have included political donors – all of the most prominent of which have been male, and most of whom have been Conservative Party donors – handed more or less complete control of multi-academy trusts through their governance.

The most well-known example of this, having been revealed by Education Uncovered, is the Harris Federation, England’s second-largest multi-academy trust, where its title “sponsor”, the Tory peer and donor Lord Harris of Peckham, controls its governance as “principal sponsor” – a position that family members will inherit when he dies.  

More broadly, in a model which dates to the origins of the academies scheme under New Labour, sponsors have been given the right to appoint and dismiss the majority of a trust’s board. The power of the “sponsor” then, over the setting of schools’ improvement strategy through their governance is more or less absolute.

This is, then, effectively private control, subject only to distant regulation by the Department for Education, but with no formal answerability or accountability to local communities.

I wrote a piece on the control of “sponsors” over academy trusts for the website OpenDemocracy, while also investigating this issue on Education Uncovered, for example with pieces here and here.

Concerns over over-centralisation of power within academy trusts, because of the control a few people and/or organisations can be given as trust “members” continues to be an ongoing theme of reporting on here, most recently in last week’s piece on the Hare Krishna-influenced Avanti Schools Trust.

I am no expert on governance within the NHS. However, one person familiar with both academies and NHS Foundation Trusts, Peter Lacey, has written that the NHS trust model is almost the opposite of that seen in multi-academy trusts, with a much more public form of control possible.

The NHS Foundation Trust model of governance “is almost the inside-out version of that seen in MATs [multi-academy trusts]. Critically, instead of a small number of self-appointed members, any eligible member of the public may apply to be a member of the NHSFT [the trust] – and thousands do,” he wrote.

Beyond this, there seems to be incoherence even within the Times piece itself.

It sums up the proposals as “plans to give hospitals more autonomy”. And yet it is hard to see how “forcing failing trusts to improve” translates to autonomy for such institutions: it seems more like increased government intervention. If the plan as a whole is really about improving “patchy NHS leadership,” then again that seems more about more control from government, rather than allowing more freedom to providers.

Even with respect to giving “well-run hospitals more freedom”, in the academies sector the reforms have not let to increased autonomy for individual schools, but rather for the overarching trust running them. This can then closely control what happens in each institution with the trust itself being, as argued above, able to be subject to effectively private control.

Another paradox, unlikely to be lost on those working in the publicly-funded education and health sectors, is that Javid is billed as considering such plans to deal with “uneven” leadership of NHS trusts, or “underperformance,” at a time when the government which would be implementing it is beset by a crisis centring on complaints that it is being extremely poorly led.

There is no sense in the report that the academies policy, while perhaps embraced by policymakers as a successful – and cross-party – example of public sector reform, continues to generate a lot of controversy, both in the terms of the national debate and at individual school level. Is the quasi-private model of control at its heart the right one for a major public service? Coverage and debate seems to skate over such fundamental questions.

The piece raises obvious thoughts that such ideas are being put forward as a distraction from the Prime Minister’s current problems over lockdown-era “parties” at Downing Street, as the report itself acknowledges, with the apparent move to cut NHS waiting times “part of an ‘operation red meat’ designed to shift the focus from rows over Downing Street parties”.

The piece adds, however, that the “academy hospital” plan was in the pipeline before Johnson’s current crisis began. “Allies* of Javid say, however, that his desire for reform long predates the prime minister’s current problems and that as the Omicron wave recedes he has a ‘six-month window’ to introduce changes before planning for next winter takes over.”

So, then, the plans were in the offing but have been brought forward for presentation – albeit with heavy usage in this piece of the conditional tense – because of the parties scandal, with a short deadline to bring in what would be yet more fundamental reform to an institution of central national importance.

Close observers might suggest this as a case study in how English policymaking, and the entire politico-media relationship in this country – is so rotten.

*Does anyone in the real world, outside of Westminster/Whitehall journalism attributing it to anonymous political sources, use this word in relation to politics?