inally, here comes the confession from the Conservatives that they have done monumental damage to the NHS. The great upheaval created by Andrew Lansley in 2012, with the support of the Liberal Democrats, blew the NHS into fragments, each compelled to compete and submit to private tender to “any willing provider”. The Health and Social Care Act’s anti-NHS ideology, trying to create an artificial “market”, was “big enough to be seen from space” said the NHS chief executive at the time. Now, a white paper expected shortly and leaked to the Health Policy Insight website last Friday sweeps away this whole misbegotten disaster. Will there be a government apology for the torment the NHS was put through, with thousands forced to reapply for their jobs, or for the estimated £3bn wasted in this bureaucratic upheaval? Probably not. Lessons learned have been made luminously clear during the pandemic: the NHS only works by cooperating. The 2012 act’s duty to compete is now replaced with a legal “duty to collaborate”; payment by results is abolished. Competition theology perversely prevented NHS hospitals working together: Poole and Bournemouth hospitals wanted to share services, but the Competition Commission barred this as anti-competitive. Blackpool commissioners were shocked to be referred to the NHS competition police, Monitor, for failing to refer NHS patients to the Spire private hospital. A year after the act was passed, the departing NHS chief executive, David Nicholson, warned: “We are bogged down in a morass of competition law … We have competition lawyers all over the place telling us what to do.” That year hospitals spent £1.67m on these lawyers. From the day Simon Stevens arrived to take over NHS England in 2014, he set about silently undoing the damage. And now, in place of competition, the country will be covered by 42 (clunkily named) integrated care systems – pulling together hospital, local authority, social care, voluntary, community and GP services. The hope is that pooling community efforts will prevent acute hospital episodes. Repealing the 2012 act means overriding any local recalcitrants, such as Leeds clinical commissioning group, which refused to merge with others. Now all of the original 211 CCGs will be abolished. Repealing the act stops the likes of Virgin Care suing when a juicy NHS service is not tendered out. Pause here to relish how the act failed to create a private health bonanza. Despite management consultant McKinsey’s excited prediction back then that the private sector would swell to £200bn by 2030, the Health Service Journal estimates that only around 9% of NHS spending is private. Companies did pluck some community plums but the only attempt to take over an acute hospital ended in ignominy when Circle handed back Hinchingbrooke hospital after just three years. Inspectors had marked it as “inadequate”. The private sector made so few inroads because austerity funding made profiting from the NHS like squeezing cash from a stone: during this era the NHS suffered unprecedented per capita funding cuts. The gaping hole in this white paper is the absent plan for social care, despite the pandemic’s brutal exposure of this sector. Boris Johnson’s pretence on his first day in Downing Street that he would “fix the crisis in social care once and for all … with a clear plan we have prepared” has yielded nothing. Like his two predecessors, he seems to be finding any solution too politically toxic. But no combined NHS and care service can be seamless when people are treated free in the NHS but means-tested for social care. Richard Murray, head of the King’s Fund health thinktank, says: “The answer is to follow Scotland, and make all personal care free.” Don’t expect that in this white paper. Alarm signals are flashing at the plan for Matt Hancock to seize Henry VIII powers over the English NHS, freeing the health secretary to follow political foibles and to favour cronies. The Labour shadow minister Rachel Reeves this week lists £2bn in Covid contracts handed to Conservative-linked firms. It’s a bad time for politicians to seize power from the NHS, when ministers’ decisions on late lockdowns and failing private test-and-trace have contrasted so badly with the NHS at its best, coping with 30,000 extra patients and rolling out vaccines at high speed. Labour will have we-told-you-so satisfaction at this very public collapse of the Tory-Lib Dem coalition’s attempt to marketise the NHS. The opposition will highlight awkward new problems, such as how “independent” foundation trusts – with their own boards and publicly elected governors – fall under the authority of their local integrated care system, with its own statutory board? Who selects the ICS leader? Yet the shadow health secretary, Jonathan Ashworth, will mainly focus on outcomes and on the abysmal state of the NHS: even before Covid struck, there were more than 4 million people on waiting lists, up from a relatively tiny number in 2010 under Labour. Austerity cuts to doctor and nurse training, with the abolition of nursing bursaries, led to nearly 100,000 clinical vacancies, cancer targets missed, public health stripped bare. A service left defenceless against a pandemic needs massive repair. Why legislate now, mid-crisis? The good reason for repealing a bad act is to seal into the new structure all the best Covid collaborations, devised in an emergency as people swapped roles and worked across boundaries outside rigid professional silos. The urgent need is to retain and grow an exhausted workforce with better conditions and long-term careers. Chris Ham, co-chair of the NHS Assembly that draws together NHS, voluntary and local council leaders, says what’s needed is “concerted action on health inequalities”. He points to Michael Marmot’s Build Back Fairer report and says “Sure Start revival, a real living wage and full employment” would affect health most. However, he fears “the will is not there” for this kind of levelling up. Without it the NHS, however structured, is destined forever to sweep up after social failure.