of ministers and NHS leaders. It took quite a while to work out what was happening. The parallel with today is the result of the Five Year Forward View. By stating, virtually for the first time in the history of the NHS, that the structural arrangements no longer have to be the same everywhere, a clutch of different ways of doing things—the new models of care—are being tried and permitted. From apparently total devolution of the health and care budget in Manchester and Cornwall; to GPs and the hospital in Northumbria seeking to turn the latter into an accountable care organisation; to multispeciality community providers in Kent and Birmingham; to other ways of trying to bring the primary and acute systems together elsewhere. In other words, the really interesting stuff, the work that may shape the way the NHS functions in future, is out there on the ground. In 1991, the centre was distinctly nervous about how the new freedoms would be used, and in some cases— notably London—rapidly pulled the new freedoms back for fear of the effect they would have. This time round the various bits of the centre that Lansley’s legislation created, are struggling to work out just how far they can— statutorily or otherwise—let go to let the new models of care emerge. And there, probably, the parallel ends. One huge difference is that in 1991 the reforms were lubricated by cash to make sure the purchaserprovider split did not crash and burn on day one. This time around, providers are projecting big deficits and a mere £200 million has been allocated so far to a transformation fund to help the innovators get there. Huge amounts depend on the outcome of the spending review now underway—how much at what speed does the NHS get? How much does social care? Will the double counting of shifting NHS cash into the Better Care Fund continue? Or, despite the political commitment to eliminating the deficit primarily through spending cuts, will there be sufficient cash to allow a tolerable settlement for each? Do these new models of care signal— if not necessarily the complete end of the purchaser-provider split—a pretty radical reshaping of it, as Sir David Nicholson suggested in his formal lecture for NHS Providers last month? The answer to that lies in the diversity being attempted locally, as well as in the decisions that will be made centrally over the coming months. BJHCM Nick Timmins, senior fellow at the Institute for Government and the King’s Fund, compares the NHS reforms of 1991 to those ongoing today The NHS in 1991: Parallels with today
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