Views And Reviews Acute Perspective

David Oliver: Local shouldn’t be a dirty word

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.j5918 (Published 09 January 2018) Cite this as: BMJ 2018;360:j5918

As the NHS approaches its 70th birthday, politicians’ desire for central control is as strong as ever. With NHS funding at around 9% of GDP1 and over a million state employees on the service’s payroll,2 Whitehall’s craving for “grip” on the NHS seems undiminished.

The risk of services failing to deliver on political imperatives—financial balance and cost improvement programmes, waiting time and access targets, patient safety, dignified essential care—is a high stakes game. Public confidence and satisfaction with local services may suffer, local executives may pay the price, the press could have a field day, and politicians risk damage at the ballot box and the court of public opinion.

Before the 2010 general election and Andrew Lansley’s 2012 Health and Social Care Act, which on paper devolved responsibility for the NHS to the “arm’s length” NHS Commissioning Board (now NHS England),3 the NHS had a very strong culture of performance management and top-down pressure. Accountability ran from the health secretary and NHS chief executive—both then in the Department of Health—through strategic health authorities to primary care trusts and the national regulatory bodies overseeing performance. These structures were swept away, and our current landscape of NHS bodies seems almost designed to confuse.

Campaigners against Lansley’s legislation want to see the statutory duty of the secretary of state to provide a universal health service restored in law, as well as a reversal of the potentially fragmenting “any qualified provider” policy.

More recently we’ve seen concerted protests about NHS England’s creation (with no primary legislation or consultation, no formal structures or accountabilities) of sustainability and transformation partnerships (STPs) and accountable care systems and organisations: for a coruscating account of those concerns I commend Allyson Pollock’s recent BMJ Opinion piece,4 with the King’s Fund’s Chris Ham for counterbalance.5 Suspicion is rife about the recent emphasis on population health, value, and variation, which have been characterised along with STPs as vehicles for further cuts in funding and services.

Yet, despite the abolition of pre-2012 structures and responsibilities, there’s still no shortage of “command and control” and “targets and terror” in a system still determined to exert grip. Examples include financial control totals,6 an ongoing focus on waiting time targets,7 and, especially, the current push towards planning for winter resilience in emergency care. NHS England and NHS Improvement have been very direct about what each hospital and health economy should set out in local plans; what action should be taken to reduce delayed transfers of care; what service components and standards should be in place.8 The Care Quality Commission’s chief inspector for hospitals reinforced this approach recently with a very directive approach.9

We’ve also seen numerous examples of the current health secretary, Jeremy Hunt, wading right into operational decisions about NHS priorities from his eyrie in Whitehall, either through his mandate to the NHS or by his personal actions.

The actions of local teams in their local environments are most effective in improving services. The fragmentation and complexity of different organisations with different accountabilities can lead to poorly coordinated care. Surely, more collaboration and boundary blurring between agencies, as well as a greater focus on maximising population health and value from each pound spent, is a good thing? As is an understanding that some challenges and solutions may be very specific to the type of population served—such as rural or coastal versus urban.

It’s right for an overall performance and funding framework and better workforce planning and training to be coordinated from the centre, along with some lighter touch regulation and assurance. But surely we want more localism, not less? We must challenge the polarisation of “central good, local bad.”

We must challenge the polarisation of “central good, local bad”

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