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NHS decisions should start ‘at the most local level possible’


By Jess Hacker
24 February 2022

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Bureaucratic central leadership could threaten NHS reforms, a report has suggested, arguing that decision-making in the NHS should instead start ‘at the most local level possible’.

Commissioned by the NHS Confederation, the report said the Government must address ‘excess bureaucracy’ or risk undermining its Health and Care Bill, currently passing through the House of Lords.

Professor Sir Chris Ham, co-chair of the NHS Assembly and author of the report, warned of a conflict between efforts to devolve decision-making and ‘the reality of central controls’, claiming this clash has ‘become a recurring feature’ of NHS reform.

In particular, Integrated Care Systems (ICSs) – which are to be granted statutory footing via the Bill – could struggle to improve patient outcomes, if central control is not addressed, it indicated.

This should start with the premise that NHS decision-making should begin ‘in teams and neighbourhoods followed by places, systems and the centre’, it said.

Meanwhile, the DHSC and NHS England require ‘closer alignment’, operating as equal partners in governance, it suggested.

Organisational separation between the two has, until now, led to ‘duplication and second guessing’ and ‘wasteful’ activity.

These ‘underlying tensions at the centre’ were exposed during the recent ‘public spat’ between the two over whether using private hospitals to tackle the NHS backlog was considered ‘value for money’.

A future operating model should make explicit the individual and distinct roles of the DHSC and NHSE when it comes to developing strategy and overseeing NHS performance, it said.

ICSs should be accountable for national and local priorities

Regional offices should become ‘thinner’, with the number of staff ‘reduced substantially’, as ICSs take on more responsibilities, it suggested.

More consideration needs to be given to their relationship with ICSs, and should be approached as ‘equal partners’ rather than falling into the established ‘NHS hierarchy’.

To this end, work is currently underway to devolve responsibility for specialised services commissioning from regional offices to ICSs, it noted.

It said: ‘The role of regions should be reviewed when ICSs have demonstrated their capabilities as system leaders, to avoid creating unnecessary complexity and bureaucracy.’

A major challenge in acting on these proposals is the ‘close involvement of ministers in overseeing performance and checking progress’, Professor Ham said.

In an accompanying blog post, the former chief executive of The King’s Fund wrote: ‘The best safeguard against micromanagement from the centre is for ICSs demonstrate they have the capabilities to deliver measurable improvements in patient care and population outcomes.’

Game-changer or failed reorganisation

In the preface to the report, Matthew Taylor, the Confederation’s chief executive, warned that the Health and Care Bill could come to be seen as ‘a game-changer in improving health outcomes, or another failed health service reorganisation’.

He said: ‘At present, it still too often feels like the sponsors of that legislation in NHS England and NHS Improvement and Whitehall have not fully understood or accepted the consequences of their own proposals.’

This comes two weeks after the Government published its integration white paper, detailing how ICSs are expected to work more closely with the wider NHS.

In January, the target date to grant ICSs statutory footing was been pushed back by three months to 1 July 2022.

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