Getting NHS reform right

21 December 2016

Reform of the NHS will be high on the political agenda in 2017. The focus in recent days has been on social care, but this is only a part of the bigger challenge. As set out in the Five Year Forward View, citizens need a dynamic NHS with integrated services, harnessing technology to deliver care when and where it will have the greatest impact. Sustainability and Transformation Plans (STPs) are charged with delivering this vision. Reform is carrying out research investigating whether they are likely to succeed, with findings to be published in the New Year. So far, weak accountability is emerging as a particular barrier to success.

An STP is not a legal body in its own right. It has no statutory duties. Instead, statutory responsibility lies with the individual organisations represented within it: the CCGs, provider trusts, local authorities and so on. Consequently, some local leaders of these organisations are experiencing tension between the interests of their own organisation and the STP footprint as a whole. There is no one person or body with the authority to make executive decisions.

Attempting to quash these concerns, Simon Stevens, chief executive of NHS England, has described the STPs as simply “the right group of hospitals, GP services, mental health and community services, local government, social care and community groups getting together and saying, “If this is the funding available in our community, what is the best way of dealing with some of our long-term and deep-seated needs to join up services…?”” STPs should not, however, be discussion forums alone: they need to have the power to act.

Greater Manchester has attracted attention following the high-profile devolution of the health and social care budget, but even Greater Manchester does not seem to have all the answers. Its progress is usually attributed to devolution but IPPR has described the Greater Manchester deal as more akin to delegation. Rather than the Greater Manchester Combined Authority (GMCA) being completely free to make its own decisions, it is limited by the agendas of national bodies. The creation of the GMCA added another layer of complexity, with existing bodies, such as CCGs, maintaining their statutory duties and responsibilities. Greater Manchester appears to be succeeding despite, rather than because of, the legislative framework.

There is little political appetite for another reorganisation of the NHS, but there is a clear need for a legislative framework that supports what the STPs are trying to do. Devolving more power to local bodies, be this local combined authorities, STP bodies or another collaborative, local approach, could be the way to free up leaders in local health systems to think about population-wide health rather than being forced to prioritise the interests of their own individual organisations. As Professor Terence Stephenson, chair of the General Medical Council, said, “We are … answerable to Parliament, not to the Government. We need Parliament to give us legislation fit for 2030, not fit for 1983.”

Devolution does not need to mean the end of the National Health Service. National consistency can be maintained through national standards and goals. Accountability frameworks, however, need to allow local leaders to make decisions themselves about how to best serve their local populations if the STPs are to have the impact that they need to.

Elaine Fischer, Research Assistant, Reform 

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