The NHS funding model confuses accountability

10 June 2016

As Reform wrote at the time, the “Lansley reforms” greatly confused accountability within the NHS. The Service would still answer to national direction, via national targets and instruction. Local authorities would play a greater role. The NHS would also answer to individuals via competition and choice. Since then the picture has been muddied further by the devolution of NHS powers to Greater Manchester, and plans to integrate health and social care.

This was brought into sharp focus on Tuesday at the Health Select Committee. As part of the Coalition Government’s localism agenda, public health was put back into the hands of local authorities in 2013 having spent thirty-nine years under the care of the NHS. The Committee met to review “public health post-2013” and discussion quickly moved to the conflict surrounding who should be paying for a new HIV medication. Health funding comes from NHS England, CCGs and local authorities; clinical guidance comes nationally and locally. It is no wonder there is head-scratching.

A sticking point at the Health Select Committee was the funding of Pre-Exposure Prophylaxis (PrEP) therapy, a medication used to prevent HIV. Recent trials have shown PrEP reduces the contraction rate of HIV by 85 percent. The World Health Organisation recommends PrEP for those at high risk. NICE are beginning a review, a process many believe should have already taken place.

NHS England recently took the decision not to fund PrEP. This was on the basis that sexual health comes under the remit of local authorities. This is a decision contested by local authorities who feel NHS England is the natural commissioner for PrEP. NHS England is seeking clarity through a judicial process.  This issue has incensed charities and politicians alike. At the Select Committee Philippa Whitford MP said that there is a feeling amongst stakeholders that now public health has been moved to local authorities, NHS England have “washed their hands”.

The confused structure of the NHS is a problem that needs to be addressed. Unfortunately, since the Lansley reforms, all Parties have been scared of embarking on what looks like a “top down bureaucratic reorganisation”. When asked at the Select Committee whether the Health and Social Care Act needs revision with regards to public health, Simon Stevens said that “there is a sense of wherever we’ve got to, there is not a huge appetite to throw our cards in the air and start again.” Both politicians and NHS England should recover that appetite.

Kate Laycock, Researcher, Reform

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