The NHS – who’s in charge?

17 February 2017

Since its establishment in 1948, the Secretary of State for Health has held overall responsibility for the NHS. The challenge has been to combine that responsibility with effective management and accountability for performance, throughout the service. Reorganisations of the NHS have seen changes to its structure, but the basic principle of NHS management remains the same: central government outlines the priorities of the service, whilst lower-tier bodies and regional offices are accountable for delivery.

Though the central government structure in charge of the NHS has remained the same since 1948, health provision is very different. The NHS comprises nearly 9,000 organisations (many delivering care from multiple locations). Medical advances mean there is capability to diagnose and treat more diseases. There is a greater understanding of what causes disease and thus how to prevent it. The population is ageing and there are more people living with multiple co-morbidities. Society is digitally enabled and expect services to be designed around their needs and delivered in real time using technology where possible. The NHS has not been responsive enough to this change.

Furthermore, across the country, populations vary starkly. In lower-tier local authorities (LTLAs), the percentage of obese adults ranges from 11.2 per cent to 35.2 per cent. Government have recognised that health and social care services must reflect the needs of different localities across the country, something the health service has previously struggled with. Its innovative idea is to split the country into 44 Sustainability and Transformation Plans (STPs) that will bring every NHS organisation and council in each area together. Organisations will agree a radical plan to change services so that care is transferred intelligently from acute hospitals to community care and prevention.

A Reform report out this week, Saving STPs, supports the introduction of STPs but finds that they lack the executive power to deliver real change. STPs are not legal bodies in their own right. Instead they comprise a group of separate organisations, each with their own statutory responsibility and individual accountability. The result is that organisational budgets and targets trump those of the STP. Organisations protect their own interests at the expense of others.

Health and Wellbeing boards (a recent programme designed to deliver local integrated health and social care) have not delivered for this reason. The limited authority and accountability they hold has stunted their progress.

To succeed, STPs need executive authority. The first step towards this is to pool the budgets of all organisations within the STP. The creation of a single budget for health and social care, under a single commissioning body, will encourage collaboration and overcome the barriers to joint working which have stymied STPs.

The second step is to introduce a directly elected individual responsible for the STP budget, whether a metro mayor or a new Health Care Commissioner. STPs will and should make controversial decisions, including the closure of A&E departments. Without consultation on such issues, changes will be seen as cuts to services rather than a movement of care out of hospital and into the community in the best interests of patients. Such decisions are locally sensitive and it is right that the public are engaged in order to avoid previous situations where central government have been held responsible for local changes to heath provision. An elected individual would provide legitimacy for the tough local decisions that are needed to reform the NHS through engagement with voters.

Kate Laycock, Researcher, Reform

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