Will NHS devolution be healthy for England?
Giving combined authorities in England the ability to run their local NHSs would make healthcare more responsive and give voters more control
The NHS will be a major topic of discussion in the coming election. But given its status as a political issue, it is striking how little control voters in England have over healthcare. Broad policy is set by Westminster MPs, but major decisions are made by civil servants in NHS England, NHS trusts and clinical commissioning groups. Local authorities have limited input and no meaningful power.
Control is rather closer to the voters of Scotland and Wales, as healthcare has been devolved to the two national governments. Both have abolished England’s split between organisations that buy healthcare and those that sell it in favour of boards that provide all NHS services in a geographic area. (Northern Ireland also has devolved powers along with a different structure, with combined health and social care organisations.) Scotland and Wales have also reduced the role of the private sector and abolished fees for prescriptions.
What would happen if English local areas gained devolved power over healthcare, perhaps through combined authorities, the groups of councils forming to run policy areas such as development, transport and planning? National funding would have to continue (as it does across the UK with the Barnett formula) and combined authorities would have to maintain care free at the point of delivery – but with control over how to achieve this.
It’s easy to imagine left-leaning areas following Scotland and Wales, but a few Conservative-run combined authorities might try much greater private-sector involvement. The NHS already outsources some care, although this usually involves lower-profile services.
The best-known exception is Circle, a private company partly owned by staff, which won a 10-year contract to run Hinchingbrooke Health Care NHS Trust and its hospital. But it is ending the deal early after losing millions of pounds, suggesting to some that significant private-sector involvement in the NHS cannot work.
Circle has drawn a different conclusion: that the NHS needs to involve all healthcare organisations in an area in “joined-up reform”, adding that “if reform in the region develops fast and a new role for us does become clear, we are happy to play our full part”. It partly blames high emergency demand and the inability of local care services to accept patients ready for discharge for its losses, although these are common problems for hospitals. Interestingly, what Circle calls for is pretty much what has already happened in Scotland and Wales (but without private sector involvement); joined-up management of a region’s NHS.
A current problem for England, and a definite advantage for the devolved nations, is size. The chief executive of the NHS in Wales, Andrew Goodall, points out that with just 10 organisations running Welsh healthcare, it’s straightforward to get a representative of them all in one room. England has around 500 NHS organisations: some of that is down to the buyer-provider split, but England also has 17 times as many people as Wales to look after.
If combined authorities ran their local NHSs, they would be running a much more manageable size of healthcare system than all of England, and they would be able to design this system based on their specific needs. Big cities can establish specialist hospital units more effectively – London has improved results by having fewer, better, stroke treatment centres – while rural hospitals, often the de facto monopoly in their areas, have to provide a wide range of services well.
Population health needs vary considerably: the proportion of people who told the 2011 census they were in bad health varied from 2.7% in Wokingham to 9.5% in both Blackpool and Knowsley.
The NHS across England has regional managers, but they have a very low profile and no specific democratic mandate. Putting healthcare on the agenda of Greater Manchester’s soon-to-be elected mayor – as well as London’s existing one – would place these decisions into the political spotlight, and give voters a direct chance to influence them.
Healthcare is local and so are many of its political issues, such as whether a particular hospital should close or change what it does. It is possible that devolving the English NHS would lead to a company (or a charity) running all of an area’s NHS on an outsourced basis, although such an experiment would be watched very carefully. More importantly, such devolution would make healthcare more responsive to local needs – not least by giving English patients a direct say.
SA Mathieson edits daily email service Council News Monitor, which covers devolution including the rise of combined authorities
Circle in talks to exit private contract to run Hinchingbrooke hospital (Guardian, January 2015)
NHS Wales: 'We need to shout about good work and progress' (Guardian Healthcare Professionals Network, December 2014)
NHS emergency care is in crisis. A new approach is needed (The Information Daily, November 2014)
The US strategy that could fix UK healthcare (The Information Daily, October 2014)
The views and opinions expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of The Information Daily, its parent company or any associated businesses.
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