The appropriate role of local government in determining health policy is a perennial policy divide.
On one side is the need for service integration, responsiveness to local circumstances and strong public engagement. On the other, concerns about the capacity of elected councillors to take on such a huge responsibility, and the tendency from the NHS's origins for the public to hold national Government accountable for the service's performance.
Former NHS chief executive David Nicholson referred to the NHS as ‘the biggest train set in Europe'. He was in charge when NHS England was established, in part, to insulate the health service from short-term political interference. But its record in so doing has been mixed and, right now, current secretary of state for health and social care Steve Barclay is known to be highly interventionist.
With the NHS under huge pressure and the Prime Minister choosing shorter waiting lists as one of the Government's five headline pledges, central control is only likely to increase between now and the next election.
Yet, away from the headlines, a quiet revolution is occurring. The main reason I was excited two years ago to become chief executive of the NHS Confederation – the organisation that represents all parts of the NHS in England, Wales and Northern Ireland – was the pending 2022 Health and Care Act.
Having spent much of the last 13 years trying unsuccessfully to persuade the Government to change policy in areas ranging from the Child Trust Fund (abolished) to a new Employment Act (indefinitely deferred), I was excited to be involved in implementing major changes that commanded broad support.
In creating Integrated Care Systems (ICS) with Integrated Care Partnerships (ICPs) at their strategic apex, the 2022 Act gave local government and other local agencies a substantial statutory role in making health policy. With the ICS's four core objectives, including improving population outcomes, reducing inequality and helping the NHS to support wider social and economic development, the Act also reinforced the idea of a wider lens on health policy.
With demand for healthcare services outstripping the NHS's ability to keep up, keeping people healthy closer to home to manage demand is the only way forward. With responsibility for public health and other areas like housing and social care, local government has long understood this and been responsible for key services.
As former health secretary, and current ICS chair, Patricia Hewitt said in her recent report, the centre of the NHS, largely comprising NHS England and the Department of Health and Social Care (DHSC), does not seem fully to have adapted to the new structures they helped to create.
While systems and place working require collaboration and local flexibility, accountability in the health service still travels upwards and within the stove pipe of the NHS. Both ICPs and place-based health and care boards exist in a kind of governance vacuum; as partnership bodies they cannot be answerable only to NHS England or DHSC but other parts of Government – most notably the Department for Levelling Up, Housing and Communities – seem to be hardly aware of these bodies.
Yet, despite the ambiguity, default centralism and inevitable shortage of money, local leaders and managers are starting to make a difference. The ICPs have drawn up strategies that demonstrate common purpose and commendable ambition. I have seen impressive collaboration and innovation in places stretching from Wolverhampton to Bristol to Tameside.
In a recent lecture to the Royal Society of Medicine I argued for five long-term shifts if the NHS is to be ready to grasp the opportunities of biomedical and technological change for the benefit of the whole community. Apart from the plea for adequate long-term funding, these were the need for a strategy for national health, not just the NHS, to reverse the hierarchical pyramid of accountability, to shift resources upstream from acute to primary, community and public health and the need for a more honest and ambitious conversation with the public.
At national level there may not be much sign of these shifts occurring, but locally, a different future is taking shape. With an election looming it is vital that through practical action local leaders show the best future lies in central Government living up to the potential of collaborative systems and places.
Matthew Taylor is chief executive of NHS Confederation
@ConfedMatthew
