To succeed over the next 10 years,the National Health Service must also be a local health service. A public service dedicated to the health and wellbeing of every person in England cannot be run as a bureaucratic offshoot of Whitehall. Instead, success will depend on power and trust cascading downwards to local areas, NHS institutions, teams of professionals and to citizens.
Autonomy matters because good services adapt, innovate and set their own direction, rather than just implementing instructions from elsewhere: achieving excellence is an intrinsic, internal process of learning and experimentation. And autonomy enables institutions and individuals to collaborate in co-evolving relationships and networks. This is essential when standardised top-down interventions do not lead in a linear fashion to predictable results; where conditions are ambiguous, heterogeneous and interdependent, as they so often are in healthcare.
This is all increasingly recognised at the frontline, where the focus is on personalised care and control. The best way to help someone live well with complex, chronic illness is different in every case – driven by the individual’s choices and circumstances – and involves many different individuals and agencies, working together in discrete ways on each occasion.
But autonomy also matters at the level of whole local healthcare systems. Adaptive, personalised frontline relationships and networks cannot be willed from the centre through direction; and nor can they come about spontaneously through market-like incentives and transactions. Healthcare networks need to be steered and nurtured by local leadership and stewardship.
The need for strong locality-wide leadership is a vital new feature in the debate on the NHS’s future and ‘The Local Health Service?’ examines, celebrates and scrutinises its gradual emergence. A previous Fabian report, Going Public, identified two key roles which neither individual providers nor central government have the capacity, insight or joined-up perspective to perform.
First, local leaders are best placed to drive service improvement, through a combination of commissioning, facilitation, scrutiny and intervention. Except in cases of serious failure, national agencies are simply too distant and over-stretched to do this job. As the NHS Five Year Forward View makes plain, it is localities that need to make choices on which new service models can combine quality and value, taking account of their own individual circumstances.
Second, only local leaders can set ‘whole-place’ strategy, looking in the round at local needs, preferences and context. This is a challenging task, even from an NHS-only perspective, given fragmentation within the service and people’s natural affiliations to individual institutions when faced with change. But strong local leadership also needs to drive collaboration across all public services (and with non-profit organisations and businesses), for example to direct resources towards prevention or create seamless personalised services.
This leads to the main controversy within the debate on NHS localism, which is not the question of whether to devolve power, but where it should be devolved to – and, in particular, whether devolution should also include significant power sharing with local government. Many on the NHS side of the fence are already embracing dynamic local leadership, by clinicians and managers, but still see clear limits on the role councils should play. For a few years, perhaps this is sustainable, as the NHS concentrates on reforms that are mainly focused on remodelling the relationship between primary, community, mental health and acute care.
But over time it cannot be, because too many of the drivers of demand are the responsibility of local authorities, who are themselves on the brink of financial collapse. For example, radical leadership will be needed, by councils and the NHS together, for local public health strategies to have any measurable impact on demand. Even more urgently, over the next three years, adult social care and housing support services may simply be overwhelmed, leaving the NHS facing a rapid rise in frail older people requiring unplanned care.
The long-term solution is for health commissioners to work with local government to jointly design services which are both ‘whole-place’ and ‘whole-person’, encompassing health, support and wellbeing. In all likelihood most of the money will need to come from NHS budgets, but the level of strategic and operational integration required suggests that local government will need to become ever more involved in NHS decisions. For reasons of financial sustainability, we will in effect see the creation of local health and wellbeing services, reporting to local government and NHS England on an equal footing.
The question then becomes, at what scale should this happen. Will clinical commissioning groups (CCGs) and councils jointly manage all health and care spending at local level, as NHS England has said might happen in some places? Or will new regional arrangements be introduced, above them, as is now beginning in Greater Manchester? The answers will no doubt be different in different places, as is the logic of localism.
The NHS should not see the expanding role of city or local authorities as a regrettable consequence of austerity and changing patterns of demand. Until now NHS localism has been remote and technocratic, but gradual integration with local government holds out the promise of far greater political leadership, democratic scrutiny and public involvement. This poses some risks (in the short-term NHS insiders might have to work harder to make the case for changes to popular services) but it will also inject local ownership, leadership and accountability. It may be that only high profile city bosses will have the clout needed to drive through major institutional reforms and be the face of local services to the public.
And what of the public? Debates on localism can sound very far removed from people’s daily lives and their own relationships with frontline services. But the test of local devolution must be its capacity to demonstrably improve individuals’ health and wellbeing. That must mean two things together – better overall outcomes and less variability in the things that matter for patients. The second point is particularly important, because the public will not accept greater ‘postcode lotteries’ in overall outcomes, as the price of local autonomy over ‘how’ services are run.
There has always been local variation in health and healthcare outcomes, and there always will be. But for decades ‘unwarranted’ variation has been too high. In times past this was swept under the carpet, but now we have the evidence to map and understand it. This includes the NHS Atlas of Variation (on differences in quality, safety, activity levels, spending and outcomes), the NHS Innovation Scorecard (on the pace of adoption of new NICE-approved technologies), and data on compliance with non-compulsory NICE guidelines.
Just because there have been high levels of variability in access, quality or outcomes historically, does not mean this should be tolerated in the context of localism. National data combined with local autonomy and accountability should create the context for locally-driven adoption and innovation, with the aim of improving performance, relative to national benchmarks. Localities should be seeking to understand whether geographic variations are explicable and warranted (ie reflecting local need or consciously chosen priorities) or imply suboptimal service configuration and clinical practice, or an allocation of resources which reflects history rather than demand or value. And similar principles apply in analysing local service patterns, including seeking evidence of the ‘inverse care law’, where people from disadvantaged backgrounds have unjustifiably inferior experiences. To make sure these approaches are followed everywhere, NHS England should provide support, to complement the scrutiny of local stakeholders.
Localism should also provide the spur to close gaps in overall health outcomes, not just those related to the provision of care. Local leaders will be able to take health inequalities far more seriously (both within and between local areas) since more of the levers for achieving change will be at their disposal. Indeed, one of the main rationales for handing NHS powers to Greater Manchester, at city region level, is to achieve a non-siloed, whole-place approach to public health, since it is expected that the new mayor will develop complementary strategies in areas such as employment, skills, transport and policing.
There are, however, limits: neither overall national performance nor geographic inequalities will improve just through local leadership. The public still expects a National Health Service across England, so devolution in healthcare must be ‘managed’. In a more localist future, there must still be a core set of national standards, underpinned by strong evidence-based institutions.
This applies especially when it comes to access to services, treatments and technologies. After all, the standardisation brought about by the last Labour government’s slew of entitlements, frameworks and targets had a hugely positive impact on both overall quality and levels of variability. It is easy to forget, for example, that NICE was conceived not to block the path of expensive new technologies, but to drive out postcode lotteries in the availability of treatments and, later, in clinical practice.
But there is also a balance to strike, because requirements must not be so prescriptive that they can only be fulfilled by squeezing out any space for experimentation, local decisions on priorities, or the possibility of sometimes going beyond the national ‘offer’.
The NHS has a proud record of securing equitable access to high quality, good value healthcare. From a global standpoint the service is very successful in combining three qualities – equity, value and innovation – and this is of course underpinned by the enduring commitment to an NHS free at the point of need. But to continue to advance on all three fronts – in the context of changing health needs and service models, as well as ongoing austerity – it will take a new wave of locally-led reform. As the NHS looks towards its eighth decade, this cannot be achieved from the centre: learning to let go is the only way forward for our National Health Service.