Getting the right balance between central control and local autonomy

A big issue to resolve in the NHS is how we get the right balance between central control and local autonomy, and as part of this how leadership of the NHS will work in practice from within the Department of Health and Social Care (DHSC) when NHS England is abolished.

Ministers have reiterated that April 2027 is a hard deadline for NHS England’s abolition, but only now are we starting to get into the detail of what the new leadership model will look like.

The Health and Social Care Select Committee is hosting a session tomorrow with the ‘holy trinity’ – James Murray, Sam Jones and Sir Jim Mackey – where the issue of the Secretary of State’s powers and the abolition of NHS England will be discussed.

So, what do we know and what are the key issues that need to be resolved as the DHSC’s new operating model is developed?

Central control versus local autonomy

The stated aim with the abolition of NHS England, other than to avoid what is seen as unwarranted duplication and waste, is to bring the NHS back under direct ministerial control.

This leads to a tension we have heard voiced openly in recent weeks, and that is about the balance between centralisation and devolution.

Many have noted that the Bill in its current form contains little to enable a transfer of power away from the centre. If anything, it risks making the situation worse unless clarity emerges as to how powers will be delegated, separated and aligned.

Our members have raised concerns with us about how enhanced powers for the Secretary of State – which include the extensive ability to direct integrated care boards (ICBs) and to set revenue limits for foundation trusts – will be exercised in practice.

Underlying that is a further unanswered question about how much direct intervention ministers want to undertake. If one justification of reserved powers is to protect the state from the risk of rogue statutory bodies, the inverse is also true. Legislation also needs to protect statutory bodies from overly interventionist political leadership.

In my view, this is mainly about protecting autonomy rather than about over-centralisation, and the operating model needs to ensure the NHS will continue to have enough operational independence. This is needed to give confidence to local leaders that they are trusted to take the decisions only they can take to improve local services and will be backed when they make them.

Over the past year or so we have seen improvements in NHS performance and financial management and that has been achieved at a time of a significant reduction in headcount at the centre and efforts from NHS England to devolve more control to the front line.

The concern now is that these hard-fought gains could be lost if we revert back to a more centralising approach. If the abolition of NHS England is to have a benefit across the wider system then that benefit must be greater autonomy, exercised in partnership, with a clear focus on delivering better care for the local population.

Options for the DHSC operating model

So, there is unfinished business when it comes to defining the kind of NHS operational leadership that will be in place post-NHS England’s abolition.

Firstly, we know that the role of NHS England chief executive will cease to exist, but we don’t know for certain what will follow. Whether the role is replicated, or changed is being debated within the centre.

While I am sure there will be a chief executive accountable to Ministers, what is around them matters too. I might not need to be much, but it must be able to provide guidance, coherence and at times direction.

While the future of this role is not a matter for primary legislation and the Bill going through parliament, the question matters for lots of reasons.

The difference between an NHS chief executive and a permanent secretary, or perhaps better, between an NHS executive and a policy-setting department, is at the centre of these issues.

It was reported a year ago that the emerging proposal was for a triumvirate model, where an NHS chief executive would work alongside a permanent secretary and a chief medical officer – with all three reporting directly to the Secretary of State and each with distinct responsibilities.

Doubts were raised earlier this summer, first in a piece speculating on the potential for the chief executive and permanent secretary roles to be merged, and then again with reports of discussions about the role potentially being ‘downgraded’ – as it was described – by reporting into the permanent secretary rather than the Secretary of State.

As we look at the options, our starting point is straightforward: the leadership model must enable the NHS to be run safely, effectively and sustainably. There are some fundamental things we need to see in the post-NHSE setup:

• The leadership model must enable the running of a complex, 24/7 national service from within the department.
• The structure must create unambiguous accountability so the public, the service, and parliament can clearly see who is responsible for what.
• National leadership must understand the realities of delivery, must be able to explain those realities to ministers and, when necessary, challenge them from a position of operational credibility.
• The structure must support a focus on sustained, long term reform, rather than short term political priorities.

Based on this our view is that an NHS chief executive role must remain distinct. It should not be a merged role with the permanent secretary, as we had pre-2007 when Sir Nigel Crisp performed a dual role.

A wider NHS executive?

A second issue is whether this role sits as part of a wider NHS executive within the department – this will be an important choice to make as the operating model is finalised.

There are advantages of having enough NHS executive capacity within the DHSC to focus on the operational effectiveness of the NHS, with others in the department focusing the policy, regulation and commissioning functions of the DHSC. In many ways, under Sir Jim Mackey’s leadership we have seen a sharpening of focus on financial control and improving performance for patients. 

But that is not to say the balance between central control and local autonomy is right. In our view, it remains too centralised, with too much micromanagement, and we need these reforms to help us move away from that approach.

As we enter a new phase in which the NHS chief executive  will most likely be working within a government department, it is essential that they are able to demonstrate a similar sense of leadership and accountability, regardless of who holds the equivalent role in the future.

I raised these concerns directly when I gave evidence to the House of Commons Public Bill Committee on the Health Bill last month, urging the need for any use of the Secretary of State’s new intervention powers to be rare, transparent and subject to clear checks and balances.

The role of regions

Another area of uncertainty being debated is what happens to regions. 

Whether their new chairs end up with full boards, and whether they will be run by NHS staff or civil servants to some extent flows from the answer to the NHS chief executive question. 

How an ICB relates to a region is an important question. The suggestion – again recently reported in the press – of regions being ‘hosted’ by ICBs has understandably been met with surprise and raises a whole raft of questions about governance and accountability. That the debate is being held in this way, semi-publicly, and with ideas floated piecemeal and without context or the underlying reasoning attached, is not ideal. 

Wherever we land with the operating model, the role of ICBs needs to be strengthened rather than consumed into the national architecture. A piece of work, involving those who will live with the consequences, to think through the options is needed.

Set up for success

We have an ongoing dialogue with the DHSC on its developing operating model and are encouraged by responses we have received so far. There is a willingness to ensure their thinking is aligned to the needs of local leaders, and that is something we will continue to push for.

Ultimately, these may feel like dry issues, but we need the right operating model and governance structures in place to protect national accountability while giving local leaders the operational autonomy they need to succeed.