The end of Lansley's decentralised dream?

PB Deputy Managing Director Dan Jones¬†writes…

Dan Jones

This week saw the publication of the HSJ’s NHS power list – the top 100 most influential people in the NHS. As pointed out by HSJ Editor Alastair Mclellan, the most striking thing about this year’s list is the ‘the domination of the centre.’

Overall, NHS Improvement and NHS England employees make up a third of the list. The first person on the list without a ‘central’ role is Mike Deegan, Chief Executive of Central Manchester University Hospitals Foundation Trust who comes in at number 38. It is worth bearing in mind the list comes out at the same time as NHS England announce the appointment of 7 new regional directors. While many of them are included in the list, it will be interesting to watch their ascent in coming years.

A key question here is what this means for local NHS organisations. Back in 2010, when Andrew Lansley set out his principles for a more place based NHS, where local decision making was central to delivery. Out went twelve Strategic Health Authorities (SHAs) and 176 Primary Care Trusts (PCTs) and in came around 240 new Clinical Commissioning Groups (CCGs) with no regional structures between CCGs and NHS England. These new CCGs were to be clinician led and focussed on delivering the needs of their local populations.

Following a long debate around the plans we have now had around five years of the new system and it now looks, well, about the same as it did prior to the changes. The number of CCGs has slowly been whittled down to 191, so only 15 more than the number of PCTs, we have reinserted a new regional structure that looks quite a lot like the SHAs that existed before.

Probably the most striking difference is the role of NHS England. Prior to the reforms the NHS had a head office and a chief executive but was largely led by the Department of Health. The reforms were also intended to ‘remove the politics from the day to day running of the NHS’. While it is debateable this was ever achieved, NHS England has certainly taken control of the strategy and overall management of the system.

While the Lansley reforms were able to shift the responsibility for running the system away from government ministers, they did not shift it to local healthcare commissioners and providers but to a new hub of power in the shape of NHS England. The new system, and the demands placed on the system by austerity, mean the centre arguably has more control over the system than any other time in NHS history.

With new regional structures taking place and STP programme shaping local delivery, we are likely to see more and more control being driven towards NHS England. NHS providers have had limited resources for several years now and therefore have very little choice other than to rely on NHS England’s patronage for support, something that is unlikely to change any time soon and will further contribute to the centralisation of power.

This also points to a future in which the person sitting at the top of NHS England continues to have an all pervasive power over the system. This has the benefit of providing consistency and continuity but does beg the question Рhow accountable should an unelected official be to the public, especially when they are overseeing £120bn of government spending?