There was an interesting paper published this way by the Reform think tank on the theme of devolution of health care. Recent devolution initiatives from the Government have been more about form that substance. We have the election for ten Metro Mayors in England next month – including two new positions, for York and North Yorkshire and the East Midlands. The Mayor of the North East will cover a larger “combined authority” than the current North of Tyne post. The Mayor of London has significant power but for most of the other positions, the responsibilities are pretty derisory. It’s an extra layer of Government without much to do. These are gimmicky prestige posts which will produce election results that will get plenty of media attention as a signal to Party fortunes. But they will have little impact on people’s daily lives.
But local democratic accountability for the NHS would be a significant change. The report suggests that the untidy nature of local government – with some areas covered by unitary authorities while others are not – would be a barrier:
“Moving towards a devolved model of health and care is made difficult by the complicated and often confusing administrative landscape of local government in England.”
There have been successful cases of joint working between the NHS and local authorities – notably in Wigan. Another success story is North East Somerset Council and NHS where “a joined-up community health and care service” by the HCRG care group.
More generally, we have Integrated Care Boards and Integrated Care Partnerships but they are of limited effectiveness:
“Integrated Care Boards remain accountable to NHS England for any resources they delegate downwards. This clearly places limitations on how flexible local budgets can be to local needs, at risk of divergence from central requirements or targets.”
The cost to the taxpayer for an occupied NHS bed is around £700 a day. The cost for residential social care around £700 a week. Of course, we should not have people stuck in NHS beds simply because social care places are unavailable. When people are being cared for in their own homes it would often be better for the same carer to administer medicine and to cook and clean – rather than to have multiple visits from the NHS and the local authority for routine tasks. The advantages of “joined-up Government” are easy to spot.
This is not to suggest that council involvement is some kind of panacea. Local authorities are given £3.5 billion annually in a ring-fenced Public Health Grant from the Department of Health. It used to go to the NHS. The money is still largely wasted.
Yet the report makes a power case for devolution:
“Devolution allows policymakers to plan services which are better tailored to the needs of their local population. Local decision makers have significant “informational advantages” over more distant central policy makers – they are closer to service users and can use local institutional and community knowledge to build more responsive approaches to health and care provision.50 For instance, communities with a higher proportion of elderly or young people could develop service offers which better cater for their needs than a one-sizefits-all, nationally-led approach allows…
“Strong accountability at a local level (particularly where some revenue is generated locally) provides incentives to improve quality and contain cost….
“Nationally standardised systems, administered and regulated centrally may find it more difficult to spread innovation. In the first instance, top-down systems tend to centralise risk and raise the costs of reform. Unless all systems are in a position to make transformative change, innovation may be put off. More localised systems are better able to experiment – risks of failure are smaller, and systems can move at their own pace towards change, rather than a pace dictated by the centre….
“Different lines of accountability and funding models between healthcare, public health, and social care obstruct attempts at integration. The parcelling up of funding between these services – and, indeed, other services which create health – contributes to a siloed approach, ill-suited to the health challenges of our age.”
What form should it take? One option would be to have elected health commissioners should each NHS Trust – as an equivalent to the Police and Crime Commissioners. Another would be to transfer responsibility for the NHS to the upper tier authorities (whether unitary authority or county councils.) But the Reform think tank proposes Metro Mayors, with their combined authorities, being given the responsibility. Each such entity would be an “Accountable Care Organization” – “responsible for a single budget and able to retain savings, but also responsible for overspends. This would incentivise a shift away from the NHS’s current hospital-centric model, towards a more community- and primary care-dominant model.”
There would be objections. Part of the myth of the National Health Service is that it is, er, national. That it is the same for everyone – not just whether rich or poor but regardless of the part of the country you live in. Thus if one area should save lives through some innovation rather than the rest of us welcoming it and learning from it we respond by complaining about a “postcode lottery.” But there is already a postcode lottery. Though the NHS has pretty dreadful outcomes compared to other countries, performance within the NHS varies considerably. The report notes:
“The percentage of cancers diagnosed in stage 1 or 2 is twice as high in West Suffolk as it is in Slough, whilst those admitted to hospital for a stroke in East Staffordshire are more than twice as likely to die after 30 days than in neighbouring North Staffordshire.”
Giving a politician direct local accountability for the NHS would be a demanding role. Imagine the emotional “blood on his hands” demonstrations when a scandal emerges. But that is better than some anonymous group on an obscure board. If we must have these Metro Mayors then let’s give them a proper job to do.
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Author: Harry Phibbs
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