Sub-regions run the NHS sub-regional hospitals, but why do they have to run the rest of the NHS?

The last few posts of July (before I shift the Health Matters current affairs desk to warmer climes) will be about some of the very big issues that I think we have learnt from the Covid crisis about how we run the NHS.

Incidentally just when you thought it was not possible to scare people about the future to any greater extent, Sunday’s interview with the Telegraph, saw the Prime Minister ratchet up anxiety another notch. He referred to his having the capability to call another national lockdown as being similar to the possession of a nuclear deterrent. As if having a pandemic killing hundreds of thousands of people is not scary enough – let’s bring up a nuclear war that would kill hundreds of millions.

And what does he mean by the metaphor? At some stage the country may need another national lockdown, and if he sees this as being similar to pushing the button for a nuclear launch – does that mean he is unlikely to do it? That might mean we would go into lockdown – as we did in March – a few weeks too late. Last time that cost us  many lives.

Or, conversely, is he is fully prepared to call a national lockdown at the moment we need it – which suggests he is similarly prepared to press the nuclear button. That would cost even more lives.

All of this is meant to reassure me – so that I will go out and buy something.

One of the bigger lessons we learnt from Covid concerns the nature of our state and the way power is distributed. There are some, including me, who feel that the Government have spent most of the crisis trying to make centralised state solutions work for every element of the crisis. This led to real dislocations between these attempts at centralised state policy and the reality of where we live – in localities. There are several real examples of these dislocations.

    • The speed with which the crisis began required developing a list of those who needed to be shielded being carried out centrally. However, the fact that 4 months later there had still been no local primary care contact with most of those being shielded was wrong. This is because the good thing about primary care is that it is very local (it works best when it is individually local). The dislocation between a centrally organised list that needed local action has been a problem for hundreds of thousands of shielded people.
    • Nationally calling for NHS volunteers was a good idea. However volunteers are needed building by building in the localities. In recent months many of us have experienced the enormous amount of empathy and assistance that has organically worked its way through our society. This happened street by street, and block by block, not nationally.
    • The future of our country is in the hands of a test, track and trace system set up nationally. This means that several weeks in, it is still clunkily trying to share data with the localities that have to act on the data. This week it is public health staff in Blackburn that need up-to-date data, not some central authority. Localities will see us through this tracing crisis because they know the relationship between streets, post codes and local communities.

On a day-to-day basis, many aspects of our lives are organised with a recognition that we live locally (but within a nation). We live here, in this street around this corner and with these friends and communities, which central power cannot comprehend or encompass.

The NHS Long-Term plan leans toward this view of how people live. It recognises that if the NHS needs to influence how people look after their own health and their health care, it is going to have to engage with people where we actually are – and not in some abstract location. We will give up smoking here, get fitter here, take our medicine and manage our health care here.

Which means that here (rather than over there) is where the NHS needs to be.

I am worried that this is not the lesson that most of those currently leading the NHS will draw from the Covid crisis.

As I suggested last week I am sure that most of the national, regional and sub-regional leaders of the NHS feel that the nature of strong central management in February and March saw the NHS (and the nation) through the crisis. And I am not sure that any counter narrative will shake their belief in the importance of centralisation.

This July, after 20 years of trying, I am giving up on any hope of decentralising NHS power over sub-regional and regional hospitals.   Many of us have spent a lot of time trying to base countervailing local power in primary care though Primary Care Trusts. I remember in the early noughties visiting PCTs and arguing that because they had the cheque book they had the power to shift hospital activity or quality. Many of them would look with sadness at what they saw as my naivety and tell me that actually all power lay not just with the hospital but with the regional and sub-regional tier of the providers. SHAs were full of people who had run hospitals and, after all, the PCTs reported to them.

10 years later on, and from a different place, I was involved with CCGs on how they could implement change – because after all they had the money. They also pointed out this did not give them power. Many people in NHSE had run hospitals and all of them in NHSI.

This is not to say that PCTs and CCGs achieved nothing. Many of them have led to improvement and change – but they have done it against the grain of the system and not with it.

Nigel Edwards – who speaks many a true word in jest – has said that after a nuclear war (see above) there will be two life forms left on earth – cockroaches and regional health authorities.  They have a staying power which tells us something important. Over many decades they fit the NHS leadership’s view of itself and what it wants to do. And, as I suggest, these same people will see the success of the NHS during the crisis as having come about through centralisation.

There has never been much evidence that the rest of the NHS – outside of regional and sub-regional hospitals – are of much interest to the leadership of the NHS. So the centralisers get to keep what matters to them.

And the decentralisers from primary and community care, the rest of public services and the voluntary sector can work with the rest,

I know there will be problems of integration between these centralising and decentralising systems. But, let’s be completely honest, the problems of integration between big hospitals and ‘the rest’ are enormous at the moment even though they are meant to be a part of the same ‘system’.

Going back to 1948 two NHS systems were created. (both called the NHS)  A nationalised hospital system and a local set of GP practices. Time to recognise that the organisation of these two NHSs needs two different forms of power- one will continue to centralise.

Let’s give the other the opportunity to decentralise.