Last week saw some pretty alarming public statements by London boroughs about their relationship with the leaders of the NHS in London. (In the interests of full disclosure I have worked for three pan-London governance organisations. I was abolished whilst at the Greater London Council and the Inner London Education Authority and missed out on the hat trick of abolitions by leaving NHS London a year before it too was abolished.) Together with 4 years of working for Islington Borough Council, I have some idea about how hard it is to create organic partnerships between different aspects of London governance.
One of the reasons it’s particularly difficult to create working partnerships between Local Government organisations and the National Health Service is the very different meanings that spring from the first word of their names. Local government really really believes in locality. Local electorates assume that their local government will respect their locality. It’s what it’s for. On the other hand the public expect the National Health Service to operate a model that respects its nationalised 1948 heritage “paid for out of national taxation with equal access for all at the point of delivery”. The two organisations really have different drivers. But a lot of the time they recognise that it’s important and necessary to work together.
It looks as if – in London – without some radical change in how these drivers work, the Covid crisis has damaged any possibility of these two organisations working together.
The London boroughs are run by majorities of the three large political parties. So when they agree about something they are doing so across what is usually a big political divide. This is unusual.
London council leaders – all of them – feel that the pandemic has worsened the centralised instinct of the NHS in London. What makes this significant is that most of the NHS leadership in London feel that much better outcomes have resulted from the greater power of a central NHS.
This is the measure of the problem.
Both sides see the same thing as being totally different. For the NHS the Covid crisis was a success because for once command was matched with control. When a local NHS trust was told by regional or sub-regional NHS leadership to change the configuration of its services they delivered that different configuration. Therefore, and unusually, the NHS in London had some control when it issued commands. Talk to most NHS leaders and they will say that this is the reason the NHS could maximise the number of acute beds to meet the crisis. And the NHS was not overwhelmed. Ergo NHS Command and Control worked, saved the NHS and saved us all. Thank you Command and Control.
For local government the success of command and control as a form of management is experienced as a problem. Three Local Authority leaders expressed their concerns in a recent Health Service Journal article,
Ray Puddifoot, Conservative Leader of Hillingdon, argued that NHS Command and Control of the Covid crisis London boroughs had allowed the NHS to “do a runner on us, and now we have to get back into control”. For him NHS Command and removed the influence of Local Government from the NHS.
Sutton Lib Dem leader Ruth Dombey claimed that local government needs to challenge “that part of the NHS that is clearly so comfortable in command and control. My concern going forward is that command and control will become entrenched and the feedback I have from people across the NHS who aren’t in the hospital sector is they have similar concerns. “
For Phil Glanville Labour Mayor of Hackney, the NHS centralisation story is that the five Integrated Care Systems have been an intrinsic part of London’s response to the Covid 19 crisis, “There are real challenges about where the democratic interface is and making sure we don’t lose sight of the fact that we are supposed to be in sub regional health and social care partnerships, but it is firmly health driving this”
London local government leaders are left threatening to park their tanks on the lawn of the NHS – but in friendly way. Myself, I am not sure if I’ve ever encountered a friendly tank but you get the point – aggression, but no shells involved.
Setting this in a wider picture, this is not the same across the whole of England. In some localities local government has become so embedded in real delivery partnerships that the NHS command and control which has driven hospital work in the Covid crisis, has not left local government feeling excluded from NHS influence.
I can’t, for example, imagine that local authorities in Greater Manchester or Surrey might feel that they had to threaten to put tanks on the NHS’ lawn. Real relationships of power for local government are a part the new normal in these areas.
But in many places nascent integration experiences have been put to a real test – and in some places lost.
I stress that this is a bigger problem than the usual difficulties for integration. In the past both sides could see similar aspects of the same problem. But in the last couple of weeks we have seen media images of NHS leaders congratulating themselves on their success of managing hospital resources in a certain way. For every congratulation others have felt even more excluded.
This sharp difference of opinion about the very same thing is a real crisis for integration. In the next couple of posts I will explore how those of us who still want really integrated services may have to come to terms with this new reality.