1 – What should be organised centrally, and what locally?

Over the next couple of weeks, as the NHS and hopefully the rest of us, look ahead a little I want to publish six posts about the near future. Una O’Brien, with her experience and knowledge of Public Inquiries will be posting twice – the first, on Wednesday, outlining the possible process issues of a Public Inquiry and the second about the questions that the future Inquiry will have to answer for us all. I will be examining how our very odd present might adapt and evolve into a future, specifically looking at issues of integrated services.

Today I want to review lessons about the way in which authority has been used in both the centralisation and localisation of services.

Just as I never expected BBC News to devote so much time to explaining what the ‘R factor’ in an epidemic is, nor did I expect them to look so critically at how central policy announced in Downing Street did not succeed in reaching all of the different parts of our society that it was meant to. Society has been going through an intense tutorial on the subject of how the management of service delivery works.

Over the last few decades we have become a nation with much greater centralised control. Devolution in Wales and Scotland is, in part, a reflection of the greater power of Whitehall. 10 years of cuts to local government funding have significantly increased that centralisation of power.

One big NHS fact undermines the argument for centralisation. When things are working normally there are one million NHS consultations every 36 hours. Good luck with organising all of them from Whitehall – or even from a region!

In 1948 the NHS was set up as if it were a nationalised service. It has always had a powerful centralising authority. The ‘N’ in its name matters a great deal to the public. But in 1948 only one part of the NHS, the hospital service, was nationalised. The part that provides the most health care – primary care – was locally organised around a series of small local businesses called GP practices. From the start for the NHS to work, practical authority needed to be both national and local.

But for most of its 70 years the NHS has seen two very different and barely interconnected systems of primary care and hospital care. One local; one national.

Within the Covid crisis, authority has been nearly all national.

And for parts of the NHS this response to the crisis has been a great success. ICU resources in the hospital sector have been very successfully ‘ramped up’. Together with the powerful ability of tens of thousands of staff to quickly learn and apply new skills across England, sub-region by sub-region, the NHS increased ventilator capacity and ICU beds at a faster rate than anyone could have imagined.

Without doubt this ability to rapidly move over 200 trusts to develop a powerful emergency purpose worked. And thousands of lives have been saved by having that ‘N’ in the NHS.

But in other ways central authority has been sorely tried when it should not have been. The fact that PPE and testing were organised centrally immediately created enormous distribution problems. Once you develop capacity from only the centre, you automatically create the problem of how to distribute that mask or that test to the millions of staff and patients that need them. If you have symptoms in Warrington, the existence of a test in Whitehall has proved to be not particularly useful.

Having capacity in Whitehall, or in a depot in the middle of the country, didn’t help when they were needed in this street and that street. It appears that the organisation of testing only really got going when someone came up with the idea of having a postal address to which to send the kit. Putting them in a car park 60 miles away didn’t work so well.

There has been a similar issue for volunteers. Whenever you go to a hospital you will quickly see that volunteers are organised locally. The friends of x hospital are there to greet you at the door. And the charity of x hospital are asking for donations for a new piece of kit. In the NHS voluntary endeavour is offered and accepted locally.

Very early on in this crisis the NHS asked for volunteers. Within a few days 750,000 people had responded to the call demonstrating the public’s wish to give to the NHS and its patients.

Most of the volunteers that I know have, a month later, not heard anything. Most of them have just got on with volunteering. The need for volunteers is local and specific. If that request for volunteers had taken place locally, (if only someone had thought of putting local authorities alongside postal addresses) matching with local people in need would have been much better organised.

The same is true for health care services in residential care homes. As NHS hospitals organised the response to Covid 19, for several weeks the local reality of vulnerable people in care homes was left out of much of the service. During the lockdown this local problem has been broadcast to the nation as being national. As the crisis had developed it had started to get regional and local airtime and eventually the national news picked up on this.

Care homes then became a national problem for the Government. But if the local relationships between the NHS and care homes had been better the solution of integrating services between the NHS and care would have been developed locally.

As the NHS gears up to meet the huge demand for health care that has been suppressed by the Covid emergency, most of the services that it will need to deliver are very local. For example, how you persuade men in their 50s with new lumps and pains to arrange a consultation with their primary care clinician to check for cancer. This will be local. The relationships do not exist to do this nationally.

But planning for the new post-Covid system is taking place centrally. To quote from one regional plan,

“The ICS is the primary level at which the new health and care system will be designed and delivered”


The ICS may well think it can design pathways of care. But it certainly won’t deliver them. That will take place within communities where relationships between a clinician’s community and the public will take place in different places and different cultures.

Physically we are a small country. But power is very centralised. We’ve learned that power needs to be more decentralised. That won’t be easy for the ‘National’ Health Service, but our future health depends upon it.