How much localism in healthcare is too much?

By and large, I share the view that England is overcentralised.

Local government has been excessively defenestrated over the years and one of the NHS’s problems has been the requirement for everything to be the same everywhere, in terms of managerial and administrative structures.

Similarity not necessary

One of the great attractions of the Five Year Forward View was that it didn’t fall into this trap. It was the first NHS document I can recall that said NHS structures did not have to be the same everywhere.

Instead, it suggested that we might move to a system where, at two theoretical extremes, a powerful clinical commissioning group might effectively take over a struggling local hospital, or a powerful and effective hospital might take over struggling primary and community services, with the aim of both being to provide better integrated care that might lead to something closer to an accountable care organisation.

One of the NHS’s problems has been the requirement for everything to be the same everywhere, in terms of managerial and administrative structures

Given this, it is no surprise that I approve of Greater Manchester’s “Devo-Manc” experiment as well as the devolutionary element of the sustainability and transformation agenda. But that still leaves me with major reservations about heading all the way down the localist route and, in particular, the possibility of handing health over to local government completely.

My reservations come from a paradox and too much memory.

Challenges of localism

The paradox is one I once heard Tony Travers put eloquently in a quote I have long since lost. It broadly went like this: if you ask the British electorate if they want more local control, the answer is almost always yes, but with that goes with an almost Reithian belief in shared standards and equity. These two desires are almost impossible to deliver in tandem; more local control will almost inevitably lead to more variation.

Meanwhile, the memories come from the 1970s and 1980s. One of the effects of the 1974 reorganisation was to put local authority members on the boards of health authorities. Conceived during a time of considerable financial stress in the NHS, local government members often fancied themselves as the “representatives of the people” within the service. The result was less an attempt to solve NHS problems locally and much more a desire to blame central government for a lack of resources.

I will never forget the results. For example, Patrick Jenkin in 1979, putting commissioners (illegally as it turned out) into the Lambeth, Southwark and Lewisham Area Health Authority when it refused to make the cuts needed to balance its budget.

What the 1974 reorganisation provided was representation without taxation; a locally democratic voice with no direct responsibility for raising the money 

That was then. The political climate within local government now is not so sour, even after seven years of austerity, but the stories go to a key issue. What the 1974 reorganisation provided was representation without taxation; a locally democratic voice with no direct responsibility for raising the money, which pitched itself against the body that did have that responsibility – central government. This has yet to happen in Greater Manchester, but that is not to say it cannot happen again.

Meanwhile, the alternative – a move to representation with taxation – would be an enormous shift, even if for some it would be the logical solution to the “1974 problem”. It would make the already controversial proposed changes to business rates look like small change; devolving the NHS budget to local government would essentially double its size overnight. Moreover, it would strain the tension between the public’s desire for localism as well as universalism to breaking point and my guess is that they would ultimately side with the latter.

So, while more localism in health and care should be welcomed and indeed, it may be that we haven’t gone far enough for many sustainability and transformation partnership leaders, let’s not pretend it doesn’t throw up a huge range of challenges. These are questions that policy makers need to think about and ideally answer now, at the start of the devolution journey, rather than pretending they don’t exist.