We’ve all gone local these days. The health secretary is handing power to GPs. NHS chief executive Sir David Nicholson is giving a bigger say to patients.
Speaking to patients, however, I am often struck by the value they place in the national part of the NHS. Indeed, some are starting to think that the pendulum has swung too far towards local discretion.
The new consultation document on the NHS Commissioning Board is a helpful start in explaining the role it will perform but it does not answer the criticisms levelled by Professor Roger Boyle. In particular, it says too little about the board’s role in driving quality improvement or its capacity to support that work. Local decision making is crucial but it has become unfashionable to say that major change often requires drive, coordination and scrutiny at a national and regional level, too.
“One of the reasons for the success so far of the stroke strategy is that it was developed as a national strategy with national backing,” says Jon Barrick, chief executive of the Stroke Association. “The difficult issue of reconfiguring stroke services has required an input from the strategic health authorities and the local stroke networks, who were supported by the national NHS stroke improvement programme.”
It helped, too, that the strategy was backed by additional national funding of £105m to cover a successful national advertising campaign as well as stroke support from local authorities.
The respiratory strategy is at a much earlier stage but again national and regional leadership has been vital in establishing momentum for change.
One of the key questions for patient organisations and medical bodies about the NHS reforms in England has been where strategy and planning will sit. The profusion of clinical commissioning groups, senates and networks has not made that much clearer and there are mixed signs about the future of clinical strategies.
I predict controversy about drugs, too. It is fair to say that patients have had mixed experiences of the National Institute for Health and Clinical Excellence. But in general, patients tend to believe that we are all in it together. Either everyone gets a drug if it is of clinical benefit, or no one does. The idea that someone in East Sussex might get a transformative severe asthma drug, while someone with a similar case history over the border in Surrey does not, would be hugely controversial for asthma patients. We see it now. The main reason that people are angry about prescription charges is the sense that the current rules are so arbitrary: if you have diabetes you qualify for free prescriptions, if you have asthma, you don’t. The changes to NICE’s powers will ramp this discontent up a degree further.
You can’t defend it as postcode democracy – small groups of people who need expensive drugs will have no realistic influence on decision making. That’s why we have NICE: to act in a way most people can accept as being fair.
Overall, patients have a distinct preference for national consistency. “When it comes to whether treatments should be available based on where we live or available nationally the British public know what they want,” says Dan Wellings, head of health research at Ipsos MORI. “Every piece of research we have done in this area tells us that national trumps local. Seven out of 10 of us think that treatments should only be available on the NHS if they are available to everyone and not dependent on where you live.”
Until very recently, the political narrative has argued that the NHS needs to change because it has not been successful. That seems likely to reinforce patient anxieties about standards and in turn accentuate worries about fairness. And local clinical leaders often need the support provided by national programmes and regional planning as well as political cover for what are inevitably controversial decisions.
Shifting from national to local could simply shift the blame but leave the odds for success unchanged. My hope is that the NHS will continue to build on the stroke strategy, not look back on it as one of the last and best documents of its kind.