What NHS England isn’t telling you, and more indispensable insight for commissioners. By senior bureau chief Dave West.

One of the first tasks as NHS England and NHS Improvement embark on their latest “joint venture” together is to fix a problem that has become an embarrassment: the complete lack of a clear, capable strategic NHS function for London.

It’s not a situation unique to the capital but a few things make it a lot more pressing for London.

Unlike the rest of the country, London managed to retain a degree of unified leadership and autonomy at regional level after the 2010-13 implosion.

That was partly down to individuals (former NHS London deputy chief Anne Rainsberry stayed to hold the ring and some decent working relationships were maintained) but also due to a recognition that it was necessary.

A major capital city, with a powerful elected mayor, a need to be represented internationally, not to mention a huge health system which is relied on nationally, obviously needed a bit of agency and autonomy.

Disastrously, it seems this status was chipped away at, perhaps contributing to Ms Rainsberry jumping ship last year.

Her replacement as NHS England’s London director, though a big hitter, is working the job part-time, on an interim basis, and is not well acquainted with London’s NHS. Jane Cummings’ other job, chief nursing officer at NHS England, can unsurprisingly be time consuming; and, as in the other regions, NHS Improvement operates independently.

It feels like particularly bad timing, partly because there are signs that London local government and mayoral interest in health is higher than usual. Just as the mayor and others may be knocking on the door to talk about public sector estate, affordable housing or pollution, in the NHS there is no one home to answer.

Inside the NHS, the lack of a single, capable London function leaves space for strong leaders to make their own weather, with no guarantee this is fair or works for the city. Elsewhere, there is confusion – last year saw a plank of north west London’s high profile reconfiguration plans put forward apparently with NHSE backing only to be knocked back at board level by NHSI.

Big and high profile trusts are falling over, which is nothing new for London, but support networks and a leadership community to help deal with it are weakened.

Travel and interdependencies across the capital mean planning at the level of its five sustainability and transformation partnerships, however able they are, would be insufficient. City-wide working can deliver: NHS London’s redesigns of stroke and trauma services are two of the UK’s most celebrated service developments of recent times.

What will it take to fix the situation? NHS England and Improvement have effectively already said they will make a joint appointment and they need to not let this drag on further.

They need to be clear the role has sufficient autonomy – not through a ceremonial song and dance about weak “devolution”, but clarity from the national point of view that the chosen person is in charge.

She or he needs the right balance between the objective of developing London as a health system and responsibility over day to day delivery, without national directors getting in the way.

Then the hard bit: getting the right person.

Some of this goes for other patches too, but in London it’s getting ridiculous.