London Eye: The NHS is getting less democratic

Since the last London Eye there has been another joint chair across trusts announced, and it is the biggest so far.

Does having fewer chairs at hospital trusts in London matter? Does it make the system less democratic?

To be clear, the system currently is not very democratic. When was the last time an FT’s governors overturned a decision of the board? Most people are not even aware FTs have governors and what their powers are.

The ongoing chair-icide in London makes the system less democratic by concentrating power in the centre. More power in the centre can be a good thing but it’s worth remembering that, had the regional tier had things more its own way over the last 15 years, then there would be only severely downgraded versions of Lewisham, Kingston and Whittington hospitals left. The pandemic response would not have gone better without these A&Es and related services.

When the regionally-appointed special administrator’s plan for South London Healthcare Trust called for the closure of the A&E at, er, another trust altogether (Lewisham) it was principally the objection of Lewisham Clinical Commissioning Group that stopped it. Now that there is no Lewisham CCG — it is subsumed into South East London CCG, and the same has happened across London — that counter-balance to the wishes of increasingly distant and unaccountable regional and national tiers is removed.

NHS London (when it was a strategic health authority) had a board, board members and board meetings – the current regional tier has none of those things in public view but nonetheless makes big decisions. Indeed the term “heavy handed” is sometimes used to describe it.

Especially on appointments, and the latest joint chairdom is the biggest yet, covering all four of the north west London hospital trusts (Hillingdon, LNWUH, Imperial and Chelwest). The first two of these already have a joint chair in former National Audit Office boss Sir Amyas Morse. It’s not clear whether Sir Amyas will take over the roles for the inner NWL trusts too, but that would seem logical.

He would be the next substantive chair for Imperial after Paula Vennells, who was given the job in April 2019 and stood down this year, after the huge injustice she had (in part) overseen of sub postmasters at the Post Office started to come through the courts.

To be fair to regional director Sir David Sloman, there have been moments in previous leaderships where trust chairs have thwarted the region’s designs.

Shared chairs shouldn’t mean individual trusts are run less efficiently, although that is possible, and it could allow regional projects to proceed more easily. But in a system that is already not very democratic, is further centralising power like this a good idea, especially to a tier with a “new approach to [public] consent”?

The one eye to rule them all

Talking of central decisions that would not have been popular, the regional office has confirmed it is not going ahead with the plan to make Moorfields Eye Hospital FT responsible for the whole of London’s ophthalmology waiting list. To be clear, this would have been overseeing the waiting list, rather than doing every procedure at Old Street.

Like everywhere else, London has terrible backlog issues in this specialty. Moorfields has already led the stop-start attempts to centralise high-volume low-complexity work into one centre per ICS. It has also effectively franchised its services to other trusts for years.

So maybe in the long-term it makes sense: they are the experts after all.

However, that the move has been suggested a few times since last summer implies that it was being thought of as a rapid fix for the current problems, rather than something more considered.

Putting one trust in charge of a large specialty across the whole of town is potentially a governance nightmare, as well as making accountability less clear.