Fulfilling the role of a strategic health authority is not easy. Some would say it is a thankless task. Running the NHS at a regional level means acting as an intermediate tier between the Department of Health and local NHS services. This means being in the unenviable position of implementing countless central government policies, imposing targets and measuring the performance of local organisations. At the same time, SHAs ultimately answer to the health secretary every time something goes wrong locally and they have to respond to national problems, too.
Since the government wants the NHS as a whole and individual organisations in particular to become much more localised, accountable to the populations they serve and to look out to them rather than up to Whitehall, where does this leave SHAs?
At just 20 months old, their role seems increasingly contradictory. The government is seemingly intent on modifying the purpose of SHAs away from the day-to-day management of their local NHS organisations and towards a strategic role that will take an overview of regional healthcare.
Apart from the obvious economies of scale in slashing the number of SHAs from 28 to 10 in July 2006, staff cuts have been driven by a push to reduce central control and encourage local innovation. Roughly half of all pre-merger posts have gone, leaving around 1,500 staff.
Commentators saw the move as reflecting SHAs' weakening role in the face of drives to have all trusts become foundation trusts, which looks likely to shift the balance of power substantially in the regions, a trend that will accelerate as the newly empowered organisations grow in confidence, expertise and entrepreneurship. Meanwhile, there are plans to give primary care trusts greater autonomy if they are delivering on the emerging concept of "world class commissioning".
Reduced skills capacity
Managers' union Managers in Partnership launched an attack on government over SHAs' staffing levels, warning that staff cuts meant SHAs would struggle to do their jobs properly in future.
"We are really fearful of SHAs' capacity to deliver with such a small number of staff. They will say that a lot of the work will go to PCTs but we're not convinced that PCTs have either the capacity or desire to take that on," said MiP national officer Jim Keegan during the merger, describing the cuts as "draconian".
NHS London saw the biggest losses in terms of staff cuts; it now employs just 130 staff compared with the 730 who worked for the five former London authorities pre-merger. Chief executive Ruth Carnell admits in "some ways" she is "worried about not having the skills and capacity in the SHA".
However, she says that having a smaller staff can be positive. "I think that ultimately having a smaller number of staff was the right thing to do because SHAs have been forced to look at the big issues.
"It has also required people in the NHS to work differently and more autonomously and it also requires the DH to change."
Ms Carnell says the DH requires the collection of a lot of performance information from the NHS. SHAs are still the medium for this, a situation she says needs to change.
"In the old days, the DH could always ask for an SHA lead on something and it was realistic that someone in one of the old authorities could provide that detail, but now that is not possible."
She says SHAs now need to work with the DH to determine what greater autonomy means for PCTs, what is key to their performance success and what can be left to local variation.
David Hunter, head of Durham University's centre for public policy and health, says a smaller workforce is leading to a more hands-off approach by SHAs. "There isn't the capacity [for them] to meddle or interfere as much as there used to be, simply because there are fewer bodies around to justify their existence," he says.
"Some people would argue that they may wither away, having built up the other organisations. At the moment, PCTs are still in the shadow of SHAs, but the power balance will shift."
Perhaps unsurprisingly, NHS North West chief executive Mike Farrar disagrees. But he concedes that in future SHAs will spend less time working with individual trusts. "It's about making sure that there is a degree of competition in the system and maintaining standards," he says.
Mr Farrar believes much of SHAs' work will no longer be about day-to-day performance management, but about working with commissioners. They will be charged with creating a system without massive variations in quality, as well as managing the dynamics between commissioners and providers.
"The capacity of SHAs has forced them only to do what they can do in terms of taking a leadership role rather than a management role. In the future, that role will be one of guardianship and stewardship of the regional NHS."
Knights in shining armour?
What the new SHAs appear to have achieved to date is worth noting, if one considers the situation they inherited, including getting the NHS back on track financially and delivering a surplus for the first time. Work has now started to focus on strengthening PCTs to help develop them into world class commissioners. SHA chief executives are also proud of the role they played in helping the government through the painful episode that was the Modernising Medical Careers debacle.
As NHS South West chief executive Sir Ian Carruthers puts it, SHAs "rescued" the medical training reforms by working with deaneries when the DH pulled the Modernising Medical Careers computer system to make sure recruitment of doctors still happened.
"There was a definite role for the SHAs there in terms of intervention and crisis management," adds Ms Carnell.
However, some find this vision of SHAs as knights in shining armour coming to rescue the government from its Modernising Medical Careers disaster a little far fetched.
Sir John Tooke's October report on the programme questioned the government's decision to devolve workforce planning to SHAs in future and recommended regional workforce plans be overseen and scrutinised by a national committee with service, professional and employer representation.
The report also wanted SHA chief executives to be held personally accountable for building relationships with local education providers, even suggesting that this should be among their annual appraisal targets.
It said: "The inquiry remains to be convinced that distributing the majority of workforce planning function and the training commissioning function to SHAs will necessarily guarantee a better outcome and national consistency."
For the time being, the government itself seems unclear as to the future role of SHAs. Perhaps it is waiting for inspiration from junior health minister Lord Darzi's review of the NHS in May. But for now, the DH appears to be developing a somewhat contradictory relationship with its intermediate tier. On the one hand it still issues edicts from the centre while on the other it expects SHAs to develop a less prescriptive approach to managing their local NHS organisations.
For example, in October the DH felt the need to issue a stark warning to SHA chief executives to send "only the strongest" trusts to foundation trust regulator Monitor to be assessed for foundation status.
In a letter to all SHA chief executives, DH director general for finance, performance and operations David Flory said SHAs must ensure trusts are nominated only if the authority is "satisfied that they should be in a position to be high performing NHS foundation trusts".
In the same month, SHAs slashed the number of hospital providers eligible for top-up payments for specialist treatment, after coming under pressure to do so from the DH. SHAs submitted a reduced list of hospitals they deemed eligible for top-ups after the DH decided a previous list was too generous.
The list details all hospitals that will receive a payment above the national tariff in 2008-09, to recognise the fact that they treat patients whose conditions are more complex than average.
The new list cuts the number of hospitals eligible for top-ups in at least one specialist area from 90 to 69. And the total number of top-ups across eight specialist areas has been reduced from 295 to 266. SHAs also came under criticism for the way the revised list was drawn up, with trusts claiming a lack of consultation.
Taking an overview
This balancing act is one reason Chris Ham, professor of health policy and management at Birmingham University, thinks there will always be a need for an "intermediate body" between the DH and the NHS.
Despite the fact that their current functions - helping PCTs become world class commissioners, developing practice-based commissioners and ensuring that non-foundation trusts become foundation trusts - will eventually become obsolete, he does see a future role for the bodies.
"There does need to be some kind of system management and oversight of the market as it evolves. There needs to be some kind of strategic overview of the local population and how services are configured. The question is how significant a role that should be," he says.
"It depends on how you see system management developing. How does the NHS look out rather than up if there are still big SHAs in place?" says NHS Confederation policy director Nigel Edwards.
Mr Edwards says that if SHAs continue to look up and take direction from the DH, they will undermine the rest of the changing NHS system.
"Their future success ought to be measured on the extent to which they don't intervene and a lack of visibility could be a good thing. For them, it should be like running the infrastructure of a hotel or a hospital: if people notice what they are doing, it means there's probably a problem."
He adds that it is important to think in some detail about the future role for the intermediate tier of the NHS.
"Who watches the watchman? What is an assurance regime for SHAs if there is a risk that they could stifle the system they are supposed to help create?"
Office of the SHAs acting director Linda Hutchinson also believes that there will always be a need for an intermediate level of NHS management.
"We recognise that the SHA role has changed and continues to do so," she says.
In part prompted by the 2006 reorganisation, SHAs have been encouraged to become leaner, less concerned with micro-management, although the rhetoric of devolution far outstrips progress to date.
There now appears to be a broad consensus that SHAs will reduce their emphasis on performance management but will still have a role in the dynamics of the local health economy, ensuring fair competition and maintaining standards, as well as supporting trusts in difficulty.
But long term it is questionable whether SHAs will need to remain autonomous. Some even speculate that SHA functions could be subsumed by the government regional offices.
King's Fund senior associate Richard Lewis sees their future role as feeding into wider regional development and regeneration initiatives rather than playing any practical role in running the NHS.
Although this idea might not be immediately attractive to NHS leaders, future closer integration with other arms of central and local government on issues such as public health and health inequalities could be a rational move.
NHS East of England chief executive Neil McKay says the clue to the future of SHAs is in their title. "We will increasingly become more strategic. I think that it is inconceivable that the system could exist without an intermediate tier, but SHAs have got to get the balance right between managing the performance of the system and giving people the headroom locally as well."
Mr McKay says the authorities will develop a wider role working with regional government offices and development agencies, as well as spending time developing PCT boards "to help develop rigorous talent-management systems and develop managers for the future".
Feeding into this, in January the Appointments Commission published a review of the NHS appointments process, which recommended SHAs take on responsibility for the ongoing training of PCT chairs and non-executive directors.
"What a national organisation can't do that an SHA can is to help assure and develop local organisations. We have specific relationships with real people in the PCTs rather than just looking at them as a set of data," says NHS London director of strategy and commissioning Paul Corrigan.
He is unequivocal in his assertion that SHAs have a future. "They have a future role in terms of system management; our job is to help PCTs look after a system that is bigger than each one of them," he asserts, adding that it is the role of an SHA to intervene only if PCTs get it "completely wrong".
"We are like a sheepdog getting people moving in the same direction. You can't get them to do their own leadership; you can correct them while they are moving, but you can't get in front of them and direct them because they are supposed to be autonomous."
It remains to be seen what future role SHAs will really play: the role of sheepdog to PCTs - one in which system management plays a pivotal role - or the more strategic task of analysing the needs of their populations and becoming more of a presence in the health inequalities debate. But the debate needs to happen soon. Roll on the Darzi review.
Strategic health authorities: past, present and future
Original role, managing input and infrastructure in the NHS:
financial management
overseeing leadership development and people management
creating successful structures within and between organisations
Developing role, including process management:
creating and strengthening self-governing provider organisations in foundation trusts
developing strong commissioning in PCTs which has now devolved into world class commissioning
Potential role, outcome management:
system management across SHA
managing outcomes of relationships between commissioners and providers to ensure what the public wants is delivered
ensuring a system with minimal variations in quality
ensuring the right balance between collaboration and competition
having a strategic role in public health and health inequalities as well as healthcare
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