A new government bill may not lead to true localism, but with new structures embracing decentralisation, it could be a big step in the right direction, argues Tim Care.

There has been much debate around the Localism Bill and whether it will succeed in making public services more relevant and appropriate to citizens. At the core is that powers will be moved away from Westminster and into local government and communities.

Debates in the NHS have centred on “no decision about me without me”. But is it just lip service? Will the organisations of the new look NHS live up to the challenge? Moreover, will the government be able to let go of the reins and actually allow the health service to be shaped by local communities?

The government has set out localism-style objectives in its response to the NHS Future Forum report, but I have my doubts about whether or not the government will actually be able to take a step back.

The bill has been criticised by opposition and lobby groups who believe it hides provisions that give powers direct to the secretary of state to make orders and regulations. Critics say the government still seeks to determine what should be done locally, rather than giving power to local authorities or communities.

The debate around the Health Bill focuses on a number of different areas. Critics were worried that the government was stepping back too far and losing its authority over the NHS – and its accountability. As a result the government has relented and agreed that the secretary of state will retain ultimate accountability for securing the provision of health services. It is made clear however that he or she will not be responsible for direct operational management. The secretary of state’s duty is only to oversee and hold to account national bodies; in particular the likes of the NHS Commissioning Board and Monitor.

Have we got the right structure to make localism happen in the NHS? On the commissioning side clinical commissioning groups certainly seem to fit the bill. These groups are drawn from practitioners in a defined region who live and work among the very population that they serve. Once approved by the NHS Commissioning Board and given autonomy over their share of the NHS budget, they will be able to make unhindered decisions in the interests of improving the quality of healthcare in their area.

The bill contains strong language about reducing inequalities and promoting patient and public involvement. Even the NHS Commissioning Board will now have a local feel to it with regional offices that will work more closely with clinical commissioning groups. If you add the idea of setting up local clinical senates and the government’s intention to strengthen the statutory health and wellbeing boards, you get a sense that decentralisation really is at the heart of these reforms.

Commercial conflict

What about the providers and, most importantly, the foundation trusts? Here you begin to see possible conflicts, not so much between the ideals of localism versus centralisation, but between localism and commercial necessity.

Foundation trusts already have a significant degree of autonomy and have been working with commissioners for some time to shape local acute and mental health services. Now, many of them also have a key role in community services, since the completion of transforming community services. Many of these trusts may also be looking to extend their businesses by merging with or taking over others that may not be able to meet the government’s timetable for converting to foundation trust status.

We will inevitably see many foundation trusts grow to become huge businesses; employing vast armies of healthcare workers across ever increasing geographical areas and, crucially, holding many of the key assets (like hospitals, equipment and know-how) that make up our health service. As they strive to integrate community services it may become more difficult than ever for these services to be split up.

If you add to all this the government’s wish to impose insolvency and competition regimes that mirror those in private business, you begin to see why there is some doubt that this model of health provision sits comfortably with the localism mantra.

Competition among providers is an essential element to driving up quality, but foundation trusts have been encouraged to set themselves up in a position of dominance in their markets, and it is questionable whether that is at odds with what the government is trying to achieve.

Avoiding intervention

It feels like there will be an uneasy partnership between government, commissioners and foundation trusts. As long as foundation trusts can protect their income and stave off insolvency, they will work well alongside commissioners; but this will not hold them back from taking difficult decisions to safeguard their businesses (just as it would not hold back a private sector health provider).

If the conflict proves too much for commissioners and quality suffers (resulting in, for example, increased waiting times), then to return to the original question, will the secretary of state be able to resist stepping in? Foundation trusts need to prove themselves to the Department of Health in order to maintain their independence, and there are many ways for them to ensure that this happens, for example:

  • Not paying lip-service to public involvement, but really engaging with their members and opening themselves up to public scrutiny, including board decisions;
  • Actively playing a leading role in the proposed clinical networks and clinical senates;
  • Listening to patients by encouraging their views and tying those views back to what the commissioning groups are saying;
  • Encouraging their clinicians to take up the challenge of sitting on clinical commissioning groups to create a vital link between the two aspects of our health service;
  • Generally, embracing localism in so far as it applies to the health service and instilling that culture always down the organisation.

Decentralisation is coming. Structures are being put in place to ensure that the power to shape the NHS is devolved down to local communities and that the decision makers are accountable to the public and patients. But the government is always waiting in the wings and will not be afraid to wield its big stick. The government will always be held accountable for the NHS by the public, and if this is the case we have to expect the secretary of state to wade in from time to time.

With the government constantly in a supervisory role, we may never achieve localism fully within our health system, but there is every possibility that we will have what Eric Pickles has termed “guided localism”.