Trust leaders urge ‘rapid return’ to local decision making

Chris Hopson said there was “nervousness” among local leaders about how the current “level four” national incident called by NHSE means some decisions normally taken at local level are now made nationally.

The move to level four – taken on 30 January – allows NHSE’s national team to direct all health service resources in England through its regional teams, while the government committed to provide “whatever extra resources our NHS needs to cope with coronavirus”.

Mr Hopson has told HSJ that if NHSE wanted to keep the level four incident in place it would have to “justify that publicly.”

HSJ has heard differing views from local leaders about this issue – with some happy with the emergency measures and others wanting to return to normality as soon as possible.

Mr Hopson said: “There’s a very natural tension here. Up to now we have been in a very serious incident. Clearly, there’s still the possibility that we may see further surges on a local or a national basis and we would want the NHS to be ready to deal with that.

“But what we’re also picking up is a concern from local organisations that they want as rapid a return to appropriate local autonomy in decision making — the way we have always run the NHS — as quickly as possible. Particularly given the need to restart services… local decisions will be vital because every trust and local system is in a different position.

“There is nervousness that a level 4 incident does hand NHSE/I and ministers a high degree of control over decisions that are normally made at local rather than a national level and there is a worry that when national leaders get extraordinary powers, they might want to hang on to them for as long as possible.”

It comes as NHSE/I is expected to publish guidance on “phase three” of the NHS’s covid-19 response, potentially setting out whether any system and finance rules will go back to normal. It may also give new national guidance on what capacity needs to be maintained for covid-19, and what are the priorities for other services.

Mr Hopson said: “Trusts are expecting a well defined national framework — the NHS must be clear about priorities as we won’t be able to do everything in this next phase. But they also want decision making about restarting services, finances and capital spending to be devolved back down to local level as quickly as possible.”

One trust chief told HSJ the level four incident should be stood down alongside steps to ease the lockdown in June. The source said: “The current financial regime encourages people to splurge money on covid and ignore where they are financially. We have got to get out of that.

“Level four should be time-limited and we’re supposed to get out of it as quickly as possible. It needs to be discussed because we can’t stay in level four forever.”

But other trust leaders said they were happy with the emergency measures. One leader said: “Level four has not been a big issue – it’s been quite helpful. We’ve met more often [with NHSE], [protective equipment] has been well managed.

“We’ve never been in a ‘command and control’ situation and been told, ‘this is what you should do’. I still feel in control of my organisation.”

Another leader said: “The large majority of trusts will be happy with the emergency measures, given the block contracts with the intention of delivering balance.

“Those that aren’t will probably be in surplus and / or wanting to see a return to PbR to maximise income, especially if they require an ongoing surplus to service loans etc.

“[The debate] is the first signs that pulling together in the best interests of the population in response to the national emergency may be already at risk of returning to a focus on individual organisations.”

However, a finance director told HSJ that a continuation of the current arrangements — with organisations expecting their costs to be met regardless of activity and without detailed scrutiny — risked some trusts not providing value for money, and a lack of an incentive to carry out more elective work.   

An NHS spokesman said: “Level four response protocols remain in place across the NHS until further notice, and will be periodically reviewed alongside the UK chief medical officers’ assessments of the covid alert level.”