The government is heralding the Cities and Local Government Devolution Bill—currently making its way through parliament, with broad cross party support for its intentions—as reversing 150 years of centralisation.
The bill opens up a number of exciting opportunities. Local partners—from Manchester to Cornwall, from Dorset to Hertfordshire—are making headway in their plans, with strategically aligned and integrated services at the top of the “to do” list.
But devolution is also an ongoing work in progress. The Memoranda of Understanding and parliamentary orders that are expected to form the basis of many devolution deals are important but, ultimately, early landmarks. Building new lines of responsibility, autonomy, governance, and accountability will take significant time and resource. Devolution requires strong local leadership and relationships, sustained commitment to local objectives, and constant attention to ensuring communities are realising its benefits.
What does that mean for the NHS? The bill’s key clause for the service is one that will enable the functions of a public authority (such as an NHS body) to be transferred to or shared with local government.
But clearly the functions of the NHS go far beyond delivering a set of services.
As well as reflecting local priorities, the NHS embodies a set of public expectations and national commitments. It is a substantial set of duties, rights, and responsibilities, from those in the NHS Constitution, to those of the secretary of state, clinical commissioning groups, and NHS foundation trusts and trusts in securing healthcare provision, continuous improvement, and public benefit.
The NHS delivers a highly complex and interdependent set of services, subject to day to day increases in demand and long term changes in need, and stretches from helping sustain independent living to providing one-off, highly specialised interventions. It is part of a national and global endeavour towards better health and wellbeing, as much as it is a local service in the neighbourhood. Its success is wholly reliant on the vision, expertise, and dedication of those who work for it.
Moreover, the NHS commands considerable financial resources to ensure access to high quality care for all through millions of patient and service user interactions every year. So proportionate, risk based regulation has a rightful place in the NHS, alongside its local and national accountabilities.
Yet at present, there is little solid protection in the bill for these aspects of the service. A government amendment allows for conditions to be attached to the transfer or sharing of functions—perhaps including, for example, a concomitant transfer of the public authority’s duties, accountabilities, and standards. While this is progress in striking a balance between local leadership and national standards, does it go far enough?
The government has resisted amendments that would make the bill more specific, framing it as an enabling bill, where local proposals will be negotiated with the government and tailored parliamentary orders made to devolve the powers appropriate to achieving the locality’s ambitions.
Attempts by peers to explore fiscal devolution to protect against financial challenges, or to make explicit the public authorities which could be affected and the range of powers which could be devolved, have been rejected on the basis that potential should not be curtailed and deals will be reached on a case by case basis.
Yet with many a slip twixt cup and the lip, it seems reasonable to balance the ambition of devolution with caution and challenge. What are the strings? Is the government giving enough? What is the local capacity? How are ongoing engagement and collaboration built into plans? Has the worst case scenario, as well as the best, been accounted for?
And in the NHS—exhausted by repeated politically driven restructures, and facing its own transformational and financial challenges—particular care needs to be taken. We should not protect what we have for the sake of it; rather we must protect what we have where it works and avoid destabilising the local progress that is underway.
The NHS is already in large part a devolved system, with provider organisations working according to the disciplines of board led corporate governance—something quite different from the politicised governance arrangements of local government. Moreover, while sharing some common ground with the wider public sector’s ways of working, the NHS has its own distinct organisational culture, which needs to be taken into account.
The duties, autonomy, and lines of accountability of the NHS are vital to its performance, and so should be an obligatory part of any transfer of functions. The NHS also has regulatory and supervisory functions that need to be safeguarded for all, rather than exposed to variability and potential conflicts of interests.
While we can expect many benefits of devolution, it remains crucial that parliament explores the full range of the bill’s implications to ensure clarity of intent and to avoid unintended consequences. This includes being specific where this will help clear the way ahead and give confidence across local areas. In reversing 150 years of centralisation, the government is setting us on a long term path of devolving powers to localities, which will outlive this administration’s intentions.
Ferelith Gaze is the head of public affairs, NHS Providers. You can follow her on Twitter @Ferelith_Gaze.
Competing interests: None declared.