We may be reaching what could come to be seen as an important inflection point for the NHS and general health policy. To understand its significance, it's worth going back to basics.
Eighty years ago, the NHS was born with two design weaknesses. The first is the service is too centralised nationally, a characteristic captured in Aneurin Bevan's promise that the sound of a bedpan dropping in Tredegar would ‘reverberate in the corridors of the Palace of Westminster'. The second is it is too locally fragmented, mainly because of the deal with GPs allowing them to remain independent businesses, but also because important elements of health and care policy have sat with local government.
Addressing these weaknesses has been central to every major reform package over the last 40 years. Each time the solution has been framed as separating commissioning from providing. Kenneth Clarke created GP fundholding in the 80s, and since then we've had Primary Care Trusts, Care Commissioning Groups and, recently, ICBs.
In each case, commissioning has been seen to fail – partly because it has never had the backing required, and partly because when commissioners challenge providers, it is providers who tend to win the argument. Faced with conflict and underperformance, a new minister feels the need to act. They can hardly abolish hospitals or primary care, so they scrap one commissioning model only for another to reappear a few years later. The way ICBs have been misunderstood, undermined and then savaged has looked an even more half-hearted attempt than previous reforms to put commissioners in the driving seat.
This is why the decision by health secretary Wes Streeting to announce new health deals for South Yorkshire and Greater Manchester is significant. Although the wording is ambiguous, it appears their new ICB chairs will function as deputies accountable to the mayors. As Streeting put it, the mayors ‘will take responsibility for driving improvements in health and care from cradle to grave, and for testing whether this model is more effective at shifting focus from hospital to community, from sickness to prevention, than the conventional NHS model'.
If mayors Andy Burnham and Oliver Coppard can show rapid and significant progress, others may soon be knocking at an open door in Victoria Street.
This could mark the beginning of a process of devolution and integration that finally addresses the NHS's two original flaws. If mayors hold the reins, their democratic legitimacy and influence over wider local public policy might give them the reach and leverage that commissioning has lacked. But there remains a long way to go.
Intriguingly, Streeting has set up an experiment in which this mayor-led model will compete with Integrated Health Organisations – NHS bodies, probably led by large acute trusts, which hold the entire NHS budget for their population.
Had such a competition been launched 18 months ago, the likely winner would have been easy to predict. NHS England has never fully understood or appreciated local government, and its world view has often been overly shaped by hospital leaders, including current and previous chief executives. But the executive is being merged into the Department for Health, which oversees social care and is more informed about, and sympathetic to, local government.
If mayors Andy Burnham and Oliver Coppard can show rapid and significant progress, others may soon be knocking at an open door in Victoria Street.
What will determine whether progress is possible? Three things will be crucial. First, mayors and their ICB deputies need to secure buy-in from NHS providers – acute, community, mental health, ambulance and primary. This will require understanding of the pressures on the NHS and having a long-term vision that works amid short-term financial and accountability constraints.
Second, it demands investment in capability and capacity to make collaboration real and lasting. This includes everything from shared data to joint job descriptions and a troubleshooting team able to intervene and resolve issues when they arise.
Finally, mayors will need to know that when they pick up the phone to London seeking advice, permission or flexibility, they will receive a sympathetic hearing and a useful response. A hotline to the health secretary will certainly help.
Matthew Taylor is chair of the Fair Work Agency
