Feature

How national a health service?

That a ‘control freak’ government should adopt a centralising approach to the NHS comes as no surprise – but Labour policy is not quite so simple, argues Richard Lewis

With the announcement of a new ‘national plan for the NHS’ and the recent furore over the government’s apparent decision to bypass health authorities in handing out new resources, this is a good time to re-examine the question of centralism within the NHS.

Some commentators have suggested that the price of the government’s budget largesse is increased central control over the way in which the windfall is spent and, by extension, the NHS is managed. So does this represent a turning point in the government’s relations with the NHS? The extent of top-down control of local NHS bodies by the centre has ebbed and flowed over the years. Yet high public, and therefore political, interest in health services has meant that the management of the NHS has never been far from the minds (and hands) of politicians. The desire to control the development and implementation of health policy has been the common ground that has united governments of very different hues.

Certainly, Blair and the senior ranks of New Labour have faced frequent charges of ‘control-freakery’ in a number of policy areas. The Prime Minister’s decision to take personal charge of the NHS ‘modernisation’ agenda and the establishment of a new Cabinet committee to agree and monitor standards for health care in England (chair: T Blair) suggests that the NHS, too, will feel an increasingly firm hand at the tiller. And yet there is a curious ambiguity that runs through Labour’s centralism – at the same time as new ‘top-down’ mechanisms are being implemented, the language increasingly stresses the need to involve front-line staff. This is the same ambiguity that has characterised Labour’s instincts towards regional government – a great idea in principle but uncomfortable in practice. So three years into the Blair administration, what can we learn about centre-local dynamics in the NHS?

First, the evidence of increased centralisation. A major plank of Labour’s health policy has been to reinforce the ‘national’ nature of the NHS. This has focused on the need to reduce inequalities in health and variations in the quality and quantity of care. In particular, bringing to an end ‘postcode rationing’, resulting in patients in neighbouring HA areas experiencing very different access to services. This policy aim has stimulated three key reforms to the NHS.

First, National Service Frameworks (NSFs) have been announced for a wide range of key service areas (including coronary heart disease, mental health, cancer and services for older people). The NSFs set out standards, services and indicators that are to be implemented nationwide and have been described by health secretary Alan Milburn as a ‘blueprint’ for local NHS services. Second, the National Institute for Clinical Excellence (NICE) has been created to provide advice to the NHS on effective treatments and to promote and spread good practice. NICE is accountable directly to the secretary of state for health. Third, the Commission for Health Improvement has been established to, among other things, review clinical governance arrangements in local NHS bodies and to monitor the implementation of the NSFs and NICE guidance. Importantly, it also has a role to investigate and intervene local NHS organisations suspected of serious failures.

Taken together, these new mechanisms provide government with powerful planning and performance management levers. While many governments may have harboured centralist intentions, New Labour has now created the tools to turn these aspirations into reality. And further evidence of centrist tendencies can be found. The fact that the government has announced a ‘national plan’ for the NHS suggests a more sophisticated approach to setting and monitoring standards and a greater role for government in overseeing management. The government’s attention to micro detail has been notable – it has even announced national standards for the cleanliness of wards.

New Labour has also recognised the strength of financial incentives in delivering their strategy. While the decision to bypass HAs following the budget may be a case of ‘over-spinning’ (since in reality, the allocation mechanism was little different to that used previously) the government has tied local hands with clear expectations on how the money should be targeted. This is hardly unprecedented. The clearest example of the government seeking to control the policy agenda through its control of resources is that of the Health Modernisation Fund. By channelling resources through the fund (rather than through general allocations), the government is able to promote its own concerns and to reduce local discretion to pursue different priorities. The fund is considerable – more than £3bn over the lifetime of this Parliament – and more than half is held centrally for allocation directly by the NHS Executive.

While it is not yet clear what shape the new ‘national plan’ for the NHS will take, it will be supported by the additional resources announced in the recent budget and due to be allocated this summer. This suggests an emerging central policy agenda that will be far more sophisticated and comprehensive than the limited range of targets and indicators (such as waiting lists and waiting times) that have driven governments so far.

But it would be wrong to ascribe wholly centralist tendencies to New Labour. Some innovations introduced by the government have had distinctly decentralising overtones. The creation of Primary Care Groups and their evolution into Primary Care Trusts has led to the development of new NHS organisations far closer to local communities than ever before, with considerable power to shape services. A significant part of their remit is to involve patients and the wider public in NHS decision-making. PCTs must have a majority of lay members on their boards, opening up new opportunities for public participation in the formal governance of the NHS.

Another important, but surprisingly unpublicised, example of decentralisation has been the advent of Personal Medical Services (PMS) pilots. The monopoly of the national negotiating mechanism between government and general practice that has characterised primary care for so long has been broken and replaced by local contracting for GP services between the pilots and their local HAs or PCTs. Old-fashioned ‘corporatism’ is giving way to a looser – and far less predictable – form of planning and decision-making. Although introduced by the Conservatives, New Labour has been responsible for the implementation of PMS pilots and now looks set to transform them into a permanent flexibility.

The government has also emphasised the importance of local innovation and initiatives in setting the future benchmarks for the NHS. The best have been awarded ‘Beacon’ status. A National Primary Care Development Team has been created with the specific remit to advise and support 40 PCGs and PCTs, and develop new models of service.

New Labour has also used the rhetoric of decentralisation, speaking often of putting frontline doctors and nurses in ‘the driving seat’. It was this sentiment that led to the government’s anxiety to ensure that recent funding growth found its way directly to service providers and was not held at HA level. This has also led to ideas (or gimmicks) such as announcing that every charge nurse will receive £5000 directly to refurbish hospital wards.

The government has been keen to renew its own relations with the ‘grass roots’, unmediated by layers of bureaucracy. This has led to a number of interventions designed to allow NHS staff and patients direct access to policy makers at the very centre. The ‘national plan’ for the NHS will be drawn up by ‘modernisation action teams’ involving more than 100 doctors, nurses, managers and patients. In addition, Alan Milburn has recently announced a national tour so that ministers can meet staff from every PCG, NHS trust and HA in the country.

So how does one judge the performance of the government so far – control freaks or decentralisers? The balance sheet suggests that neither label is wholly justified although a drift to centralisation seems apparent. New Labour clearly sees health as a policy area where the ‘forces of conservatism’ still hold sway and attempts to modernise must be driven through using ministerial will. It is for this reason that the government has been determined to press ahead with the introduction of NHS Direct, walk-in and healthy living centres despite the, at best, lukewarm support from the professions. If the government is to finally end the resource drought that has plagued the health service for so long, the price will be an NHS shaped very much in New Labour’s own image.

The government has sought to create new alliances with ‘hands-on’ health professionals, often by shunning traditional routes of communication within the NHS. This direct approach is, perhaps, more suggestive of a brand of populism than of decentralisation. Selected and often unrepresentative individuals (albeit many with credibility in their own fields) securing access to central decision-makers does not guarantee good policy. Nor does it create structures that ensure effective local planning and implementation.

But perhaps Tony Blair has correctly read the mood of the public, which seems to share his concern over the variability of access to and quality of NHS care. Given this, the introduction of NICE and NSFs appear long overdue.

Whether the top-down instincts of the government can be reconciled with vigorous new PCTs potentially introducing a powerful local dimension into health care planning remains to be seen. In the new NHS – with a national plan, national standards and service frameworks, and a new enforcement arm in CHI – how much local difference will really be acceptable?