We arrive at this conclusion on the basis that the structure of the NHS in London has become much more complex since April, with many more organisations involved in commissioning and regulating care than previously. The roles of these organisations are often ill defined creating a risk of incoherence and confusion at the very time when urgent changes in how services are provided are needed. The increased powers given to regulators, like Monitor and the Office of Fair Trading, to scrutinise service changes also mean that there are likely to be delays in implementing these changes, even when commissioners and providers agree that they are needed.
The alternative we propose is to designate NHS England's London office as the strategic commissioner of services across the capital, working closely with clinical commissioning groups (CCGs) to take forward the work started by NHS London and primary care trusts since Ara Darzi's 2007 review. Providers would work through three networks based on the footprint of academic health science networks and would be led by London's most experienced managers and clinical leaders. Each network would comprise foundation trusts and NHS trusts and network leaders would be empowered to bring about necessary service changes within the strategic framework created by commissioners.
All of this can, and should, be achieved without the distracting and destabilising effects of further restructuring. However, the approach we advocate requires that the rules on market regulation are either suspended or amended substantially to avoid harmful interference and delays in implementing service changes agreed between commissioners and providers. There is an inexact, but not entirely inappropriate, parallel here with the banking crisis of 2008 when the rules on state aid and mergers were changed in the face of deep and unprecedented difficulties in the banking sector.
The growing financial pressures facing many providers in London, evidence of wide variations in the quality of care, and the high proportion of providers yet to achieve foundation trust status mean that – in our view – a radical response of this kind is essential. It is unrealistic to expect fledging organisations like CCGs to be able to act with the urgency that is needed, not least because no other health care system places so much power in the hands of GP commissioners. There is also a grave danger that the fragmentation of commissioning between CCGs, NHS England and local authorities will make concerted action in dealing with London's challenges well nigh impossible. Only leadership by a strategic commissioner, bringing together managers and clinicians with experience of leading change in the old system (as seen in improvement in stroke care), alongside CCG leaders who have been handed major responsibilities in the new system has a chance of success.
Our thinking has been influenced by the experience of the Veterans' Health Administration (VA) in the United States in the 1990s which underwent a major transformation under the leadership of Ken Kizer. At the heart of this transformation was the establishment of regionally-based integrated service networks comprising a number of hospitals and other facilities in place of the fragmented, hospital-centred system that existed at the time. The VA's headquarters acted as the strategic commissioner and funder, holding the networks to account for their performance and transforming care delivery by reducing hospital capacity and investing in services in the community. By focusing on improving quality and outcomes, Kizer in effect 'saved' the VA, and an equally bold approach is needed to provide Londoners with the standards of care they have every right to expect.
- The full report: Leading health care in London
- Details on London's acute hospitals and their configuration
- Our infographic showing the relationships between health bodies in London
- Highlights from our report launch: What are the prospects for service change?
- Our press release on this report
- More of our work on London health care and systems