The importance of place and the need to allow as much local discretion as possible is well known to national leaders and was reflected both in NHS England’s pre-Christmas document on integrated care. It is also clear in the Department of Health and Social Care’s White Paper that sets out the plan for new legislation, even if with perhaps counter-intuitive results: to avoid a one-size-fits-all statutory approach to this critical building block, it simply avoids putting forward any specific new legislation at all to underpin arrangements at place (there are other proposals that could indirectly help working at place, such as giving NHS organisations a duty to collaborate). The goal of maintaining the current more permissive approach to place-based working shouldn’t be misinterpreted by parliamentarians to think that somehow place isn’t important. It is - but there is no simple statutory model that can preserve the energy and tailoring to local circumstances, communities and services that are so vital to success.
Assuming the current more permissive legislative approach survives contact with parliament, there is still a deep historical and cultural challenge to the NHS from a new way of working that accepts and supports greater local autonomy on the ‘how’ services work together as well as the ‘what’ they choose to focus on. Whether its clinical commissioning groups, primary care trusts, primary care groups or health authorities (and the long line of organisational structures that precede them), the NHS has been characterised by one model, applied all over the country with identical structures and responsibilities. At times and for some areas it also meant limited room for maneuver over the scope for any local priorities as well, largely because the long list of national priorities left little time or resource to do anything else.
To make this change the NHS will need to become comfortable with a greater variation in the models of governance and delivery. These models will also include non-NHS partners at their core, whether local government, the voluntary and community sector or social care providers. Of course, they will also include general practice, which while core to any definition of the NHS are not in themselves NHS bodies in the way trusts and foundation trusts are. This is important as these bodies are outside the formal NHS management chain and have different cultures and histories. This may be a particular challenge to those who grew up with NHS command-and-control performance management. There will also be genuine concerns over governance and transparency, and although not for legislation, national policy-makers should need to set clear minimum expectations for both.
National and regional leaders will also need to hold their nerve: organisations and geographies that have been seen as high-performing have often had, de facto, a higher degree of autonomy than others. The real challenge to more traditional approaches will be in areas that are not seen as high performing, where there maybe a temptation to revert to more traditional, organisation-specific, intervention and control. This is not to say that this new system will go ‘light’ on poor performance, but it does mean that systems and places should lead the improvement effort and be allowed time to make changes.
Lastly, while it is important to get local ownership at place, this does not mean that everyone has to re-invent their own wheel. There will be many common challenges – how to allocate resources to place in a way that is equitable and efficient for example – where the centre can share its expertise and provide support and tools to local areas. Ways to structure provider relationships and collaborations at place will be another. It will also be important for areas to be able to learn from one another as they evolve and this can clearly be facilitated rather than each having to find their own way. Our report seeks to support this by setting out a series of principles for local health and care leaders to help them in their efforts.
Does a leopard ever change its spots? Will the NHS step away from one-size-fits-all and a tendency for centralisation? The case for greater local autonomy has been made before but never truly lived up to its potential. I think there is reason to be more optimistic this time, not least because the legislative approach adopted by the Department and NHS England and NHS Improvement is designed to keep the space free for greater local determination. But away from Whitehall, as a generalisation, wider system partners are more engaged now than they have been before (partly driven by the need to co-operate arising from the Covid-19 pandemic) and there is a greater awareness of the opportunities system working at place can offer and greater learning on what is needed for success. Of course, being aware of the danger of slipping back into old habits is also the first step in avoiding them.