Devolution in the NHS – could it work this time?

‘The NHS is more hierarchical than almost any other organisation I can think of.’ This was the most striking sentence in Wes Streeting’s speech on 13 November to NHS Providers. It was also refreshing. 

Speak to anyone working on or close to the frontline in the NHS and they will tell you that there is a degree of top-down control that routinely stifles innovation, creativity and just basic good sense. It also generates deep wells of frustration that depresses morale, making recruitment and retention of staff a daily challenge.

In place of this hierarchy, Streeting outlined a sweeping plan: triple devolution. Power and resource will be pushed out of Whitehall to integrated care boards, to providers and to patients. Ultimately, the centre will be much smaller, issuing far fewer ‘diktats and demands’.

But there’s a catch. (There’s always a catch.) This new autonomy will have to be earned. That’s where the tough talk about sacking failing managers, setting up league tables for trusts, and centralised performance management of providers comes in. In essence, the NHS will have to prove it is grown up enough to be given the keys to the car.

For veterans of the long-running local government devolution debate, this will all sound very familiar. The Conservative Party in power had similarly bold plans to push power and resource out to councils and mayors on the basis of earned autonomy. The problem is it didn’t work very well. Councils got tied up in hugely time and resource intensive processes in order to demonstrate to Whitehall that they had the right to new freedoms, which were often refused, and then, even when granted, were underwhelming. The whole thing was painfully slow and so conditional that there were endless opportunities for the centre to water down the originally bold vision. As the great academic authority on local government Professor Tony Travers put it, the whole process just went to prove that ‘England is so centralised, it even does decentralisation in a centralised way’.

'As the great academic authority on local government Professor Tony Travers put it, the whole process just went to prove that ‘England is so centralised, it even does decentralisation in a centralised way’.

Perhaps Streeting and his team are fully aware of this risk, but it’s impossible not to worry that in a few years’ time the main legacy of their plan will be the league tables and the central performance management of trusts rather than a fundamental reshaping of the NHS. In short, when push comes to shove, Whitehall and Westminster always seem much more enthused by the earning bit of earned autonomy than the autonomy bit.

What went unsaid

It’s a worry sharpened by what the Secretary of State didn’t mention in his speech: culture. The autonomy and agility of those frontline staff mentioned above are stifled as much by the informal behaviours and mindsets that permeate the NHS as they are by its structures and distribution of resource. There is a ‘do to’ culture deeply ingrained across much of the health service which means power is exerted over those in less senior roles as well as over patients and communities, leaving them voiceless, disempowered and disheartened.

If the government is really serious about challenging hierarchy, it will have to confront this culture. Put simply, a wholesale shift from the ‘do to’ mindset to a ‘do with’ mindset that recognises frontline staff, patients and communities as equal partners in collectively driven change rather than unthinking cogs in a machine, passive recipients of care, or atomised customers.

'If the government is really serious about challenging hierarchy, it will have to confront this culture.'

Without such a culture change, even full-scale triple devolution will simply transplant the control freakery of central government into the senior leadership teams of the integrated care boards and providers.

Credit is due to the Secretary of State for finally putting his finger firmly on the biggest challenge facing the NHS after years of misdirection from previous holders of his office. 

But a big part of dissolving hierarchy is leaders recognising how their own ways of working may be reinforcing the very problems they are hoping to solve. If this process of decentralisation is itself shot through with a controlling mindset that favours structural shifts over culture change, then the high hopes expressed yesterday risk going the way of previous efforts to unleash innovation and creativity across the public sector.