NHS regions should be part of the NHS, not the department

The great health policy guru Nigel Edwards once quipped that the only things guaranteed to survive a nuclear war are cockroaches and regional health authorities.

And indeed, amid the messy abolition of NHS England, its seven regions have indeed survived. Though not, alas, in the form of health authorities. Instead, like the rest of NHSE these regions are to be rolled into the Department of Health and Social Care. This looks to be a mistake. They would work much better and be of more use to ministers if they were outside the department.

The NHS has, pretty much, always had regions (and, on the odd occasion when it has not, they have been re-invented) for the simple reason that the NHS is far too big to be run personally by even the most centralising of health ministers.

The role has not always had the title ‘region’ in it. They started out as hospital boards in 1948 and ended up as the ten strategic health authorities that Andrew Lansley abolished as part of his 2012 reorganisation. There was no provision for regions in that legislation. But pretty soon, and for the reasons just cited, the new bodies created by the act invented their own regional structures.

Regions are needed because at their best they act as a two-way transmission service. Telling the centre (for good or ill) about what is really happening on the ground (and thus what might actually be achievable), while telling the ground what the centre most cares about among the zillion requirements and initiatives that ministers have a tendency to launch. And helping enforce that.

With a board and a budget they can undertake the larger scale reorganisation of hospital services that can be needed – either on the grounds of quality as with the concentration in London of hyperacute services in 2010 – or across hospitals as the promised shift from hospital to community takes place leaving some hospital departments too small to be viable. They can drive innovation at scale which the Integrated Care Boards, even when reduced from 42 to 26 or so, are not always large enough to do – and a key aim of the 10 Year Health Plan is to drive digital and other innovation at scale.

Furthermore, they have an absolutely crucial role in talent management. These days, there is trouble finding sufficient people of calibre to apply for chief executive posts. Too much pressure. Too high risk. In the past, regions used to actively look after people’s careers, grooming individuals for the next step up – a job that can be better done over a wider footprint than just that of an ICB. This does still happen, but not as actively as it should. And an old role needs reviving. Namely ensuring that there are people with a grasp of the whole system, not just one bit of it.

One side effect of the purchaser-provider split is that managerial careers have tended to become concentrated on one side or the other of that. If the Integrated Care Organisations that the 10 Year Health Plan promises are to become truly effective, a cadre of people will be needed who have a grasp of all of acute and community care, and of general practice and social care, and not just one part of it. Social care aside, the old management training scheme, and some of the talent management programmes, used to do that.

And there is more. Not least that the regional jobs can be the stepping stones to the national ones which are not always easy to tackle if the jump is from a tier below that.

So the question is: are these regional jobs best done by civil servants operating inside the department, or by people with NHS operational experience working outside in the service? By an authority answerable to the centre, but not of the centre?

It is thought that none of the current regional directors particularly want to be civil servants. Currently they remain with their protected terms and conditions of service. But what happens when they depart? With these jobs operating within the department there will be a temptation to appoint a civil servant. As one retired but very senior civil servant puts it, ‘I do not think that jobbing civil servants with very little real world operational experience will be remotely up to the task of difficult conversations with the big beasts running NHS trusts. If these posts were to become staffed by civil servants, there will be a real Imbalance of power.’

In announcing the abolition of NHSE, Wes Streeting said it would involve ‘the biggest decentralisation of power’ in the history of the NHS. But he must know that by pulling into the centre the sort of honest broker voice that regions can bring, he risks doing the opposite of that.

It is clear that, in the aftermath of the hasty decision to abolish NHSE, some thought was given to turning them into proper regional health authorities rather than merely being creatures of the department. That did not happen, largely, one suspects, because it just seemed easier not to do it – although interestingly it is proposed that each region will now have a regional chair (but no board) to ‘strengthen regional governance and leadership’. Maybe that points to a bit of a rethink.

One key reason why ministers may not now want to create freestanding regions is that having abolished ‘the world’s biggest quango’, along with local Healthwatch, the integrated care partnerships and much else, they will not want the NHS Bill to be seen to be creating seven new quangos.

There is, however, a solution to that. Current NHS law allows ministers to create, by way of secondary legislation, Special Health Authorities. Current examples of these include NHS Blood and Transplant and NHS Business Services. Once the Act is through, and without the fanfare of primary legislation, ministers could use those powers quietly to recreate the regional authorities that one suspects they will discover they need.