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The role of regions in health and care: what can be done between systems and the centre?

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The advent of integrated care systems (ICSs) has driven a renewed focus on the role of local places within health and care. While ICSs themselves are large and typically cover populations of more than 1 million people, the key building blocks that sit underneath them are much smaller in scale.

Place-based partnerships bring together a range of organisations and professionals involved in the delivery of health and care services, and operate on geographies similar to those of upper tier local authorities. Below them, multiagency teams and primary care networks come together at the ‘neighbourhood’ level, working on patches of between 30–50,000 people. Within the discourse surrounding policy over recent years, we have also seen references to ideas like subsidiarity, and the need to localise and decentralise decision-making and power of all types has been a major theme in politics since the 2019 general election.

At the same time, however, the ‘centre’ of the NHS has remained strong. The Health and Care Act 2022 allowed several previously arm’s length bodies to be incorporated into NHS England, and there is still far more ‘vertical’ accountability in the system running to Ministers and to Whitehall than there is ‘horizontal’ accountability out to communities and the public.

We have a situation then where health and care has significant strength at the national level, and significant strength at the system level and below. But what lies between these two loci of power? In a word: regions. However, post-ICS restructure, it feels as though the health and care system is still trying to figure out what powers and responsibilities sit best in this squeezed middle tier.

'The challenge for regions is to harness their position on the midpoint of these axes so as to make sure that they can be ‘best of both’ rather than ‘neither nor’.'

The NHS in England is currently divided into seven regions, which according to the NHS’s Operating Framework, act as ‘the co-ordinating point’ between NHS England and ICSs, and exist to help those systems implement their plans and strategies. We then have other major organisations who provide regional leadership such as combined authorities. While sitting outside the NHS, the 10 combined authorities that exist in England have significant power over policy relating to the social determinants of health, in areas like housing, transport, the environment and economic planning.

So what role can these regional bodies play in helping us achieve better health outcomes?

This is something The King’s Fund has been thinking about in some recent pieces of work. If the benefits of local working are in granular knowledge and specific expertise, and the benefits of national working relate to economies of scale and leverage – then the challenge for regions is to harness their position on the midpoint of these axes so as to make sure that they can be ‘best of both’ rather than ‘neither nor’.

In order to make this a reality, we have identified five potential approaches regional bodies can take to boost what’s happening below them and influence what’s happening above. This enables them to be important players within the landscape of health policy, with a distinct role carved out for them based on the unique potential that exists in the space between local and national.

  • Hosting dialogue – Regional bodies have the ability to convene stakeholders from a variety of backgrounds. As collaboration is intrinsic to their role, they can help bring others together and encourage collaboration, between partners more focused on delivery and those more focused on strategy.

  • Influencing and brokering – Regional bodies can act as a bridge between the local and the national, taking specific priorities from their patches and communicating them up through the system to those involved with national level decision making. They can also lobby for further devolution of powers to their areas, so as to enable local strategies to be implemented and objectives be met.

  • Hosting expertise – There are certain types of expertise that are hard to justify investing in at a local level, such as skills relating to data, analysis, the law or leadership. By the same token, however, if those types of expertise sit only at a national level, then resources are likely to be pulled in too many different directions to be truly useful to each area of the country. Regional bodies are well placed to provide these skills to partners working below them.

  • Incentivising and stimulating – Regional bodies can offer incentives to partners to do or not do certain things in order to achieve agreed outcomes. Combined authorities may find it easier for these kinds of incentives to be financial, but regional bodies of all types can provide incentives and stimulation through their soft power, and the power they have simply through offering public recognition.

  • Monitoring and evaluating – Regional bodies can use their powers or leadership to try to ensure certain outcomes are achieved through partnerships. This need not mean taking on an old-fashioned performance management role – instead, the focus can be on bodies holding each other to account.

Regional bodies at present seem to be one of the areas of the health policy landscape that is most up for grabs. However, there can be real benefits to be gained from working at this level. Unlocking them means a renewed focus on what the regional contribution can be – and the list of approaches above offers a starting point for thinking that through.