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The establishment of integrated care systems (ICSs), and, to a lesser but important extent, the emergence of large provider collaboratives begs the question of what NHS regions are for. October’s operating framework set out nine roles for regions, which represent NHS England at a local level. One might expect the forthcoming Hewitt review to guide, or tie, the hands of those regions in how they discharge their roles.
Yet just as some in the NHS argue for regions to go, or to go quiet, wider public administration in England becomes increasingly regional. Tied to the notion of levelling up, efforts continue to shift decision-making, with Cornwall the latest area to sign a devolution deal. Combined authorities bring together expertise historically held in local government upper tiers, but they also, crucially, take on roles previously held in Whitehall. Whether through Mayoralities or clustered investment zones the long, if slow, march to more devolved regional leadership in England is an established trend.
The NHS must no longer ignore that trend, nor imply that it has a more advanced alternative through 42 variously shaped ICSs.
A different role for the future?
Traditional regional functions have focused on joining up NHS organisations. Their number ranging from four to twenty-eight, it is a role that has always been retained (Edwards and Buckingham). The 2022 Health and Care Act’s landscape places an onus on co-operation, creates integrated care board (ICB) structures, and asks the Care Quality Commission (CQC) to regulate partnering behaviours.
However, it is the co-ordination beyond the NHS, not within it, where there is at least as much to do, and a lack of clarity on how and who. The NHS has to consider what its partners need from partnership, or it will design something alone that may struggle to fit the wider world.
There are three big roles for regions here. What they have in common is flipping the script from regions talking with local leaders about the here and now to regions as holders of foresight about health and care systems over the coming decade. All three roles below use the scale and endurance of the regional tier as an asset not an encumbrance.
Inevitably, future proofing starts with workforce. Not writing plans or holding scenarios, because such demand-side views will always be ground-level led but regions as the catalyst for supply-side innovation. There is a worldwide health and care workforce gap, and that means that those who are economically inactive need to be induced to choose the care sector. The sector needs leadership shaped to the dimensions of the real labour market where public services compete with retailers, industry and hospitality. This is local not national, but often a much larger local than statutory NHS bodies, even many ICSs. Shaping has to operate on behalf of the whole of health and care – distribution does matter between organisations amid ongoing scarcity. Regions can credibly shift funds from service to training, and influence how curriculums reflect future need not legacy delivery.
Economic development could seem far from the role of the NHS, even if it is the fourth priority from the 2022 Act. And yet the contribution that the NHS differentially already makes especially in deprived local economies is significant. Through spend and employment, the NHS is material to economic stability. The knowledge and digital economy are central to any growth plan. So inclusive growth and community development have to be something health bodies take very seriously. For all the great work of academic health science networks (AHSNs) in this space, their own success in many ways makes the argument that a regional-level view brings value to this field. Large investors are looking for the replicability and reach that that view can offer. Putting this remit at the heart of future health regions gives an unambiguous signal that the NHS seeks a key role in levelling up.
The public health world has been latterly restructured and risks being so yet again, despite gaps in the expert public health workforce. Regions sit at the heart of the Office for Health Improvement and Disparities and the UK Health Security Agency. If we see health inequalities not as the cost to be met to promote fairness, but as the route to sustainability – because the consequence of exclusion is profoundly expensive – then we need to ask regional bodies to guard the equity of outcomes that are being delivered at place. Addressing inequalities demands disruption, and the license to experiment benefits hugely from the heft of regional leadership as well as the space that scale brings for local comparison and study.
But that won’t happen, will it?
The implied working model is networked not hierarchical, based on knowledge and skills – with ICBs inviting in regional specialists. The NHS operating model has to cease its tendency to functional duplication where tiers oversee what is done elsewhere. Chris Ham and colleagues reported scepticism about their modest plea for behavioural change – a shift from top-down performance management. The proposals here are more radical – purpose not just style.
Health as wealth is an idea that has almost taken flight at times this century. Now may be its time, with a cross-party emphasis on growth, yet an unavoidable need to address health inequity if we are to improve outcomes. Regional bodies that are primarily about health - not about the NHS - can be central to truly devolved public services looking ‘out not up’.