Jury still out on NHS independence

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The King's Fund Deputy Policy Director Anna Dixon welcomes the debate around creating an independent NHS and reducing political interference in the day-to-day running of the health service, but says an effective case still has to be made for full arm's-length governance.

The question of NHS independence is once again being raised as demands for less political interference in the day-to-day running of the health service gather pace.

In case you missed it, this was the 'big health idea' of the political party conference season. The three main political parties seemed to have caught the bug – with politicians of all persuasions calling for a shift in power away from the Department of Health and government ministers.

Chancellor Gordon Brown floated the idea of giving greater independence to the NHS – similar to the Bank of England’s monetary policy committee. Health Minister Andy Burnham called for a BBC-style charter for the NHS.

Although details from the Chancellor were vague, Mr Burnham was slightly more prescriptive and suggested the idea of an NHS constitution that would be renewed every 10 years, mimicking the BBC charter process.

The Conservatives joined the party and reasserted their interest in the idea. Speaking at the King's Fund earlier this month, their leader David Cameron announced his party's intention to introduce an NHS Independence Bill in the new year that would stop the NHS being treated like a 'political football'.

Shadow Health Secretary Andrew Lansley set out the three main elements of the Bill. First, it would create an independent NHS board responsible for the allocation of resources and the commissioning of services. Second, there would be an economic regulator, modelled on Monitor, and a quality regulator, modelled on the Healthcare Commission, to regulate the providers of health care. Finally, a consumer health watchdog would be established with power to intervene through the regulator to ensure that patients get the services they need.

The Liberal Democrats also nailed their colours to the mast by backing more independence for the NHS.

Given the political interest in the issue, the prospect of greater independence may not be too distant a reality. Yet, the idea of an independent NHS board is not a new one. Since the inception of the NHS, central management of providers has waxed and waned.

Radical changes to the NHS mean it's hard to see what management functions are left to hand over to an independent NHS board. The NHS is increasingly characterised by devolved management of local services. The day-to-day running of health services is being put in the hands of local managers and boards as more NHS trusts achieve foundation trust status. Regulation of providers is carried out by semi-autonomous organisations, such as the Healthcare Commission, Monitor and NICE, responsible for ensuring quality, financial viability and cost-effectiveness of services.

However, further debate is needed to clarify the respective roles of regulators, the Department of Health and parliament in taking decisions about funding, setting standards and defining the strategic objectives for health and health care. We need a debate on how to ensure that the actions of a devolved and diverse health system meet clear policy objectives that have public support. This is likely to involve more than a 'simple' structural change at the centre.

Of course, there is something attractive both to politicians and to professionals about separating the making of policy from the running of daily business. But politicians will always look to meddle in the health service – after all we're talking about a £100-billion business funded by taxpayers. Patients and the public rightly demand political accountability from their elected representatives. Perhaps we shouldn't be talking about taking politics out of the NHS, but rather about putting the right kind of politics in place.

The Department of Health, regulators and parliament all have a legitimate role to play. Going forward it will be important for politicians to be clear about what those roles are and to ensure that decisions are made openly.

The NHS is much more complex than either the Bank of England or the BBC. An effective case still has to be made as to whether full arm's-length governance will guarantee a better health service.

This article was originally published in Insight, The King's Fund bi-monthly update, October 2006.