The health and social care white paper: How can increased central control work alongside permissive local approaches?

by Tom Hampshire Partner

Email +44 (0)7957 496863

A new white paper has set out the Government’s intentions to improve health and social care for everyone by building on the remarkable collaborations we have seen throughout the COVID-19 pandemic. It suggests a path of evolution rather than revolution, and it emphasises the duty to collaborate. However, there is much that it doesn’t explain – indeed it leaves some big questions unanswered.

PwC invited a cross-section of senior leaders from across the NHS to a roundtable event to reflect on the implications of the proposed legislation. These discussions highlighted concerns about how the system would work.

One of the most commented on aspects of the white paper on health and social care reform has been the degree of control that the Government is proposing to take over the system.

Much of what is proposed is very centralist:

  • consolidating arm's-length bodies (ALBS);
  • powers of direction over the new-look NHS England;
  • a flexible and amendable mandate;
  • requiring local authorities to provide data on social care;
  • the ability to fund social care providers directly;
  • and the ability to intervene earlier in reconfiguration decisions.

This is quite a shift in a landscape that, from 2000 onwards, had foundation trusts (FTs) and then subsequently clinical commissioning groups (CCGs) with very localised accountabilities. Many commentators are worried about this shift away from localised decision-making and note that some of these proposals may not survive parliamentary scrutiny.

Yet the white paper also commits to permissiveness on the detail of local integrated care systems (ICS) arrangements within broad parameters and it doesn’t propose a standard operating model for how the place-based and ICS-wide collaboratives are formed or the role they play.

There are hints of earned autonomy playing a part, and maturity matrices are currently being developed. So, this may offer a glimpse of the dynamics and culture of the new system.

Tighter control when needed, looser permission when all’s well - it’s something we have seen before. A previous administration abolished GP fundholding due to the inequality it had produced and standardised some of its principles in the policy to establish the universal coverage of primary care groups (PCGs) and then primary care trusts (PCTs). But at the same time, they established FTs which could take more local control if they were assessed to be capable and well governed.

This may feel like a feature of the relationship between the Government and the NHS and local authorities for now, but it will be a golden thread throughout the new system as NHS and local authority leaders wrestle with the relationship between the ICS and the place; and locally between the place and the neighbourhoods/ primary care networks (PCNs).

People on the ground talk a lot about the primacy of ‘place’ or of ‘the neighbourhood’/PCN in making decisions. But the driving principle should be what the evidence tells us about the best level to organise and deliver care in terms of outcomes and costs, not the dynamics of a one-size-fits-all could be seen to be anticipating problems.

In looking back through recent NHS history, we can assess how the tight-loose spectrum has worked or failed. Differentiating between having powers and using powers might point us towards some of the emerging legislation. Holding powers in reserve, while building models based on earned autonomy and respect for local democracy, might serve the new health and care system well.

If you have any thoughts, or if you would like us to talk to you or your senior team or board, please get in touch and please read our further three blogs on the white paper.

by Tom Hampshire Partner

Email +44 (0)7957 496863

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