Where are NHS England's powers going?
Research Assistant
Having regularly called for NHS England to be scrapped – most notably in April last year, but from as far back as 2017 – Re:State strongly endorses the recently announced news to abolish NHS England. (And our recent Quangocracy report raised the very issues with public bodies that the PM detailed in this speech).
We have consistently advocated for closing “the world’s biggest quango” because we believe in localised, devolved decision making. But NHS England’s abolition is only the first half of achieving this.
The other necessary component is decentralisation of powers in the English health system. A first step was taken in this direction with the creation, in 2022, of Integrated Care Systems (ICSs) to coordinate the delivery of health and social care across 42 regions.
Based on accountable care organisations, it was hoped ICSs would facilitate far greater integration of health and care services, which would in turn deliver cost savings, a shift towards prevention, less reliance on hospitals, services tailored to local needs and improvements in health inequalities.
Yet worryingly, recent announcements ask Integrated Care Boards (ICBs), responsible for the ICS’ NHS budget and commissioning services, to halve their running costs by December. This indicates the original vision for ICSs is increasingly a work of fiction, and the end of NHS England has not been explicitly connected with the urgent need for front-line empowerment and decentralisation.
For a long time, the English health system has been characterised by excessive overcentralisation. Vast numbers of targets, priorities and operational guidance for ICSs and NHS services leaves ICSs bogged down in meeting, and proving they have met, centrally set requirements rather than innovating for local areas.
NHS England’s abolition won’t be enough to fix this. DHSC has had similar criticisms levelled against it as those of NHS England. Consequently, whether the potential positive effects of decentralisation are felt will depend on who takes over NHS England’s responsibilities.
As argued in Close Enough to Care, DHSC’s role should primarily be a strategic one, instead of focussing on the day-to-day delivery and commissioning of services. There is no doubt some functions are best delivered nationally. Typically this is the case where economies of scale can be capitalised on, whole-system strategic thinking is required, standardisation is necessary or highly beneficial, a high degree of specialist input is needed, or collaboration with other national functions is necessary.
Practically, this means DHSC should only be responsible for a small number of functions, including things like regulating health services, allocating capital budgets, major cross-cutting infrastructure projects, national responses to medical crises, and commissioning highly specialised care for rare conditions.
Halving the operating budgets of ICBs at the same moment NHS England is abolished sends a worrying signal, and may also result in highly unequal outcomes. The size, capacity, and running costs of ICBs vary markedly, even when the ICS population size is accounted for. It is certainly important that overstaffed, ineffectively staffed or otherwise inefficient ICBs are forced to address this. But the new requirement applies equally to all ICBs, despite such huge variations in their operating models and efficiency, and despite the reality that many of these new institutions are still getting established.
In the face of an ever more expensive health system that is failing to deliver for so many citizens, now is the time for those in the centre to let go of some of their control. To evolve and decentralise the health service, the end of NHS England is just the start.