Independence rules! Or does it?

James Gubb, 31 May 2007

Having an independent NHS seems to be the big idea at the moment. Cameron is all for it, Brown is pondering it and Andy Burnham, the likely successor to the embattled Ms. Hewitt, is apparently sympathetic. As are a number of influential bodies. Steve Dewar, Director of Health Policy at the King’s Fund, re-ignited the debate in 2003 with his paper ‘Government & the new NHS – Time for a new relationship?’; Fiona Godlee, editor of the BMJ has been a long-term supporter; the Health Services Management Centre at Birmingham University, including Chris Ham, argued for it in their paper ‘Things can only get better?’ (April 2007); the BMA followed suit this month in ‘A Rational Way Forward for the NHS’; and today the Nuffield Trust released a pamphlet by Prof. Brian Edwards reviewing the various forms independence could take.

Broadly speaking, most advocate an independent NHS board to take on the day-to-day running of the NHS, leaving ministers to set budgets and the overall ‘strategic direction’. The general idea behind this is that if we can stop the NHS being used a ‘political football’, then staff and managers could for once take a longer-term view and focus on delivering high-quality, efficient, patient care rather than constantly having to re-structure and re-organise to take account of the latest reform initiative, or constantly being wary of the next government attempt to micro-manage.
It is easy to have sympathy with this view. Re-organisation of NHS structures has, over the past decade or so, been hyper-active and, in numerous instances, contradictory. GP fundholding was abolished, only to be ultimately re-hashed as practice-based commissioning. New Labour apparently abandoned the idea of an internal market in favour of ‘partnerships’, only to re-introduce competition. PCTs were established and then subsequently many were merged. The same occurred with SHAs. Keiran Walshe went so far as to describe the NHS as ‘an organisational shantytown’. Then you have the contradictory stance of a government talking up greater freedom of various parts of the NHS from central control, but unable to resist the temptation to intervene where political pressures exist – most damagingly undermining NICE by fast-tracking the cancer drug Herceptin, undermining incentives for PCTs to become efficient by top-slicing budgets and, most recently, pressurising financially sound NHS Trusts to make a surplus in order to balance NHS books. Sounds like a reasonable case for an independent board, more sheltered from political pressures, to run the NHS within certain parameters?
But if it was made clear to the public that such a board was responsible say for all but the strategic direction and budget-setting, would the board react to the inevitable media storms and political pressures that would then come their way any different to an elected politician? It is also hard to imagine that ministers would not lean on the board at all, given the enormity of the NHS budget, £92bn. Separating what is policy and what is delivery, i.e. where the responsibility of the DoH ends and the responsibility of any NHS board begins, would be incredibly difficult. Would, for example, the board make decisions on NHS tariffs? Would the board make decisions on how to allocate budgets across PCTs? Would the board be able to set national standards? Crucially, would we even want a board formed (most probably) of unelected managers, health professionals and others making such decisions anyway? Yes, the board would be accountable to parliament, but would we want elected politicians presumably still ultimately responsible for the £92bn budget (the ministers) to be able to duck out of the loop?
However, these – though obviously important – are perhaps more technical matters. Ultimately, if an independent board was to deliver better services on the NHS, people probably wouldn’t be too bothered about an apparent democratic deficit. However it is far from clear that it would. As Julian Le Grand writes: ‘If you hand over the control of the NHS to this independent board, there is a danger that you are going to create not so much a BBC, operating competitively, and responsive to the needs and wants of the people who are listening to it, or watching its programmes, but something more like one of the old nationalised industries, which was not an efficient and effective way of running a service.’ In this sense creating an independent board is ignoring the more fundamental problem: that the NHS, because it is funded through general taxation and enshrines the principal that everything should be free at the point of use, will typically always have cost containment and not quality as its number one priority.
But even taking arguments over funding aside, the fact that Foundation Trusts (and ultimately all NHS Trusts) are already largely independent from direct government control; that PCTs are ultimately responsible for commissioning care; and patients now able to choose where they are treated, the ‘internal market’ could and should begin to remove the ‘political football’ effect. Ministers, if able to properly inform the public of this system, should be able to take more of a step back. If not, this is perhaps more of a case for an NHS ‘Constitution’ than an independent board. What is especially ironic is that creating such a board, at least on the vast majority of models posited by Prof. Edwards, would involve yet more of the radical structural upheaval that its creation is supposed to be the remedy of.