‘Secret plans to close hospitals’: the perils of centralism

Catherine Staite

The Kings Fund’s warning, that there are ‘secret plans’ to close hospitals, comes as no surprise to local government. A number of local authorities, including Birmingham City Council, Sutton and Camden have decided to publish the NHS’s ‘Sustainable Transformation Plan’ (STP) for their area, against the wishes of the NHS, because of concerns about lack of transparency and particularly the lack of engagement with communities about the best outcomes.

Anyone with any knowledge of public services and complex systems will understand that the NHS needs radical reform.  Resources are trapped in hospitals but the need is mainly in the community, particularly for people with long-term conditions and the frail elderly.  It is widely accepted that we need to shift from a reactive ‘each emergency as it comes’ approach, to a more proactive strategy.  The changing demands of an ageing population, who need a combination of proactive medical and social care, close to home, are also widely acknowledged.

We could meet these challenges through an holistic ‘cradle to grave’ approach to prevention, early intervention, self-management and better use of technology, co-designed by all key services, in partnership with the public. In spite of the long-standing consensus that such a strategic approach is needed,  we seem doomed to prop up an inefficient, centralised health service because no-one seems able to start the conversations which could activate the levers of change. So we go on from year to year, teetering on the brink of catastrophic failure. The fact that we haven’t yet had a catastrophic failure, has created misplaced confidence in a ‘muddling through’ approach – but we are on borrowed time.

Simon Stevens has articulated the problems and solutions very well in his plans for the health service.  What it may be hard for him to acknowledge is that you can’t change an over-centralised, monolithic service like the NHS by behaving like an over-centralised monolith.  The NHS operates in parallel universe, underpinned by a deficit model in which the answer is always more money for the NHS. Some STPs do propose radical changes in service configuration, including hospital closure. Those might well be the right approaches but require careful, deliberative engagement to avoid a hugely damaging backlash. We need a fundamental shift in attitudes and values for everyone, including the wider public, patients, carers, front-line staff, managers and ministers, in order to engage in a very different sort of collective conversation.

Local government has a crucial role to play in the reform of the NHS and in supporting engagement. While the NHS continues to be expect increased funding, local government has lost about 40% of it’s funding since 2010.  While no-one in local government welcomed austerity, many acknowledge that it has provided a catalyst for change – and concentrated minds on finding new ways of working.

Local government has demonstrated a notable degree of adaptability, innovation and creativity that has helped to provide some degree of protection to services for the most vulnerable. We have now arrived at the point where no amount of transformative change can overcome the gap between the complex social care needs of the most vulnerable and the money available to meet them.  Social care has also reached a tipping point, as evidenced by the record numbers of people waiting for care to be in place before they can be discharged from hospital. The STPs were a good opportunity for the NHS and local government to work together to support the co-design of truly sustainable reform. Instead, the NHS has fallen into the familiar trap of seeing itself as pre-eminent, rather than as part of a complex system, where failure in one part can lead to devastating consequences elsewhere in the system.

Long-term solutions to the problems of the NHS can only be found if all parts of the health and social care system work together. One of the key ingredients of success will be effective engagement, as an essential pre-requisite to behaviour change – both of patients and professionals.   Co-design and co-production of change are the only ways to liberate the resources trapped in delivering the wrong service at the wrong time.  Policy makers have access to useful evidence on ‘what works’ to help change behaviour but that evidence is not being applied consistently. For example, being overweight has become normal. We need to reset expectations to create a ‘new normal’.  A coherent and well-funded public health strategy could help deliver that change and would not only improve the quality of life of many people in the short term, but also reduce the incidence and cost of preventable diseases in the future.

What a pity we’ve had an NHS centric and secretive approach to necessary change.  The consequences will be resource-consuming conflict and damage to the public’s trust in public services.  Those are not good outcomes for anyone.

Catherine Staite 02

Professor Catherine Staite is Director of INLOGOV. She provides consultancy and facilitation to local authorities and their partners, on a wide range of issues including on improving outcomes, efficiency, partnership working, strategic planning and organisational development, including integration of services and functions.


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