Protect clinicians’ say over local health service changes, warn NHS leaders

Warning that new government reforms will hand ministers largely unchecked new powers over local health services

21 September 2021

Government reforms that are set to hand ministers largely unchecked new powers over local health service decisions, such as hospital closures, risk undermining public confidence in the NHS if they lead to further political meddling in the day to day running of the health service.

A coalition of health organisations have joined forces to call for ‘checks and balances’ on proposed new powers for the Secretary of State for Health and Social Care which would enable them to intervene at any stage of a decision about changes to local service.

Such ‘service reconfigurations’ include changing the location or the type of treatment provided by an NHS organisation. Ministers in Whitehall could end up making decisions about local GP and dentistry services without having to disclose the basis of their decision to patients and the public. This is despite there already being a well-established process in place for consulting on changes to local services.

The NHS Confederation, Local Government Association and the Centre for Governance and Scrutiny have recommended an amendment to the Health and Care Bill which is being considered by parliament. This would require the ministers to consider clinical advice from senior local doctors and justify publicly why the decision made was in the public interest. The proposal also has support from the British Medical Association and National Voices.

The organisations’ amendment also proposes that the Secretary of State must consult with the relevant local council’s health overview and scrutiny committee before any such decision is made. While outside the scope of the NHS, there is concern that the bill could bypass to the local democratic accountability provided by health overview and scrutiny committees.

Matthew Taylor, chief executive of the NHS Confederation, said: “There is widespread support for most aspects of the Government’s NHS reforms, which have been largely driven from the bottom-up by NHS leaders to enable more coordinated care for patients. There is consensus among NHS leaders that this will not result in ‘privatisation’ of the NHS.

“But one area where there is real concern is over the proposal to extend ministerial control over changes to local services. The NHS costs £150 billion a year so accountability to Parliament is vital. But the risk is we end up with more politically motivated decisions which erode the NHS’ clinical and operational independence. We already have one of the most centralised healthcare systems in the world and if these reforms are to work then we must resist further centralisation of power in Whitehall.

“Ideally, these powers would be removed. But, at minimum, there needs to be public transparency on the decisions that are made by the secretary of state and the evidence base upon which they are made. In our view this must include a requirement for the secretary of state to have regard to, and publish, the clinical case offered by the Integrated Care Board in relation to any decision.

“Ultimately, any ministerial intervention in local service changes must be fully transparent if public confidence is to be maintained.”

Jacqui McKinlay, chief executive of the Centre for Governance and Scrutiny, said, “Effective, local accountability should be the bedrock of a responsive health and care system. Over the years, the powers of health scrutiny committees – comprised of elected local people – to refer key health changes to the Secretary of State has helped to secure this accountability.

"This provides the need for robust review, without unnecessarily drawing national actors into debates about the design of services at a local level. The power of referral has rightly been used sparingly, but the fact it exists acts as a powerful corrective in a landscape where wider democratic oversight is not always present. Removing the power of referral would have serious unintended consequences – for the quality and effectiveness of local health services but also for Government, which would struggle to carry out a similar level of oversight at a national level. Decisions made at a local level should be subject to local accountability, rather than direction from Whitehall.”

Many NHS leaders are concerned that difficult decisions about local services, taken for reasons relating to quality, safety and/or finances, will be overturned or derailed for political reasons if these new powers are granted to the secretary of state.

If they are granted, then the coalition argues that there must be greater clarity over when and how they are used. This should help to avoid the confusion that surrounded the recent example of Lancashire Teaching Hospitals Foundation Trust, where the former secretary of state put on hold a planned consultation on the potential downgrading of the A&E department at Chorley Hospital, with very little information being made public to justify the intervention.