David Oliver: What functions should remain within NHS central government agencies?

The latest major reorganisation of the NHS’s government departments and central agencies1 begs the hypothetical question of which functions can best or only be served by central bodies operating at national level. Hypothetical or not, I do have to give the question some empirical constraints.

First, data from the British Social Attitudes survey2 and other big datasets such as the Health Foundation/Ipsos rolling polls3 on public perceptions of the NHS show little support for a wholesale shift away from a tax funded, universal, free-at-point-of-care health service and continuing support for the NHS’s founding principles, even though public satisfaction with the current service is at a record low.4

Second, even within universal healthcare systems in high income nations with publicly funded services rather than insurance or copayment models, the NHS is arguably the industrialised world’s most centralised.56 Several others have more devolution of power and accountability to regional administration, closer to where healthcare is provided.7 My question is, what are the things that can be done only at national level in our current publicly funded system? Imagine starting with a clean slate.

Well, I’d say that the traditional civil service roles supporting government policy development and commitments, implementation, primary and secondary legislation, and government communications are a given. So too is the departmental funding round with the Treasury and the distribution of that funding from general taxation and national insurance to NHS organisations8 (whether or not through local and regional intermediary bodies such as integrated care boards or any newer non-central organisations that may emerge). Price setting for activity and contracts is another one.

It also seems clear that a government department or other national arm’s length executive agency is best placed to collect and produce genuinely national datasets—on NHS performance and activity, public and population health, and NHS workforce. Likewise for national clinical guidelines and technology appraisals, along with genuinely national programmes for clinical audit or quality surveillance and improvement.

Screening, vaccination, and health protection programmes also seem to me to sit best at national level, as well as programmes to tackle health inequalities, whether or not with regional arms for local oversight. I’d also argue that centralised control makes sense for commissioning of services for highly specialist or rare conditions, which will cover huge populations and need to be distributed at regional level. The same could apply to procurement at scale of some key equipment and technology and of procedures best not duplicated by hundreds of local organisations—for example, cybersecurity and the administration and distribution of research funding.

Despite significant concerns about the role of regulators and the quality of professional or organisational regulation by bodies such as the General Medical Council, the Nursing and Midwifery Council, and the Care Quality Commission, it surely still makes sense for these to be national bodies, although they must improve their own performance and operating models if they’re to restore confidence.