National Voices Daily Insight: Striking a balance between central and local decisions

Today’s Daily Insight is guest written by Charlotte Augst, chief executive of National Voices as part of a National Voices “takeover” of HSJ. Find out more here.

While turbulence in Westminster continues, making it frankly impossible to predict how this will impact the delivery of health and care services during this next period, it is clear that the NHS is preparing for a tough, if not the toughest, winter.

One question that raises its head in every crisis, and does so again now, is the balance between central control and local decision making. This is reflected in Jim Mackey’s rather muscular assertion that some of the activity levels around elective recovery are“inexplicably low”. And also in Amanda Pritchard’s demand to bring back ‘mothballed’ beds into active use.

If these declarations ignore overwhelming realities of staffing levels, sickness absence, covid infection rates and so on, all of which will vary from place to place, they represent the least helpful form of “grip”.

On the other side of the debate, coming down more firmly against unwarranted variation, we have Sam Mountney, who is also incoming interim head of policy at National Voices. Like many other organisations who work with communities living with rarer conditions, his argument is that it is not possible to advocate for consistently higher standards of care without support from the centre.

Yes, decisions need to be made locally, but we cannot have the same argument about the need not to forget for example neurological conditions in 42 systems as if from scratch.

So, as we move into possibly the toughest of all winters, with a resurgence of emergency style command rooms, where do we need to strike the balance? Two points need to be made here:

1) The pandemic has shown us that places, through local leaders, can make decisions quickly and fully sighted of the enablers and barriers which shape the local context. The ‘permission to act’ granted during the pandemic is still talked about by NHS and place leaders as one of the positive changes that occurred during that period.

2) Whether a decision needs to be taken centrally or locally, the most important thing is that all the relevant actors are in the room. This needs to include the voluntary and community sector now more than ever. Anything that helps communities cope will ultimately take pressure off the NHS. And helping people cope is the bread and butter of community activity – be it through supporting carers, providing information and advice, reducing loneliness or bolstering peer support.

As we face the implosion of urgent and emergency care, on the back of years of decline of both social and community care, it is understandable that the NHS will get drawn into command and control style decision making. It is still just as important to not lose sight of the needs for ongoing, non-urgent, healthcare, and how it needs to be properly co-designed and co-delivered in partnership with communities and their organisations.