The biggest centralisation of the NHS so far?

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Andrew Lansely has proposed a decentralisation of Britain’s most loved institution, placing the NHS commissioning budget in the hands of GP consortiums – devolving commissioning power to the providers of the nation’s health.

We know that centralisation is bad for the NHS, excessive centralisation of the health service can push out the local initiative essential for meeting patients' needs.

And can lead to micro-management from the political centre.

but how decentralised will the NHS be after these reforms? It seems to me that Lansley’s proposals could lead to the biggest centralisation of the National Health Service so far.

The Department of Health describes the future system as one that “is built around patients, led by health professionals and focused on delivering world-class healthcare outcomes”

- Giving commissioniong power to GP consortia encourages the fragmentation services. These are closer to the communities which they serve are therefore more directly accountable. Decentralisation is seen as a route to increasing accountability to the local population. Not only that but Local participation and engagement of the public is key in the bill and is an important element of the DH’s authorisation criteria for CCGs. – politically popular in the age of the ‘patient-led NHS’, when ‘patient experience’ is the buzz phrase of all stakeholders of the system….all seems to make sense?

Well… What is perhaps less obvious is that this approach is also way of increasing central control and accountability (the opposite of the intended consequence it seems).

Although spending power will be in the hands of the practices, their contractual obligation will not be local. All practices in the UK will be contractually bound and accountable to one NHS commissioning board. Contracts will apply to all practices, irrespective of various local populations. So much for reducing the micro-management of  the political centre. Primary care could be less locally sensitive than it ever has been.

The health bill was constructed to increase patient involvement over the care they receive. As I mentioned, CCGs will have to demonstrate public enagement to become authorised, e.g. through close working with cancer networks for example… but hang on… where do CCGs come in? they aren’t involved in the contract between practices and the NHSCB, they can’t hold the practices to account, so the patient engagement is just lipservice?

Further, as far as I am aware, there is no evidence that local participation has changed local policy. There is a strong central steer about the mechanisms for involvement. Centrally defined performance targets tend to override any decentralised freedoms.

So – we have (unintendely, maybe) created more centralisation than before, where the providers don't have enough time - given the torrent of instructions and performance management criteria from the centre - or the contractual obligation to work through the needs of their local communities and to manage them in a way that makes sense locally.


The above article is an opinion article written by Melissa Morris, Founder of, part of a series of opinions on the NHS reforms on this blog.

If you have any questions or comments, please contact Melissa



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