By Steve Gulati, Associate Professor and Director of Healthcare Leadership at the Health Services Management Centre
The announcement that NHS England will be formally disbanded, with its functions moved to the Department of Health and Social Care (DHSC), hit the headlines last week. However, this shift had been signalled for some time, with departures of senior figures and a growing tone of government announcements suggesting a willingness to take more direct responsibility. Much has been written about the change from both the political and the policy viewpoints, but what might it mean from a leadership perspective?
One of the key drivers behind the change was to address a ‘democratic deficit’ by centralising functions to the DHSC and that by so doing there would be a clearer line between directly elected political figures and accountability for health and social care performance. There is some merit in that argument. Going back to the Lansley reforms of 2012 (famously described as being “so big they can be seen from space”), one of the criticisms at the time was that ministers would be able to claim ‘plausible deniability’ shifting blame for difficulties at the door of managers and clinicians rather than at elected officials. In this context, the Secretary of State for Health and Social Care Wes Streeting’s decision to rebalance lines of accountability, can be seen as being bold, decisive and courageous.
There are, however, some factors to guard against if the new arrangements are to be effective. Having worked at the former Department of Health in my time in the NHS, there is undoubtedly a risk that officials and advisors focus on ‘pleasing the minister’ and avoid discussing truly difficult, yet crucial, issues. Volume of work for a centralised department of the size of DHSC also presents a potential risk, with bottlenecks and delays in decisions; and the temptation for politicians to make decisions that are, or appear, to be informed by party political interests is ever present.
On the other hand, the criticism that the Streeting reforms will result in a ‘Whitehall knows best’ approach to policy is no more or less likely than under current NHS England arrangements, which are equally far removed from localities or neighbourhoods. Locally informed decision- making was much more likely at Integrated Care Board/ System (ICB/ ICS) level, and the implications of the current reforms on ICBs and ICSs is still playing out.
Whilst the human cost of potential job losses and the inevitable uncertainty about implementing policy must not be overlooked, Mr Streeting’s actions have been clear and decisive. Clear leadership can mitigate the risks of centralising accountability. This means appointing a skilled and diverse team, facilitating free thinking and new, sometimes controversial, ideas, and resisting the impulse to create a siege mentality within the newly expanded DHSC.
As ever, the true test will come when difficult decisions need to be made and justified, and by taking direct accountability in such an open and direct manner, there will be no place to hide for a project as ambitious and important as real, much needed change in our NHS and Social Care services. That, rather than structural change, is a true test of leadership.
- Find out more about Steve Gulati
- Back to Social Sciences Birmingham
The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of the University of Birmingham.