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Centralising the NHS – the local Democratic Deficit at the heart of the NHS Long Term Plan

February 24, 2019

The more I read the NHS Long Term plan  the more confused I become. The source of my confusion is the following tiny paragraph lurking in Chapter 1 of the NHS Long Term Plan that sets out the deadline for establishment of the sub regional Integrated Care Systems  and by implication the end of local (local authority level or ‘place based’) Clinical Commissioning Groups.

This paragraph states that by April 2021 (just over 2 years away) Integrated Care Systems –  will cover the country and that each Integrated Care System will typically involve one Clinical Commissioning Group which will be leaner and more strategic organisations that support providers to partner with local government and other community organisations.

If my understanding is correct this will lead in most cases to the number of organisations that are responsible and accountable for making local health systems work dropping considerably – which means that accountability for system governance becomes more distant from local authorities and from local people.

In the graph below I compare the present involvement in sub regional Sustainability and Transformation Partnerships of local authorities and CCGs with what the world might look like once all Integrated Care Systems have been created – with one CCG for each ICS. My working out is all here – I have counted this manually so there will be mistakes!

As the graph shows currently the number of CCGs by NHSE region are roughly comparable with the number of local authorities – so, generally speaking the NHS and local authorities have similar governance geographies. This changes radically in the new world.

In simple terms I think the current and future governance of the local health system is a bit like this:

NHS England might say that my representation is not fair, after all they promise:

  • Place Based Plans that feed into ICS strategies – I say these are plans not accountable organisations rooted in places
  • Primary Care Networks – I say these are vehicles for the delivery of local services – which might include some coproduction
  • A wide range of mechanisms to facilitate joint provision at a local level such as local ‘alliance’ contracts, lead providers, Integrated Care Providers etc – again, I say all of these are about the integrated provision of batches of services and are not concerned with local governance and accountability.
  • Local Authority Over View and Scrutiny continues – this is true but they now also have to keep an eye on the ICS with no additional resource.
  • Local NHS Trusts continue to exist – which is true – but they are only responsible for their services.

In summary (as I flagged up in an earlier blog) I think the current plan will see a weakening of local accountability for the way in which local health systems work.  Instead there will be more of a focus on developing and delivering integrated local services with an aspiration that that these will be tailored to local need.

To some degree this dissonance is highlighted by the New Local Government Network in their challenging blog about the long term plan.

What next?

Local Authorities and Clinical Commissioning Groups have a small window to work together to create local structures that at the very least enshrine some form of local accountability at a place level for the local health system as a whole. The challenge is to do this in a way that rises above the NHS England focus on managing services and instead creates mechanisms that recognise that decisions about health and wellbeing are a compromise between clinical evidence, local ambition and social determinants.

If anyone reading this thinks I have got the direction of travel wrong please let me know.

Declaration of interest – I am a lay member of Sheffield Clinical Commissioning Group

What do you think?





2 Comments leave one →
  1. malcolmrigler permalink
    February 24, 2019 08:54

    I too feel confused about what is being proposed. Might this document below and the development of links with Local Government and The Society of Local Council Clerks be one way of trying to achieve some clarity and positive action ?

    WHO/Europe | Revitalizing primary health care for the 21st century…/health…/Health…/primary-health-care/…/revitalizing-primary-he...


    1 Nov 2018 – Countries across the WHO European Region played a pivotal role in the Global Conference on Primary Health Care, held in Kazakhstan on …

    A quote from the document.


    In the closing session, the Deputy Mayor for Health of the city of Rennes, Charlotte Marchandise, presented the Almaty Acclamation of Mayors and expressed the commitment of the WHO European Healthy Cities Network to the Declaration of Astana.

    “When it comes to health, we need local governments. We must help people who live, work, love and play in our cities to live a healthy life,” she said.


  1. Centralising the NHS – merging Clinical Commissioning Groups | Local Democracy and Health

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