Policy Papers


The virtues of decentralisation for health services in crisis

Michael Lambert |

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Executive Summary

  • The ability of the National Health Service (NHS) to respond to the Covid-19 pandemic has been undermined by the gradual dismemberment of structures for regional organisation of the complex range of health services in a modern society innovated during World War II, whose utility was reaffirmed with the creation of the NHS in 1948
  • Introduction of the internal market and other forms of ‘competition’ within the health services have resulted in the loss of regional co-ordination capacity, institutional memory, expertise and the ability for organisational and service units to think beyond their own horizons.
  • Wartime Emergency Medical Services provide a historical lesson in how and why decentralisation and the development of an intermediate, organisational tier at the regional level within health services matters in creating resilience.
  • For decentralisation and regions to be effective in the current NHS, they require a statutory footing, autonomy, and resources.

Introduction

Whilst the Covid-19 pandemic has affected every aspect of people’s lives, health services have been central to the government response in Britain. Lockdowns and social distancing were imposed to prevent the NHS being overwhelmed. Test and trace services were created to contain the reproduction of the virus across the population. The mass vaccination programme is seen as the solution in permitting social contact. The NHS is crucial to overcoming the pandemic.

 

The NHS has been beset by problems throughout. A shortage of Personal Protective Equipment (PPE) hamstrung the initial response. Temporary Nightingale hospitals, though built with impressive rapidity, lacked both staff and facilities to operate. There were insufficient ventilators and tests available. Pathology laboratories lacked resources and capacity to process tests. Staff sickness and self-isolation limited the effectiveness of hospitals to admit patients, let alone care for them in oversaturated Intensive Care Units (ICUs). Routine provision has been halted to increase bed space for Covid-19 patients, leading to mounting backlogs and waiting lists. Vaccination is emerging as a possible bright spot in the government’s otherwise blighted record, but supplies and distribution are erratic, leading to shortages in some parts of the country and a staggered response in the immunisation programme. In short, critical weaknesses within the NHS have inhibited the response to the pandemic.

 

The response of the government to the NHS has been in line with its approach before the pandemic: hollowing out expertise and capacity in health services. PPE shortages were managed through inflated national contracts, often under allegations of nepotism. Nightingale hospitals remained un- and under-used in favour of private hospital capacity. Testing has been contracted out to a range of external companies along with further investment in private consultants to manage the confusion and complexity this has created. Reduced hospital staff due to absences caused by sickness and stress leave remaining colleagues overworked and more under pressure. The backlog of routine treatment continues to mount, with further private hospital capacity being bought to stem the tide. The establishment of mass vaccination centres has left established General Practitioner (GP) distribution with shortages. Most of these decisions have had to await deliberation and completion of commercial contracts handled solely at central government level, even though paradoxically the Health and Social Care Act of 2012 had removed the responsibility of the Secretary of State for the health of citizens since 1948. These cumbersome, commercial arrangements only serve to intensify existing problems in and of the NHS.

 

Centralisation, fragmentation and competition have been the reality in the NHS for decades despite claims of devolution, patient choice, and ending a command-and-control approach. In evidence submitted to the Health and Social Care Select Committee on Delivering Core NHS Services during the Pandemic and beyond in April, I pointed to the demise of the intermediate regional tier as pivotal in hollowing out the infrastructure in health services necessary to respond to the pandemic. Understanding how and why the state built such a tier in the first instance provide clear lessons on how to organise health services effectively in a crisis. In oral evidence to the Health and Social Care Committee and Science and Technology Committee on the Covid-19 Lessons Learnt Inquiry in January 2021, the current NHS Chief Executive Sir Simon Stevens readily conceded that health services were stymied by the lack of a ‘buffer’ between the centre and localities.

 

Sub-national, regional capacity for organisation in health services were first built during the Second World War under the auspices of the Emergency Medical Services (EMS). Whilst analogies of the Blitz Spirit and wartime national emergency have become something of a trope in discussions of Covid-19, they are apt when it comes to the mobilisation and organisation of health services. This has already been identified by History & Policy in a roundtable on ‘The real lessons of the Blitz for Covid-19’. Although the war brought unprecedented state intervention into the health arena, this was achieved through decentralised, collaborative and resourced development of a previously fragmented, disorganised and competitive health system. If the government insists on fighting Covid-19 as a rhetorical wartime enemy, it would do well to heed the real lessons of that experience when it comes to the NHS.

 

Mixed Economies of Health

Before the Second World War began in 1939, health services in Britain constituted a ‘mixed economy’. These were based on six key components. First, independent private voluntary hospitals. These were a product of Victorian medicine, serving as principal centres of acute medicine, teaching and research, and were funded by philanthropic donation, subscription and local mutual hospital contributory schemes. Second, municipal hospitals, which were created by the 1929 Local Government Act effectively rebranding as hospitals old Poor Law infirmaries, which had dealt primarily with chronic patients and the elderly. Third, public health services including immunisation, domiciliary visiting and the control of infectious diseases dating from the Notifications of Diseases Acts of 1889 and 1899. Both public health and municipal hospitals came under the jurisdiction of the Medical Officer of Health (MOH), based in local authorities, and funded by local rates and central grants. Fourth, mental hospitals which were accountable to both local authorities and the Ministry of Health through their inspection agency, the Board of Control. Fifth, GPs provided primary care to insured workmen through nationalised insurance committees which were created as part of the package of Liberal reforms from 1906-11. Sixth, and lastly, was the voluntary sector, which provided a range of services to each of the above through a combination of public and private funding. This complex mixed economy perpetuated inequalities in access, competition between abundant providers in large cities, and led to extensive duplication and overlap of services in some areas and under-provision elsewhere (in the most rural areas for instance).

 

These tensions in the mixed economy were the source of numerous government and independent inquiries throughout the period. The end of the First World War in 1918 saw the creation of a new Ministry of Health and provided the stimulus for many of these reports, owing to the transformation hospital services had experienced. The most radical of these was the 1920 Dawson Report which advocated comprehensive and unified health services under local authority jurisdiction. This expensive and transformative vision was rejected in a context of post-war austerity and a trenchant defence by the private voluntary hospital sector. Their touted solution remained voluntary cooperation and coordination at the local level with modest government support. The 1921 Cave Report on voluntary hospital finance advocated the creation of local committees, which soon lost momentum as the small exchequer grant dwindled. These invariably bolstered the already privileged elite teaching hospitals, which dominated medical education and research, at the expense of their smaller counterparts, further heightening inequalities within the voluntary sector. Independence and rivalry remained fierce.

 

Inadequacies within the public sector were also laid bare by the First World War. The Onslow Commission into local government reported in 1925 and 1928. These reports showed how fragmented local responsibility for different government functions, particularly those of the Poor Law, had become and that they were no longer fit for purpose in the face of mass unemployment, a sick and ageing population, and the constant push for economy. The ensuing 1929 Local Government Act established municipal hospitals, which increasingly threatened the virtual monopoly on acute services held by the private voluntary sector since its inception. The expansion of other functions in public health, housing and slum clearance served to strengthen the role of the MOH as an omnicompetent servant within the local authority. There remained, however, minimal collaboration across the public and private sectors. Voluntary hospitals were jealously defensive of their privileged position whilst local authorities sought to expand their rudimentary services.

 

Economic crisis after 1929 intensified the situation but failed fundamentally to alter this balance of power. The financial position of voluntary hospitals became ever more precarious. Bequests and fundraising often focused on high-visibility capital development at the expense of more mundane maintenance and service expenditure. This fuelled growing annual deficits. These were increasingly met through mutual Hospital Contributory Schemes. These were organised by employers and employees through a system of insured payment to provide access to hospital services for workmen. This also began to change the relationship of hospital authorities who had governed access and admission of patients. More importantly, it raised issues of reciprocity, membership, and distribution of payments across and between hospitals and localities involved in the schemes. Once again, the voluntary hospitals sought a voluntary arrangement in a report commissioned by the British Hospitals Association. The 1937 Sankey Report advocated a system of regional councils which would be federated centrally to the Ministry of Health, conceding some local authority representation in return for financial security. Although unable to secure the desired resources, the impact of these arrangements resulted in many leading voluntary hospitals in large cities forming united hospital groups to defend their political and financial position against municipal hospitals.

 

The picture of health care in Britain before 1939 remained one of discord and fragmentation. Despite numerous inquiries and commissions, tentative recommendations left hospital and health services divided, expensive, competitive, and inequitable. Voluntary cooperation and coordination had not worked. Economic stringencies imposed by post-war austerity and the Great Depression worsened these difficulties but failed to overcome them. Unwillingness to look beyond the horizons of hospital meant integration was never close to being materialised despite a recognition of the need for supra-local organisation. The Ministry of Health remained aloof, content to keep a supposedly benevolent eye in maintaining the status quo and provide a steer when pushed, but not wanting to antagonise any party to the mixed economy.

 

The Emergency Medical Services

The Second World War provided the necessary crisis to engender a transformation in health service organisation. It achieved this through greater central intervention from the Ministry of Health and a ratcheting of spending and its mandated involvement. Crucially, this was achieved not through a homogenous and centralised state but through a decentralised one which acted both as buffer between centre and locality and a lightning conductor for issues and ideas. This was not realised through the intentions of the government or Ministry of Health but in the reality of managing a complex health service during an unprecedented crisis. The creation of a meaningful intermediate tier was instrumental in this process, realising what had been politically impossible before the war.

 

The Emergency Medical Services (EMS) were not planned with decentralisation in mind. Nor did they encompass each of the six dimensions of the mixed economy of care, with GPs and mental health largely an afterthought. The EMS was not, as often believed, the NHS-in-waiting through the establishment of hierarchical governance and medical advice mechanisms. Its priorities were firmly on dealing with Blitz damage on the population and hospitals themselves, with casualty departments, orthopaedic and neurological specialisms, and linked diagnostic and pathological capacities remaining the order of the day. Certain hospitals were identified for inclusion in the EMS, with many being augmented by new ‘EMS hospitals’ – usually timber huts – constructed to expand the numbers of beds available. These were often at the periphery of major towns and cities premised on the prospect of damage to voluntary and municipal hospital stock concentrated in city centres. Crucially, hospitals were not nationalised. Access to facilities was made through a series of payments for beds – whether needed or not. Premises were brought up to standard in treating casualties, and the concomitant demands on medical and nursing personnel. To prevent abuse, financial payments were to be made and monitored centrally.

 

The EMS was administered from the Ministry of Health through 14 civil defence regions, each headed by a Senior Regional Officer (SRO) and supported by a litany of officials including Hospital, Nursing, and Establishment officers. Civil defence were also responsible for a range of war-related functions beyond health, each accountable to a different central government Ministry or Department. Initially they possessed little autonomy and had a strained relationship with central government departments unsure of the utility of these new intermediary bodies. This was true of health where planning for EMS hospitals, huts, personnel, and capital spending were limited by the demands of the Ministry to send their own overworked inspectors rather than use regional figures or advisers. They were suspicious of hospitals, municipal and voluntary alike, overstating their own needs or exploiting the situation. Despite collaboration and cooperation once again being the watchwords of the day, regions remained impotent.

 

The Blitz and Liverpool

The experience of the Blitz fundamentally transformed the role of the region as part of the EMS and its relationship with the wider health services. Alarmed at the advance of the Nazis and the threat of invasion following Dunkirk, the summer of 1940 was marked by a flurry of circulars, guidance and directives which empowered civil defence regions with greater autonomy in relation to the EMS, and mobilise staff capacity, expertise, and experience in rising to these new demands. Decentralisation was engaged with hesitantly and reluctantly as internal discussion within the Ministry of Health demonstrates. The Ministry had only just obtained powers in relation to hospitals which they were on the brink of deploying. However, it was a necessary step given the potential disruption of the work of the Ministry through its evacuation from London. This relinquishing of power over capital spending, the planning EMS hospital facilities, resourcing, and personnel all served to shorten lines of communication within the health services and build locally-situated approaches.

 

Whilst London was the epicentre of these combined experiences of the Blitz and regional decentralisation, the City of Liverpool also provides an insight into how regional decentralisation and empowerment were critical in building a health system beyond rhetorical aspirations of cooperation. These relate to organisational arrangements and the management of casualties across hospitals, specialist services, and responsibility for civilian and military patients.

 

Initially, organisational arrangements were fraught. Liverpool’s segmented and saturated voluntary hospital sector and its large municipal counterpart fuelled conflict and competition. Efforts to overcome this through planning proved promising on paper. Moreover, civil defence region 10 – the North West of England – was divided in two, reflecting historic animosities between Manchester and Liverpool. Accordingly, Liverpool and North West Cheshire had their own Hospital Group Officer beyond that of the region proper. The Phoney War continued pre-war divisions through the EMS structure. However, decentralisation and the Blitz – which in Liverpool occurred during May 1941 rather than 1940 as in London – proved transformative. The exigencies of damaged hospitals evacuated to the periphery, the need urgently to create space for casualties, and the impact of attacks beyond Liverpool to Birkenhead on the Wirral led to rapid changes in organisation. Regional staff, advisers and specialists were instrumental in providing order amidst such chaos, resourcing and reshaping plans, and acting as an intermediary between local hospitals and the Ministry.

 

Nowhere is this form of compromise more apparent than in the case of specialist services which had, as was the case in most municipal hospitals outside London, been the monopoly of the voluntary sector. However, the physical location of many of the inner-city hospitals and their vulnerability to attack led the Liverpool Hospital Group within Region 10 to adopt a hub-and-spoke approach to hospitals. This comprised an inner ring of casualty cleaning and reception areas adjacent the waterfront constituting the first line, surrounded by more peripheral hospitals for the second; these were typically former Poor Law, now municipal, hospitals swallowed up by the expanding conurbation. Previously under-resourced municipal hospitals were, in turn, afforded access to medical staff and their expertise in a range of specialisms, but also the technological and medical resources needed to operate them. It is here that the Walton Hospital gained X-ray diagnostic and neurosurgery operating theatres and Broad Green Hospital expanded with dozens of EMS huts to accommodate a range of chest and thoracic surgery cases. The legacies of these decisions can be found in two of the city’s specialist hospital trusts today.

 

Although Liverpool suffered extensive damage and casualties as a result of the Blitz during May 1941, its EMS services oriented towards casualty departments and specialisms became increasingly redundant as the war progressed. Because the EMS as a franchise scheme was based on buying beds with their linked clinical and nursing expertise, the fading threat of bombing led to a change in purposes. This was recognised at the Ministry through regional reports on empty beds, disputes with insurance bodies on payment and responsibility for patients, and under-treated categories of patient due to unsuitability of hospitals. Liverpool was no exception. The change in payments from the Ministry, combined with Liverpool’s status as a major port reinvigorated through US entry into the war during 1941-42, further transformed the organisation of health services and their relationship to one another in the region. Existing and expanded acute capacity was used for a range of civilian patient categories and treatment needs. Redundant space in un- and under-used hospitals was repurposed for different medical purposes, such as convalescence or isolation. Moreover, EMS hospitals were also used to host military and merchant marine casualties arriving at the port from the Atlantic convoys or theatres of war, either for treatment or recovery before transit.

 

Region as the Building-Block of the NHS

As the Liverpool example shows, the regional infrastructure was central in decision-making and planning, which suited changing service needs rather than simply the interests of individual hospitals or sectors. The autonomy, resources and authority they possessed facilitated the creation of a health system which had not previously existed in the city. It became greater than the sum of its parts The appointment of a range of specialist staff servicing the EMS within the region permitted the development of relationships between and across individual hospitals, the region, and the Ministry. These included full-time administrators alongside medical, surgical and nursing advisers who facilitated compromise in services between hospitals, and the region’s own blood transfusion service in line with Ministry guidance.

 

Decentralisation came at a cost for the centre, the principal one being financial. Voluntary hospitals benefited enormously from the arrangements, allowing them to realise capital schemes, maintain sites and expand specialisms they had been planning for decades. The costs to the Ministry and Treasury were significant, with claims coming principally from the established teaching hospitals at the expense of smaller institutions, further heightening inequalities. Such was the scale that the Ministry complained of voluntary hospitals demanding further financial compensation during the interregnum between the end of the EMS in 1945 and the appointed day of the NHS in 1948. They wished them to live on ‘EMS fat’ for the duration. Beyond this, regions began to develop their own power base through concentrated relationships across hospitals on an institutional and individual basis which translated into the establishment of Regional Hospital Boards (RHBs) under the NHS. Ultimately, enforced under the exigencies of wartime, decentralisation to the regions engendered the kind of cooperation and coordination which had inspired the imagination of inquiries since 1918.

 

Initially, the region did not transcend all differences. The teaching hospitals were able to maintain their independence after 1948 through direct accountability to the Ministry of Health under Boards of Governors rather than RHBs. Royal Liverpool United Hospitals – the local voluntary hospital merger in 1936 – became United Liverpool Hospital: the Board of Governor for the newly minted Liverpool region, finally free from the thumb of Manchester. RHBs struggled to integrate hospitals left in the cold under the EMS, particularly those beyond Blitzed centres transformed by war. Moreover, disclaimed hospitals, particularly Catholic institutions common to Liverpool, remained outside these plans. Crucially, mental hospitals, public health and GPs remained separate to these regional processes of integration, being ossified in a tripartite NHS until 1974.

 

Region not only made the NHS from 1948 to 1974, it remained the building block for successive transformations. Regional bodies were irreplaceable in moulding a nationalised hospital system into a national health service. They delivered for successive Labour and Conservative Governments in their policies of the day, but beyond this created many facets of the NHS we take for granted today including capital, supplies, training, research but also access to modern specialist services, expert clinical advice, and legal, personnel and administrative expertise. Tensions remained with the centre despite these successes, and Health Ministers including Labour’s Richard Crossman and the Conservatives’ Enoch Powell both questioned its utility. In 1974 regions were formally unified everywhere outside London, where elite teaching hospital interests prevailed, with RHBs and Boards of Governors merging into Regional Health Authorities (RHAs). Here they reached their technocratic apex at the centre of a complex planning system above Area and District Health Authorities intended to consult with local populations, reduce health and resource inequalities, and modernise facilities.

 

Paradoxically, regions contributed to their own demise with the abolition of the Area tier in 1982 creating a system of line and performance management directly to the Department of Health and Social Security. This was used to deliver successive cuts throughout the 1980s at the behest of the Thatcher Governments culminating in the creation of a purchaser-provider split and an internal market. On paper region became redundant in a regulated market and was phased out in 1996, being reinvented as outposts of the NHS Executive, an arms-length body separate from the Department of Health. Region returned in 2002 in the form of Strategic Health Authorities (SHAs) which were used by New Labour to deliver a range of targets, scrutinise service rationalisation and modernisation, and capital schemes including Private Finance Initiative (PFI). SHAs were abolished in 2013 yet regions endure with NHS England in name alone. Concurrently, government policies have shifted back towards voluntary coordination and cooperation encompassing a range of private and public partners within an internal market.

 

Conclusion: Lessons for Today

The lessons from the history of the EMS experience are clear in the context of the current crisis. The preceding period of contracting, privatisation and marketisation which was initiated under the Thatcher Governments of 1979-90 has served to hollow out the NHS. The capacity to co-ordinate, local memory, and experience developed under each region has been eroded under a succession of reorganisations and reforms. These have been compounded through the hiving-off of a range of specialist functions into non-governmental bodies such as Monitor, the Health Protection Agency, and the NHS Business Services Authority which creates further complexity in the national health system. Although there remains notionally a national health service, it is as fragmented, divided and riven with competition as the mixed economy was before the Second World War. It is no accident that the rise and fall of the internationally recognised strengths of a national, universal and accessible system go hand-in-hand with the rise and fall of region. Government would do well to relearn lessons from history on the importance of the region as an irreplaceable level capable of rendering all the complexity involved in delivering health services.

 

The lessons for government are threefold.

First, voluntarism as a principle of cooperation and coordination does not work. In the current NHS commitment to integration remains a rhetorical commitment but without recognition or resources. Initiated since 2016 and intensified during the pandemic, there have been significant changes to both purchasing and providing arrangements within the internal market moving back towards supra-local mergers. Yet these bottom-up initiatives including Primary Care Networks (PCNs), Integrated Care Systems (ICSs) and Sustainability Transformation Partnerships (STPs) are without meaningful authority. They lack the authority, expertise, capacity and autonomy to act beyond the interests of their constituent fragmented elements. Much like the interwar tensions between voluntary and municipal hospitals, partnership is a lauded trope which lacks value, whilst individual organisational or service goals trump those of the region. For regional organisation to be effective, it requires mandated and statutory footing.

 

Second, and paradoxically, proper decentralisation is a virtue in the development of service capacity and state building. The desire of the centre to control everything results in extended lines of communication and inapposite top-down solutions. Such solutions remain remote from sites of implementation and lack validity. Experience from the EMS shows that decentralisation empowered officials to develop networks with previously siloed and fiercely independent hospitals. These fostered what would now be recognised as buy-in from partners which meant solutions also emanated from the bottom-up, even if they delivered what was also required from above. Moreover, an empowered regional tier can respond locally and mobilise resources during a time of acute crisis, as was shown during the Blitz. The regional approach to lockdown and protecting NHS capacity adopted by the government during the pandemic seems curiously disconnected from experiences on the ground. For each region to be effective, it needs autonomy and trust from the centre.

 

Third, and finally, are resources. Voluntarism remains ineffective because it lacks resources. Decentralisation in the NHS in its current form remains ineffective when it lacks resources. Resourcing was essential in lubricating the new working arrangements of the EMS after years of austerity, economy, and stringency before 1940. Resourcing fostered collaboration and compromise across previously competing interests. Resourcing supported the development of medical, surgical, nursing, and administrative staff able to engage in a dialogue with existing providers and look beyond their immediate organisational horizons of their own institution. Resourcing also undermined narrow competition which had existed between hospitals and services. The importance of this cannot be overstated. 

 

Today, a decade of austerity, bed rationalisations and reductions, the fragmentation of workforce planning and marketisation have hollowed the ability of health services to respond to a crisis. For regions to be effective in times of crisis, they need resources, and trust (albeit monitored and accounted for) in their discretion on the use of those resources. For decentralisation and regions to be effective in the current NHS, they require a statutory footing, autonomy and resources. Judging by the NHS White Paper entitled Integration and Innovation published on 11 February, the government has failed to learn this. The White Paper's formula of local voluntary cooperation and coordination over a statutory footing, greater centralisation over autonomy, and continued cost cutting with new forms of spending restraint over investment are an unlikely combination to revive an exhausted NHS. 


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Further Reading


Steven Cherry, Medical services and the hospitals in Britain, 1860-1939 (Cambridge: Cambridge University Press, 1996)

Cuthbert L. Dunn, The Emergency Medical Services, 2 volumes (London: HMSO, 1952, 1953)

Nigel Edwards and Helen Buckingham, Strategic health authorities and regions: lessons from histories (London: Nuffield Trust, 2020)

Martin Gorsky, John Mohan with Tim Willis, Mutualism and health care: hospital contributory schemes in twentieth-century Britain (Manchester: Manchester University Press, 2006)

Michael Lambert, Philip Begley and Sally Sheard (eds.) Mersey Regional Health Authority: a witness seminar transcript (Liverpool: University of Liverpool Department of Public Health and Policy, 2020)

Alysa Levene, Martin Powell, John Stewart and Becky Taylor, Cradle to grave: municipal medicine in interwar England and Wales (Oxford: Peter Lang, 2011)

Graham Mooney, Intrusive interventions: public health, domestic space and infectious disease surveillance in England, 1840-1914 (Rochester, NY: University of Rochester Press, 2015)

Geoffrey Rivett, From cradle to grave: fifty years of the NHS (London: King’s Fund, 1998)

Richard M. Titmuss, Problems of social policy (London: HMSO, 1950)

Charles Webster, The health services since the war, 2 volumes (London: HMSO, 1988, 1996)

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