Final Report > Chapter 24: A Health Service which is Well Led > The leadership and management of the NHS

The leadership and management of the NHS

14 We recognise that, so long as the NHS remains a publicly funded service and that healthcare continues to be provided primarily through trusts, NHS primary care trusts and through staff employed by the NHS, the NHS is a state-run organisation with a virtual monopoly in the provision of healthcare. It follows from this that how resources are used within the NHS is subject to Parliamentary scrutiny through the accountability of the Secretary of State. This being so, we accept that management of the NHS must be the responsibility of the DoH. This is not to say that the Department should manage every detail of activity. Historically, as was set out in `The NHS Plan': `The relationship between central government and the NHS has veered between command-and-control and market fragmentation. Neither model works. The NHS cannot be run from Whitehall'. [6] Nor, we would add, can it be run like a commercial organisation in which the values of public service and of the healthcare professionals are replaced by a culture of commodity and commerce, if it is to keep faith with its founding principles.

15 `The NHS Plan' recognises that the quality of care provided for patients will have the best chance of improvement when clinicians and managers have the freedom to lead and manage local services within a national framework. The Plan emphasises that, progressively, there will be less central control and more devolution as standards improve and services become more focused on patients' needs. The challenge will be to make that a reality.

16 We are in no doubt that intervention from the centre should only be contemplated when it adds value. Such value can most effectively be added at the strategic level, by establishing and monitoring national systems, rather than by direct intervention or directing the management of individual trusts or individual professionals. We recognise that this shift will take time, that a process of change is involved, but would argue that there needs to be progressively much greater self-discipline on the part of central government. The prime focus should be on supporting local management and on helping health authorities and trusts to deliver care which is safe and of a good quality. We understand, as we have already made clear, that if Ministers are accountable to Parliament they will be inclined to want to direct. Furthermore we recognise that there are, and should be, occasions on which central government must have the power to intervene and take action. But this must be carefully judged if a sense of local leadership is not to be undermined. The answer lies in a gradual understanding of what the centre is responsible for, together with the parallel development of local mechanisms whereby institutions and managers at the local level can be held accountable. And, in between, there is the necessary development of a middle tier of leadership and management able to see beyond the individual trusts and take account of the interests of the wider community. On this account we welcome the creation of the new health authorities which will take on this role.

Footnotes

[6] `The NHS Plan'. London: Department of Health, 2000. Para 2.31