Fear over quality of care if NHS centralises further

There is a real risk that the next government will resort to central control of the NHS, reversing the gains of recent years and damaging patient care, warns the outgoing chairman of Monitor, the independent regulator of the self-governing NHS foundation trusts.

“As public expenditure tightens, the natural response of governments of any colour is to think that central control and central dictation is the only way to keep control of the money,” William Moyes, who stands down at the end of the month, told the Financial Times.

The autonomy of foundation trusts, the growing separation of the commissioning of care from its provision, the use of diverse providers, with a degree of competition and choice, might be seen as “just too risky” so “everything becomes pulled into the centre”. 

That would be “a huge mistake” when “the only way to run a healthcare system in a developed country in the 21st century” was to have a decentralised approach where “people are not looking up to the secretary of state to see if they have done the right thing, but are actually looking at the patient and asking themselves: ‘Is this the right thing for the patient?'”

If clinicians and hospitals were simply reduced to carrying out instructions, “that will not produce good services for patients”.

Reflecting on his six years as head of Monitor, Mr Moyes said progress with reform of the health service had moved much too slowly because “at the official level there is still not enthusiasm [for the programme] in the Department of Health.

“I think there are still a lot of people who really would rather go back to the 70s and [a time of] central control.”

Given that Tony Blair, former prime minister, had bet his government’s majority on forcing through the policy of free-standing foundation trusts, Mr Moyes said: “It never occurred to me it would take so long, and be so hard to persuade the government to implement its own policy, which is what I have spent six years doing with my colleagues.”

All hospitals were meant to have had the chance to become foundation trusts by early 2008. But half have still not achieved that.

“Half the hospital system is still not capable of saying it is financially viable and well governed [the requirements to achieve foundation trust status],” Mr Moyes said.

That included big teaching hospitals in Oxford, Nottingham, Leicester, Leeds, St George’s in London as well as large institutions in Plymouth, Southampton, Bristol and Liverpool.

If you lived in such a town or city, and the hospital was in effect saying, “‘well, actually, we are not really very financially strong and our governance is pretty poor’, how would you feel about that?” Mr Moyes said.

The fact that in many parts of the country the NHS remained a mix of foundation trusts and hospitals still answerable to Whitehall and the secretary of state meant that the full benefits of the reform programme were not being felt. Health authorities were continuing to worry about operational problems in hospitals, not about commissioning the best care for patients.

The time had come, he said, for the department to recognise the NHS was not a “a system” of people and buildings the secretary of state had to be involved in managing. Rather, it was a “mutual insurance system” which “defines standards, defines efficiency [and] looks after the interests of patients who pay the cost of the insurance. It challenges inefficiency. It challenges poor quality. It is aggressive and goes for the best. It shapes the whole service”.

But the department had never accepted that, and “the culture, and the unsaid assumptions of a lot of people in healthcare is that this is an integrated system that is managed from the top, and therefore they can’t see the logic of the reform agenda”.

That “underlying culture of corporatism” remained the biggest single obstacle to the decentralised approach that was essential to deliver the best healthcare.


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