130.The 2012 Act made significant changes to the landscape of organisations that sit at the top of the NHS and the wider health and social care system. In many ways, the duties and functions of these national bodies were designed to facilitate the operation of choice and competition within the NHS. During our previous inquiry, we heard of a number of ways in which the national architecture of the NHS poses a barrier to more integrated, collaborative and place-based working.
131.NHS England and NHS Improvement (comprising Monitor and the NHS Trust Development Authority) are the two organisations with the greatest responsibility for setting the direction of, and overseeing, the NHS. These two bodies mirror the purchaser/provider split at a national level. During our last inquiry we heard how, as the NHS locally has developed through the formation of sustainability and transformation partnerships and integrated care systems, having two bodies at the top of the NHS has resulted in conflicting messages for those on the front line. In response to this concern the two organisations are already working closely together to align what they do, provide more joined-up support for local health systems, and establish integrated teams to carry out most of their functions. Evidence to this inquiry supports the view that the current close working relationships has been successful in a number of cases, an example being the joint work between the two organisations on the Five Year Forward View for Mental Health.
132.However, this joint working is limited by current legislative constraints. The two organisations are unable to formally carry out functions jointly, there are constraints on sharing board members and there are separate accountability arrangements to the Secretary of State.
133.Over the last few years, there has been debate about whether NHS England and NHS Improvement should merge. A House of Lords ad-hoc committee established to look at the long-term sustainability of the NHS and adult social care recommended that the two bodies should be merged. We ourselves also concluded, in our last report, that a merger of NHS England and NHS Improvement was one of the legislative proposals that was worth considering.
134.The legislative proposals suggest that NHS England and NHS Improvement should be brought together more closely beyond the limits of the current legislation, whilst clarifying the accountability to the Secretary of State and Parliament. The proposals suggest this would allow the two organisations to go further in:
135.It is proposed that this be achieved either by creating a single organisation which combines all the relevant functions of NHS England and NHS Improvement (including Monitor and the TDA), or by leaving the existing bodies as they are, but providing more flexibility to work together, including powers to carry out functions jointly or to delegate or transfer functions to each other, and the flexibility to have non-executive Board members in common. A preference for either option is not specified in the proposals, but both would require primary legislation to achieve. The accountability between the Secretary of State and the organisations would need to be appropriately defined in legislation, if a single body were created.
136.There was general support expressed for the proposal that NHS England and NHS Improvement should continue to be brought closer together, including wide support for creating a single organisation responsible for all the existing functions of NHS England and NHS Improvement. Despite the wide welcome for the proposal, many echoed the view that further detail was necessary and that more clarity was needed around the implications of creating a single organisation. While it was thought that the proposal would be received well within the workforce, caution was expressed about the speed at which any reorganisation would be undertaken. There was also concern that the focus of the reorganisation would be on cost cutting. More widely, the NHS Confederation said:
We need to avoid creating a large and all-powerful organisation which is too big to challenge and too large to function effectively. It must be able to balance its roles of regulating and supporting NHS organisations and it will need to have the right culture and appropriate checks and balances.
137.We commend NHS England and NHS Improvement for the efforts they have made to work closer together. However, we are aware that further progress is hampered by the legislation covering the two bodies. In an era of local systems, the NHS at a national level should operate with one voice, so as to avoid any incoherence in the support, guidance and direction local systems receive. We support in principle the proposal to merge NHS England and NHS Improvement into a single body, but await further clarity on the implications of the creation of a single organisation. In particular, we are concerned about the degree of central control that would result from this merger, especially in light of the other changes put forward. When these proposals come before us again as a draft bill, one of the issues we will want to consider very carefully is how local autonomy will be protected under the new arrangements.
138.Arm’s Length Bodies (ALBs)—that is, public bodies established with a degree of autonomy from the Secretary of State—play an important role in supporting the health and care system. They include not only NHS England and NHS Improvement but other bodies with crucial roles of their own, such as Public Health England, the National Institute for Health and Care Excellence (NICE), NHS Digital and the Care Quality Commission.
139.NHS England and NHS Improvement have put forward proposals to enable ALBs to act in a more joined-up way. The changes would establish new powers for the Secretary of State to transfer, or require delegation of, ALB functions to other ALBs, and to create new functions of ALBs. Stakeholders have questioned how the Secretary of State might look to exercise these powers, and what protections might be undertaken prior to the use of such powers, for example adequate stakeholder consultation.
140.We would like more clarity on how establishing powers for the Secretary of State to transfer powers to arms-length bodies (ALBs), or require ALBs to delegate their functions to another ALB, will be used to support the delivery of the NHS Long-term Plan and the goal of better integration. The strategic intent behind this power is unclear.
178 Health and Social Care Committee, , Seventh report of Session 2017–19, HC 650
179 NHS England and NHS Improvement, , February 2019
180 Royal College of Psychiatrists ()
181 House of Lords Select Committee on Long-term Sustainability of the NHS, , Report of Session 2016–17, HL 151, April 2017; Health and Social Care Committee, , Seventh report of Session 2017–19, HC 650
182 NHS England and NHS Improvement, , February 2019
183 NHS Confederation ()
Published: 24 June 2019