Risks and opportunities in the new NHS

Posted: 12 November 2010 by Richard Baldwin

The prescription for the NHS is now clear - less central and more local control, with GPs in charge of who gets what, when and where. The aim is to use GP skills and knowledge of patients to get services right. However, the challenge does not end there, because services can only be right when the facilities for delivering them are also in good shape.

So how would decentralisation work for facility or infrastructural development? There are two issues. The first is about the skills needed to get estate development and management right. And the second is about strategy – ensuring that there is the correct mix of infrastructure across the NHS and that change happens smoothly.

On the first question – skills – it will be vital to make sure that the people commissioning and paying for buildings are just as good at it as doctors are at spotting a hernia. That’s not so easy, because doctors are trained for years to diagnose hernias and have lots of practice. But they are not architects or engineers and, given the singularity of building programmes, they are unlikely to gain much experience. They may engage with perhaps a couple of projects in their careers. So, to get the best outcome, they – or whoever else commissions infrastructure - will need help from people who know the ropes.

Then there is the second question - making sure not only that a single building is right, but that the mix across the NHS works. We know it’s not right at the moment – most experts agree that the acute sector has too many beds, creating  significant cost inefficiencies often without any clinical gain. Decentralising spending will expose the unsustainable nature of those overheads. In short, handing the responsibility to the GPs should be a healthy catalyst for change. The challenge will be to avoid it being an unhealthy recipe for chaos.

Lots of senior figures across the public sector are chewing over such issues. They know that a degree of standardisation and central control can offer benefits from sharing knowledge and strategic balance, particularly with regard to buildings.  But there is a tension with GP-led consumer power which could be great for shaking up the way we currently deliver our services. Getting the best out of the interplay of these forces – for the whole system – is a big challenge facing those setting the future direction of the NHS.