We can’t sort health and social care until we let go of central control


The ten macro trends in the NHS (see my Book 1) are creating many more chronic, out-of-hospital conditions and even ‘new’ conditions such as diabetes and dementia that make the boundary between a medical condition and a social condition meaningless.

What we have to do now is to give local leaders the authority and support to get on with it – and to protect them from the interference that is often exercised by the national bodies and by central government.

Why? Because the health and care system as currently designed cannot cope. Even before the pandemic, A&E visits were up 22 per cent over the last nine years. That’s almost 24 million attendances. This is largely because of the failure to tackle the growing problems of deteriorating health in poorer communities and the needs of an ageing population.

This leads to radically different conclusions about how health services should be delivered:

1. It has as much of an emphasis on keeping the population healthy as on treating them when they become ill.

2. If we are to improve the health of the nation, the most significant and crucial agent is not central government but the properly-sized regional authority, with NHS services embedded in the provision of broader community services that determine the health of the population.

3. These regional authorities should be founded on a proper area-based economic footprint, like the combined authorities, amalgamating many of the currently smaller-sized, stove-piped local authorities, and encompassing NHS services.

4. These devolved health and care systems need to be structured more boldly than the integrated care systems launched in 2019 by Corporate NHS as a good first step.

5. The overarching authority should be a new one made up of both the NHS and amalgamated local authority organisations. There should be no question of one body taking over another – it will need to be a mix of both but with clear lines of authority.

6. Regional democratic legitimacy is important. There must be a single, democratically elected, regional leader and that can only be a mayor, such as exists in Manchester with Andy Burnham, in London with Sadiq Khan, and in the West Midlands with Andy Street. Obviously, there is only a small number of mayors currently, but this structure should be extended as quickly as possible to cover the whole country.

Improving the health and wellbeing of the British population requires not just reform of the NHS and social care, but also reform of the way that the country is governed.

A radical shift is also needed if we are to create liveable cities as urban populations grow. Much more emphasis needs to be placed on understanding the social life of cities – how government, public agencies and urban planners can design spaces, but more importantly, services can help neighbourhoods flourish. Unravelling what makes a place work means understanding and examining the particular social life of that community and the multitude of influences – past and present – that shape it.

This can’t be done from the cosseted square mile of Westminster and Whitehall. What is the history of a neighbourhood? Is its story one of growth or decline? What is its spatial relationship to the rest of the city? How is a place understood and defined by its residents, and in relation to neighbouring places? Is it integrated? Segregated? Socially excluded? Politically engaged? What is its reputation today and in the past?

These are challenging questions for many public agencies to deal with, especially in light of local government and public sector job cuts. Yet, objectively these things matter, and they are essential to understand if urban sustainability is to be a genuine policy goal.

Devolution of power from London and the extension of newly integrated health and social care into the other fundamental drivers of health and wellbeing – education, employment and housing – is a vital precursor to restoring the vitality and dignity of the denuded regions of England.

The approach advocated here is based on the principles of ‘equity, territorial justice and solidarity’. It calls for a radical re-fashioning of the structure of economic governance, based on a new federal constitution that would provide for a cohesive and balanced process of decentralisation, enabling national and regional governments to adopt inclusive models of development that promote more and better jobs, and target resources at the most disadvantaged areas and people.

Just how much power will be decentralised is uncertain, and the white paper announced in 2021 is ambiguous in that it doesn’t really do anything to integrate health and social care, and has centralising tendencies, such as provisions for greater political control from Westminster.

So how do we get ‘the best NHS?’ Stephen’s considered answer to this question is being published by Radix Big Tent in 12 parts – one part a month – so don’t miss No 1 and No 2! Book #3 (‘Battling health and wealth inequalities‘ is published this weekend and we are discussing this blog at our Friday forum ! See you there!

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Radix is the radical centre think tank. We welcome all contributions which promote system change, challenge established notions and re-imagine our societies. The views expressed here are those of the individual contributor and not necessarily shared by Radix.


  1. Stephen Gwynne says

    Whilst I support this approach, the devil is in the details, especially regarding regional fiscal and monetary policy.

    Similarly the outcomes of regional democracy may result in an entirely different vision of what you set out here in that decentralised regions will become more politically and therefore culturally autonomous. Therefore expect a diverse range of political perspectives from the left to the right and increased competition between them.

    Lastly, the ecological footprint of regions and especially regional cities are increasingly reliant on import dependencies whether from other regions or other countries. Thus food and energy security are clearly federal concerns which then incorporates transportation, skills, the health of workers in order to sustain the physical infrastructure of these federal concerns.

    Hence top down necessities meets bottom up desires with increased regional political competition potentially disrupting the required cooperation at the federal level.

    I would strongly recommend reading this review which highlights how algorithms and rules can make human decision making much more robust and effective despite the sacrifice of individual human agency.

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