Evolving governance

A new government with new ideas and new technology facing new challenges, as well as plenty of old ones. People in governance positions must adapt or die. Principal consultant Aidan Rave sets out some challenges and opportunities.

Now that the general election is finally behind us, thoughts inevitably turn from the poetry of the campaign trail to the prose of governing.

The inbox awaiting West Streeting, the newly appointed secretary of state for health and social care is by any measure a daunting one. The challenges are manifold and complex; from finances to recruitment to crumbling RAAC-built hospitals, every problem is likely to be of the wicked variety.

All the while the inexorable march of an ageing, increasingly sedentary population will drive demand ever upwards, which in turn will ensure that health inflation continues to run at least 2-3% hotter than in the wider economy.

There will be opportunities of course, should the new incumbent find time to consider them. The role of AI in healthcare has been much vaunted and given the challenges, it is surely time to seriously test the possibilities it might present?

Missing detail

On the campaign trail, the political parties vying for our votes remained circumspect about their detailed plans for health and social care. Beyond the inevitable statements about ‘more doctors, nurses, appointments’ etc, and the tiresome promises to ‘cut out waste’, any specifics about structure, roles and responsibilities or strategic direction have been for the most part absent.

Perhaps this signals a preference for evolution rather than revolution, which, given that the system-oriented ICBs will celebrate only their second birthday during the week of the general election, would seem sensible.

It is therefore to be hoped that the temptation to indulge in any large-scale restructuring can be resisted; not only would it be a distraction at a time when neither the NHS nor local government have the capacity for distraction, but it would also be futile.

System first

Conceptually and structurally, a system-based approach, guided by system leaders affords the best chance of creating an integrated approach to effective healthcare. Our national obsession with the NHS conveniently ignores the fact that 80% of an individual’s health is influenced not by pathology but by society, so developing a system-wide approach to addressing the social determinants of health simply cannot be effectively led by the NHS alone.

Any attempt to restructure the current arrangements would surely have to take this into account and therefore be little more than a variation of the existing theme. The relative immaturity of relationships between NHS and local government leaders remain a cause for concern in some areas but in the two years since the advent of integrated care boards, we’ve had not only the post-Covid demand spike to add to the already-substantial health backlog, but also the cost-of-living crisis, which has pushed many families and communities to the point of subsistence.

These are hardly conducive conditions in which to nurture delicate relationships, so more time and focus on system leadership would be a much more effective use of ministerial energy than yet another restructure that would surely end up broadly where it started.

A time to build

Local government and NHS leaders could also use the new session of parliament to reset what at times has become a slightly fractured relationship. As the NHS embarks on its own period of relative austerity, its leaders could learn much from their local government counterparts, many of whom have the battle scars of nearly a decade and a half of more or less managing to keep the lights on despite swingeing cuts to their budgets.

Similarly, local government colleagues can learn valuable lessons from the NHS; there is no monopoly on good ideas, innovative thinking and effective leadership. For this to happen, egos will need to be suppressed and emotional intelligence brought to the fore – a challenge that can be driven at an individual level, with no permission required from above.

As well as resetting their own relationships, local government and NHS leaders should also apply the same vigour to resetting their collective relationship with the voluntary and community sector, so often the poor relation in terms of system leadership. The solution to the health and social care challenge lies at least in part with the ability to not only predict the patterns of chronic and preventable disease, but to put in place the means to alter the conditions and behaviours that drive them in the first place. This places the voluntary and community sector at the forefront of the strategic challenge ahead and they should be treated not as an associate, but as a full partner in meeting it.

Of course, much of this is down to leadership within the systems themselves, rather than ministerial guidance from Whitehall, but as ever when it comes to leadership the tone set from the top – the mood music if you like – will be a critical factor determining success.

More than anything else, the new Secretary of State would do well to recognise their own limitations in addressing this challenge, and recognise the role that local leaders will play. Giving them the support and resources they need to do the job will help to make headway in meeting the seismic challenges ahead.

This is an edited version of an article originally written for the MJ