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Our great leader has decided to reopen one of the founding arguments of the NHS.
Back in 1948, Aneurin Bevan insisted the service must be national. Funded, controlled and accountable at the centre. To end the unfairness of what we later called postcode care.
Herbert Morrison wanted local government to run it.
An interesting historic note; Peter Mandelson is the great-grandson of Herbert Morrison, and of course we have since learned about Streeting's connection to Mandleson.
Mandelson was part of a Sunday supper party… regular guests included Wes Streeting and a small circle of personal friends around Mandelson, with social gatherings and political discussion
Other accounts describe 'kitchen cabinet' style Sunday evening meetings involving the same network.
From Morrison’s great-grandson’s dining table to the Department of Health, the argument about who should run the NHS looks to have come full circle.
Morrison was a towering figure in post-war Labour politics and, the chief advocate for local government control of the NHS.
Bevan won.
Streeting now wants to run the experiment again.
In Greater Manchester and South Yorkshire, mayors like Andy Burnham and Oliver Coppard will gain real influence over NHS priorities, budgets and strategy.
Alongside this, NHS-led integrated health organisations will be asked to run whole-place budgets in a more traditional way.
Two models. One system. Let’s see what works.
At one level, it’s a sensible question.
Health is not made in hospitals. It’s made in homes, jobs, schools and streets.
Councils control housing, planning, environmental health, transport and much of social care.
If you want to prevent illness, not just treat it, those levers matter far more than another outpatient clinic.
There's also a democratic argument.
Most people couldn’t name their ICB chair if you paid them. It's likely they can name their mayor. If services fail, voters know where to point the finger.
So far, so logical, but…
… scratch the surface and the problems start to stack up.
First, accountability.
Streeting says there will be two politicians overseeing the system; himself and the mayor. That sounds neat, but...
... in practice it is a recipe for muddle.
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When waiting lists rise, who is responsible?
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When money runs out, who decides?
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When priorities clash, who wins?
The NHS already struggles with blurred lines of control. This doesn’t fix that. It compounds it.
Second, inequality.
Some places have strong leadership, stable institutions and the analytical muscle to manage complex systems. Others don’t.
Devolution in England has never been even. Handing more control to local areas risks widening the gap between the best and the rest.
The postcode lottery didn’t disappear. It was designed out. This risks designing it back in.
Third, capability.
Local government has been through a decade of austerity that has hollowed out public health and left social care threadbare.
Councils are not sitting on spare capacity, waiting for more responsibility. Many are struggling to meet what they already have. You cannot devolve what no longer exists.
Fourth, timing.
This is being layered onto a system already in upheaval; ICB cuts, NHS England’s abolition, workforce churn, financial pressure.
The service is being reorganised while it is still trying to recover from Covid and the last reorganisation.
That is not reform. It is movement without direction.
And then, there is the biggest problem of all: this is being framed as an ‘experiment’.
Health systems are not laboratories. You cannot control the variables. You cannot run clean comparisons.
By the time outcomes are visible, the structures will have changed again.
What you get is not evidence. You get interpretation… usually shaped by whoever is in charge at the time.
So what is really going on?
The NHS is being asked to do something it cannot do on its own… improve population health.
The drivers of health sit outside its control. So the answer is to move power closer to those who hold those levers.
The instinct is right, but…
… the execution risks creating a hybrid system, half national, half local, and wholly unclear.
Bevan chose clarity.
Morrison chose locality.
Streeting is trying to combine both.
In the NHS, that usually ends the same way.
Everyone has a say.
No one is in charge.
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In todays’ new podcast, Niall dickson and I talk to Andy Burnham about this and his whole integration menu in Manchester. It's a cuppa-builder's listen!!
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