A Critical Evaluation Of The Public Management Reform Agenda In Relation To Decentralisation In The Nhs
The decentralisation of the NHS has been part of a considerable agenda put forward by the public sector in general in a bid to create greater efficiencies and to ensure that the end user is gaining a better service within the budget confines. Over the years there has been a decided move towards the notion of decentralisation of the NHS as a means of ensuring that localised decisions are made more readily and that they are in keeping with the needs of the individuals in the area. Despite the benefits associated with decentralisation there are also several negatives including the lack of consistency which have been identified and considered during this paper.
Recent pressures across the public sector has led to an increasing focus on ensuring that greater efficiency is achieved in some of the key services being provided across the UK. In this paper, the focus is on the NHS and how decentralisation could potentially allow the NHS to provide a more efficient service to the end users, i.e. the patients. Whilst still retaining a tight budget is still paramount, recent reforms have involved giving much greater control at the local level to the overall NHS budget which is estimated to be in excess of ?80 billion. In particular, GPs have been given much greater control over the way in which services are delivered and arguments have been presented that individual GPs are in a much better place to identify the needs of their particular patient group and therefore the budgets which are available to them will be used to better effect (Audit Commission 1996). Despite this, any major form of decentralisation of public service needs to be considered in much greater detail, in order to ascertain whether or not true efficiency is being achieved, or whether there are some failings of the decentralisation process which need to be dealt with, before the underlying aim of decentralisation can be achieved (Leach et al. 1994).
Specific agendas have been set out in order to achieve decentralisation within the NHS with several primary care trusts (PCTs) taking this policy in creating their own sets of rules and requirements when it comes to the direct provision of services within their area, with a large focus being put on the patients themselves. For example, as part of the management review, the focus was placed on patient satisfaction and gaining information from the patients themselves, in terms of how they felt their individual needs were being met. This could be seen as part of the wider concept of “patient first”, which aims to ensure that the NHS is making decisions at the lowest level which directly impacts on the patient, something which requires at least some degree of decentralisation to be instigated (Batley and Larbi, 2004). Decentralisation in this case has therefore been a process of transferring authority and decision making suggesting that devolution is the key method of decentralisation with the key factor being the shift of power and decision making from the central organisation to the individual areas.
The management reform agenda across the NHS changed the traditional way that patients are looked at and considered them as customers, rather than the end consumers who have little or no choice as to how they receive the relevant services. This new agenda focuses on the patient as a partner in the NHS, rather than an end user with no choices available to them (Clarke et al. 2000). This shift is central to the overall agenda regardless of the actual practical approach taken in each area.
When combining the underlying concept within the NHS with principles of decentralisation, it can be seen that decentralisation is in fact a fundamental part of delivering this new agenda. Decentralisation is viewed as a means of transferring authority from a central location down to other levels within the organisation. When applying this within the NHS, this would allow individuals at the local level to make decisions in terms of how the budget is spent and how patient services are planned and delivered, rather than being dictated to by a central authority.
The Overall Approach to New Public Management
Decentralisation does not come alone, but as part of a wider reform package agenda which looks at the overall performance of the NHS. More specifically, this involves taking into consideration not only the way in which decisions are made, but also ensures greater accountability for performance management at a localised level. This again is an example of devolution and the shifting of overall power rather than maintaining the power centrally.
When it comes to applying the agenda for the change for the NHS, the ultimate impact for those within the NHS is that decision-making is carried out at a level which is much closer to the end user, thus ensuring that individual user needs are taken into account in much greater detail than they would be if these decisions were made at a higher level which is largely divorced from the needs of the end-user. Difficulties do however emerge when decentralisation is not undertaken in a consistent manner, as this may result in a situation whereby certain areas are dealt with very differently from others, resulting in the so-called postcode lottery, with end users having little or no confidence in the NHS and even changing their own geographical location, in order to allow them to receive services which they deem to be important. This general approach to decentralisation is being seen under the umbrella term of new public management agenda and the recognition that when it comes to providing public services there needs to be bottom up input if this is to be successful and if budgets are to be used appropriately and efficiently.
This creates a potential discrepancy between the need to ensure consistency of service and consistency of performance, but also allowing individual providers to have a degree of flexibility regarding how they deliver the services within their specific area. One of the benefits which are perceived to be linked to the decentralisation of the NHS is the fact that the individual patients are more likely to receive the appropriate level of care which is tailored to their needs. Where decisions are made at the local level, it is likely that the decision can be made more effectively and arguably with better knowledge of what services precisely are required.
By adding greater power and choice at a more local level, be it within the primary care trust itself, or even at such a local level as the individual GP practice, this requires individuals at this lower level to have a broader range of skills; it will also require these individuals to become involved in people management and budget, planning, which may require a shift in training and may even be unsuitable for certain types of personalities, to such an extent that it may be necessary to have a change in management structure, at the local level (Gilardi, 2008). Essentially therefore the approach involves creating a framework agenda which establishes the overall principles yet allowing individual PCTs to apply this with reference to their own individual circumstances and position.
Accountability is an interesting by-product, which has happened as a result of the decentralisation of the NHS, where the organisation itself and the people making the fundamental decisions in relation to budget allocation and the services being provided are much more visible to those who ultimately receive these services and this makes the whole process considerably more accountable. For example, the GP who has made a decision as to who should receive a specific treatment will need to inform those individuals, personally. This makes the decision making process much more personal than would be the case, if the decisions were being made centrally, with no direct contact with the end patient. Although this is seen as an interesting way of achieving accountability which is relatively effective, it can also create difficulties within the local service itself, with countless additional pressures being placed on GPs and local service providers, as they now require much greater people management skills, as well as the ability to undertake clinical work which they originally trained to undertake.
Evidence of NHS Decentralisation
In order to test these theories, it is helpful to look at any evidence which has emerged in terms of how decentralisation has impacted upon patients within NHS, in recent years. There is at least some evidence to suggest that, where local health boards make the decisions, they feel more responsible for those within their locality and this may result in certain groups of the community gaining a more appropriate response to their requirements. However, there is also some concern that, by having decentralised powers, certain groups are able to gain greater attention than other groups, simply because they “shout louder” or are asking in a more constructive way to reflect the feelings that are dominant in that particular area but this may mean that other minority groups are overlooked (NHS 2010). Consider, for example, a geographic area which is heavily dominated by an elderly population. Whilst decentralised powers may allow for this group of elderly individuals to receive more tailored care, other smaller groups may then find that their budget is curtailed to such an extent that they do not receive the basic level of care which other patients in other care regions would receive. Where these types of local decisions may be deemed to result in a more efficient allocation to the people, it can lead to feelings of discontent amongst the public in general (McKevitt, 1998).
Despite the higher level of general interaction between the health service and local groups and individuals, there is no evidence that this high level of local participation has had any impact on local policies; however, any form of interaction directly between those who make decisions and those who use the services are ultimately likely to shape the types of policies that are being applied, even if this is not immediate or direct (Robinson and Le Grand 1994).
Arguably, the success of decentralisation is likely to depend on the checks and balances that are presented, at a local level, and the way in which each local authority deals with this increased power which is being given to it. By having patient involvement at ground level and ensuring that patient partnerships are maintained, at all times, a much greater level of public involvement will be achieved. This will enable the positive effects of decentralisation to be enjoyed more readily (Pollitt et al 1998).
Problems with Decentralisation
The difficulty which has arisen from the decentralisation of the NHS is the fact that there is still the need for some form of central co-ordination. Moreover, where funding is being provided from a central source, a considerable amount of time and effort is placed on competing for the central resources which, in itself, absorbs some of the funding that is available and should be better directed towards the end users.
In order to retain at least some control, the agenda within the NHS involves having certain defined performance targets which are centrally allocated and which, to a large extent, override any freedoms which decentralisation may encourage. For example, if a local authority is under pressure to provide certain care for specific groups in society, the amount of choice and freedom which they have at a local level is substantially reduced (Goddard and Mannion, 2006).
From the outset, it was the intention to create an independent NHS trust which is able to make its own decisions and which is no longer under the direct control of central government. However, this has not been entirely achieved. The government has taken the approach of focusing on management agenda at every level of the NHS, suggesting that local entities and local foundation trusts need to earn the autonomy which they seek. With this in mind, it could be argued that the decentralisation process within the NHS has created a framework which will enable successful localised decisions, in the future, but that this will in fact take a prolonged period of time and will require a shift in management activity and interaction, before the benefits of decentralisation can be fully enjoyed. In the meantime, local NHS foundation trusts will still require a central control.
Nevertheless, shifting budget choices and decision making power more towards those who are closer to the end users is undoubtedly likely to be beneficial to the provision of efficient and targeted services, in the long-term. However, with this type of localised decision-making comes discrepancies between localities; this in itself can create problems within the overall NHS system which need to be reverted to central control, if the differences are not to become so major that they are destructive to the overall benefits which are seen to be linked to decentralisation. By looking at the management agenda within the NHS, the realities of achieving efficient decentralisation, it becomes apparent that it is simply impractical to state that decentralisation can happen entirely, or that it is going to be successful in every single situation. It is concluded, therefore that, whilst the decentralisation of public services, in this case, has provided opportunities for the link between the end user, i.e. the patient, who is now perceived to be a customer, with those providing the services, is much closer and allows for greater efficiency when it comes to allocating resources. Furthermore, central control still needs to be maintained, at least to a certain extent, if there is to be sufficient uniformity in the way that the services are provided and if this flexibility in itself does not create more problems than it solves (Burns et. al. 1994).
One thing that is certain, however, is the fact that decentralisation within the NHS will be a gradual process, with certain aspects of this decentralisation requiring much greater control and a much slower process, in order to ensure that consistency of service provision and decision making is fundamentally maintained within the NHS, while also allowing this to be applied at the local level to meet with local demands, something which is at the heart of the new NHS agenda.
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