There are few surprises in the Health Foundation's recently-published NHS Productivity Commission report, Breaking the cycle: How to build a more productive NHS. This is not a criticism. Some arguments cannot be made too often.
Echoing the ‘from this to that' formula in the NHS 10-year plan, the commission calls for four shifts: from constant churn to stable direction, priority overload to focused accountability, excessive compliance to freedom to deliver and from episodic change to capability to improve.
The report may not win prizes for originality – full disclosure, I was a very inactive member of the commission's advisory panel – but it scores highly on timing. Each of the core problems identified can be linked to over-centralisation. This is a particular problem for the NHS, with its pathological control issues, politicised leadership and history of morale-sapping reorganisations.
In passing, I should share two universal truths offered by a friend who has spent a successful career advising organisations about change. First, the most important factor to productivity is staff engagement and second, engagement nearly always declines during processes of corporate change. Imagine how different the history of the NHS might have been had health secretaries internalised and acted on those simple insights.
If strategic authorities are to increase the quantity and quality of work in their areas, they need a coherent, overarching government vison to help shape local strategy and action and they need to be able to see how every new central initiative and command relating to work speaks to that vision.
It is clear Andy Burnham's Government intends to increase the influence and responsibility of local government, particularly mayors of strategic authorities, in relation to health. The means of doing this – balancing a national devolutionary shift with sensitivity to local needs and capabilities – is a live debate in central government.
In the past, the NHS has been where occasional bursts of devolutionary intent in Whitehall come to die.
Looking at the barriers to devolution across government, not just in health, the outline of a grand deal can be traced. On one side, the centre needs to do things differently.
It must reduce the thickets of central targets, performance indicators and regulatory frameworks that mean NHS managers spend more time looking up and obeying rather than looking out and creating. But frustration at central control is also about clarity.
The centre needs to get better at joining up across key policy issues. For example, there are at least five strands of interrelated government policy around work and its future – education and skills, employment rights, reducing economic inactivity, improving productivity and the impact of AI.
If strategic authorities are to increase the quantity and quality of work in their areas, they need a coherent, overarching government vison to help shape local strategy and action and they need to be able to see how every new central initiative and command relating to work speaks to that vision.
If this is the quid, what is the pro quo? A big concern among ministers and officials is the capability of local leaders to take on new responsibilities and freedoms. This is not to disparage local politicians and officers, but to recognise how decades of under-funding and over-control have eaten away at local capacity and confidence.
There is also a worry – especially in relation to places with mixed political control – that different layers of local government and complex geographies will mean energy gets dissipated by local friction.
Given the UK's fiscal challenges, building local capability cannot rely on injections of money. There will be functions and senior people moving from the centre to localities, but devolution must also involve a step change in local collaboration. Too often the capabilities – whether expertise, data or capital assets – exist locally but they are locked up behind organisational walls rather than being used to enable transformative change.
The research literature around ‘relational co-ordination' underlines the importance of collaboration but also the extensive and challenging practical work which must be done to make it more possible.
The NHS Productivity Commission reinforces the case for greater devolution. Making this happen in health and other policy areas will require both central and local leaders to put the public interest over self-protection.
Matthew Taylor is former chief executive of the NHS Alliance
