My Lords, I rise very briefly to support the probing Amendments 89 and 90, in the name of the noble Lord, Lord Hunt, about the role of local government and the NHS. I speak as somebody who has been an NHS manager—I think I said previously that the noble Lord, Lord Hunt, was in the higher echelons of NHS management when I was a mere trainee. I have also been a local government council leader and recently I have been an NHS non-executive director.
There were clear issues as we went through the Health and Care Act. As the noble Lord, Lord Hunt, said, it seems like we are having the same discussion. It is not that we want to say, “We told you so”, but the structures that have been set up and the cultures and behaviours of the two organisations mean that they are incompatible with what we all want to achieve, which is a localised and systematic approach to dealing with people who go through the NHS and care system to improve health and reduce health inequalities between areas.
The NHS, by structure, looks up. It looks up to NHS England and the department. The way that the funding goes means that the levers that the Secretary of State or the senior directors of NHS England can pull will mean that NHS staff, in terms of managers and leaders, will look up and will respond to a top-down approach. The culture within the NHS is top-down, top-down, top-down. Local authorities, and particularly local councillors, look out. They look out to their area: that is who they serve, that is who, predominantly, gives them their marching orders—not somebody above them from a national organisation and a central ministerial area of government.
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I saw how it works recently. I was the non-executive director of Chesterfield NHS Hospitals Trust. Even at budget level, the way that the levers are pulled from the regional level to determine what hospitals do is quite startling. Therefore, unless the Government look at what has happened in Manchester, which I think was called “devo max”, where at least some of the levers—not all, but some—come down to a local level, so everybody looks out at NHS level and at local government level to be able to deal with local needs, rather than somebody sitting in Whitehall making a decision for the whole country and everybody in the NHS having to march in the same direction, we will not get a significant change in improving health and reducing health inequalities at a local level that is
systematic and can work. That is why I think these two amendments are important, and the Government will ignore them at their peril.