STPs, Devolution and Primary Care: Interview with Stephen Dorrell

More than 20 years after becoming John Major’s Health Secretary, Stephen Dorrell is still pushing for better integration of health and social care for the UK. He is under no illusions about the size of the task, but as Chair of the NHS Confederation he is in a position to talk outside of party boundaries and look at the problems from the outside in.

Stephen’s political career began in 1974, a 22-year-old going up against John Prescott for a seat in East Hull. As he describes it, being a Tory candidate at the height of the Cod Wars wasn’t the easiest of tasks. Speaking of losing his first contested seat he says, “I fought East Hull, and East Hull fought back”.

His first seat was Loughborough in 1979 – after changes to constituency boundaries in 1997 he then represented Charnwood, where he served as MP until standing down from Parliament in 2015.

His first role was as Parliamentary Secretary in 1983, joining Thatcher’s government in 1988 as Government Whip. After stints as Heritage and Treasury Secretaries, he was appointed Secretary of State for Health between 1995 and 1997 as part of John Major’s Conservative government.

He took on the role of Chair of the NHS Confederation in November last year and it’s clear his passion for driving improvement in healthcare remains undiminished: “If you want to change something, you have to make the case (for) why what you’re proposing to do would be better than what we’ve got now,” he says, “The simple way of putting it is: do we engage with local communities in enabling them to lead healthier lives or do we just hire more cardiovascular surgeons? Expressed that way, most people can understand it.”

THE NHS CONFEDERATION AND PRIMARY CARE

Dorrell became head of the NHS Confederation in 2015, an umbrella organisation that represents NHS Trusts and other health commissioning and delivery organisations such as the National Association of Primary Care (NAPC). He explained the role of the Confederation to FPM, as well as setting out some of its goals:

“It speaks on behalf of its members and the point of view of the clinical commissioners. We’re working with the NAPC to bring them into the Confederation as full members on behalf of the voice of Primary Care.”

“You can’t do healthcare without engaging with social care and social housing, which are local government responsibilities. I see the NHS Confederation as an organisation which is committed to the joined-up relationship which need to exist if we’re to deliver efficient use of taxpayer resource, but more importantly, effective achievement of health objectives.”

SUSTAINABILITY AND TRANSFORMATION PLANS

In April 2016, Stephen was appointed as independent chair of the Birmingham & Solihull STP Board, working alongside the Birmingham City Council Chief Mark Rogers, who has ultimate responsibility for the programme. Dorrell said at the time that across the region, “we need to recognise and celebrate our successes, but we also need to understand why health inequalities still persist and what we can do about them”.

There are 44 STPs ‘footprints’ in England, with only four being headed by non-NHS Executives. The STPs haven’t been looked on favourably by the general public, nor many sections of the press, but Stephen sees the process as an opportunity to take a system-wide view of what the NHS can – or should – provide.

“Only four of (the STPs) are led by people from the Local Authority side of the fence, and that was part of the reason I was attracted when I was asked to go and do the job in Birmingham and Solihull – that I do think it’s important that we look beyond the traditional silos of primary, secondary, tertiary care, and look at the health service in the context of being one of a range of health services delivering a set of objectives to a community.”

“It’s argued (there’s a) need for joined-up care between health and social care, which you can’t do without talking to the local health authorities and the NHS, but the objectives set out in the STP are the right ones - the decision-making process about the use of public money which should happen in public with proper accountability and proper visibility. That’s the good news.

“What’s less good news is that this is being done on an unrealistic timescale and without sufficient clarity. I don’t think anyone involved in the STP process would regard it as being anywhere near perfect, but the objective of a system-wide view that includes local government in the use of public resources seems to me to be the right objectives”.

DEVOLUTION – THE FUTURE OF HEALTH PROVISION?

As well as the challenges of moving towards an integrated service, the Confederation has been reviewing the devolution of services, with a particular focus on the responsibilities that were handed to the Greater Manchester ‘Devo Manc’ scheme that created a ‘combined authority’ between healthcare and the local council. The idea of not merging providers, but empowering commissioners to work with them to provide a joined-up service is one that Dorrell has supported as a future model of health provision:

“As you think through ‘place-based’ services, to use the current jargon - public services which are designed across the traditional silos to focus on the needs of citizens and communities - you will increasingly be challenged to justify, for example, the distinction between primary care and community health services, which only exists because of a political decision in 1946. How much longer do we have to live in silos that were created on the basis of a political fix?

“We have a silo between community and primary health, and with social care – joining those services up so that as a citizen I can receive support to enable me to lead a life that is as healthy and rewarding as possible, that’s the challenge to which the devolution agenda is addressed.”

Asked if this devolution approach will be adopted more widely, he believes that it will be something that the current government will progress.

“I understand that this is their intention, to continue with a programme of combined authorities, increased devolution, encouraging local communities to step forward to rethink the way that public services and local government work. It isn’t just about public services, it’s about local government developing its role within a local community - that continues to be the direction of travel.

“I think there’s an increasing recognition that thinking of public services as national silos is a way of reducing their effectiveness in the service of citizens – they need to be joined up and they need to be built around the needs of local communities. If you’re doing that across the range of public services, the idea that you do it across all public services except health just seems to me to be so absurd that even to state it is to demonstrate that it is nonsense.”

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