Shaping up to improve health: the strategic leadership role of the new Health Authority

The latest return to service planning in the NHS, while harnessing the perceived benefits of previous market approaches, nevertheless signals a radical change in the long-term role of the Health Authority. It is timely to examine the actual objectives of Health Authorities in view of their envisaged strategic leadership role. The emphasis on improving health and ironing out unacceptable local inequalities places the ‘quality’ agenda at the forefront of Health Authority policies. Notwithstanding the role of Regional Offices, Health Authorities will in effect become the overseer of clinical governance arrangements, including the implementation of a more evidencebased approach to service delivery and organisation. The new all-inclusive Health Improvement Programmes represent the raison d’Ltre of the Health Authority of the future. It is argued that insufficient attention has been paid to the legal framework required to support prioritisation decisions for which Health Authorities and PCGs will be held accountable. Available case law suggests that the extent to which central guidance has been followed will be critical in reviewing commissioning decisions. Given the trend towards National Service Frameworks and the development of the National Institute for Clinical Excellence, the question arises of what incentives exist for Health Authorities to pursue the evidence-based approach to its natural conclusion (i.e. as one means of rationing scarce resources). Perhaps the key objective of commissioners will in fact be to avoid adverse publicity in the face of increasingly complex (and open) rationing decisions. In addition, the implication that national guidelines on clinical and cost-effectiveness will have to be adhered to sits somewhat uneasily with recent government assurances regarding clinical freedom and professional self-regulation. Attention is given to equity considerations, the difficulty of identifying common objectives and maintaining productive relationships across organisations, and barriers to changing clinical practice. Conflicting incentives are likely in applying different dimensions of the National Performance Assessment Framework, making the Health Authority’s long-term role (regulator of resource use, quality and service configuration?) a particularly difficult balancing act in ensuring administrative, clinical and political accountability in health care.