Burnham's push for power in every postcode is important for future health and care
Prime Minister Andy Burnham’s commitment toputting power into every postcodesignals an important evolution in thinking about the future of health and care. His call for greater devolutionrecognises that. . .
Prime Minister Andy Burnham’s commitment toputting power into every postcodesignals an important evolution in thinking about the future of health and care. His call for greater devolutionrecognises that decisions made closer to the communities they affect are likely to be more responsive and effective. His commitment to addressing the wider determinants of health and putting power into every postcode can be understood as pointing towards the deeper reform of subsidiarity—the principle that decisions should always be taken closest to where they will have their effect—beginning with people, building outwards through autonomous and accountable teams and communities, and asking each higher level to do only what cannot be done effectively closer to them. While devolution can create the conditions for these different influences to be brought together, it is subsidiarity that determines how power, responsibility and decision-making should operate within those conditions. Subsidiarity starts with peopleSubsidiarity does not mean power being delegated down through the system to where it is assumed to belong. It begins with people. Responsibility should move outwards and upwards only when the action required cannot be taken effectively at the level closest to them. The first level is therefore the individual and their family or carers. People are not simply recipients of services. They create much of their own health through the decisions they make, the resources available to them and the support and connections around them. This requires more than encouraging people to take responsibility for their health. It means creating the conditions in which their agency can flourish: removing barriers to gaining and using the knowledge, skills and confidence to act on what matters to them. High-quality shared decision-making is fundamental, ensuring that professional expertise and evidence are combined with each person’s preferences, circumstances and appetite for intervention. Community Health and Wellbeing Workersoffer one practical expression of this approach. Recruited from the communities they serve, they build trusted relationships, help people address the wider factors affecting their health and connect them with local sources of support. They demonstrate that health can be created with people and communities rather than simply delivered to them. Professionals and teamsThe next level is the interaction between people and frontline professionals. The National Association of Primary Care’sPrimary Care Homeandneighbourhood healthwork has consistently highlighted that clinicians and other professionals need sufficient autonomy to respond to the person in front of them rather than simply following centrally prescribed processes. That autonomy must be matched by clinical stewardship: responsibility for decisions that combine evidence with what matters to each person, while recognising and minimising professional bias, and for the outcomes and value obtained from finite collective resources. The objective is neither unrestricted professional freedom nor greater central control, but better decisions made in partnership with people around what matters to them. Individual professionals must, in turn, be supported by effective local teams. Neighbourhood health will not be delivered by assembling representatives from different organisations in a multidisciplinary meeting. It requires “real teams” with a shared purpose, mutual accountability, psychological safety and the freedom to improve how they work. These teams should bring together primary care, community services, mental health, social care, local government and the voluntary and community sector around the needs of a defined population. Their purpose is not merely to coordinate existing services but to create health, prevent ill-health, proactively support people with long-term conditions and avoid inappropriate escalation of care. Neighbourhoods and regionsWhere decisions cannot be made by people or frontline teams alone, neighbourhood arrangements should provide the next level of support. Their role should be to create the relationships, data, resources and infrastructure that enable local teams to act—not to replace one form of central control with a more local version. Some responsibilities will necessarily flow further upwards. Regional government and integrated care systems can align investment across health, housing, employment, transport and other civic services. They can address inequalities between neighbourhoods, support shared infrastructure and undertake functions where scale genuinely adds value. This is where devolution and subsidiarity become complementary. Devolution gives regions greater scope to act. Subsidiarity ensures that they use that power to strengthen the agency and capability of people, communities and frontline teams rather than accumulating responsibility for themselves. A different role for national leadershipSubsidiarity does not imply a weak or absent national government. National leadership remains essential in establishing rights, setting a clear common purpose, distributing resources fairly and protecting standards. However, it should be more disciplined about distinguishing what must be determined nationally from what is better decided closer to people. National government should define the outcomes the country is seeking and ensure equity between places, without unnecessarily prescribing how every community achieves them. Success will also require different measures. Waiting times and access remain important, but they cannot tell us whether people are gaining greater agency, communities are becoming healthier, teams are flourishing or inequalities are narrowing. Measures such as healthy life years, metabolic health, person agency and workforce experience would provide a more rounded account of whether reform is creating health rather than simply delivering more activity. Mr Burnham is right that power must leave Whitehall. But devolution will remain incomplete if power simply settles in regional institutions. His emerging vision in the round seems to point towards the deeper reform of subsidiarity: beginning with people, building outwards through autonomous and accountable teams and communities, and asking higher levels of the system to do only what cannot be done effectively closer to them. Power in the NHS has accumulated upwards, shaped by a culture designed for different health and care needs. As those needs and expectations of agency have changed, putting power into every postcode must mean more than relocating institutions. It must enable people, communities and frontline teams to exercise greater agency, responsibility and decision-making. Register for free to get full access to the site and our newslettersSign up todayRelated articles