In the context of whole person we need health services to be aligned with all the other public services. We need to focus on tackling the social determinants of poor health, investing in better health, and only the public service approach can do that. Only local authorities can be the focal point for bringing public services together. Only those who are accountable to us through a democratic process should be allowed to make decisions about how public funds are allocated and priorities set.
But, the antipathy that exists within the health service to local government is matched only by the reluctance of most local authorities, already coping with austerity, to get involved in health services which are seen as shambolic.
Whatever method is used to plan or commission should take into account all of the public services and the total of resources available. It is incidentally an argument against ring fencing of funding for separate services.
There are three reasons why local authorities ought to also have the strategic responsibility for the planning/commissioning of health services:-
- it brings the democratic accountability we rely on for (most) other public services
- it allows for total public funds for an area to be allocated to best overall advantage and for strategic investment decisions – population based decisions
- it allows for economies of scale – especially in management, administration and support functions
And arguably there is one further reason:-
- Local authorities are better managed than health services (in terms of procurement, sharing services, service integration, commissioning) – they are many years ahead on the “best value” journey. They are also far better at resisting vested interests and conflicts of interest – its one reason why we have democracy.
Alongside the basic ideological case for democracy this is about how we get the greatest value from public funds. For most of the lifetime of our NHS public money flowed to the “providers” of healthcare based on history – just roll over what was used the previous year plus a bit. Long waits and restrictions on access balanced the books. There was no planning, no sense of public involvement in decision making and no measures of value for money. Two decades of commissioning by various flavours of NHS bodies have not managed to change things much and we constantly hear (for example) that the priority attached to acute care is detrimental to developing community care – care closer to home. The biggest inefficiencies in our NHS are arguably no longer in providers being “inefficient” in delivery (although they are) – it is that we allocate spending on the wrong things.
Responsibility and funding for social care is with local authorities and subject to means testing in contrast to free “health” care. Sixty years ago this did not appear to matter much, now the fact that our care is split between two armed camps that do their best not to communicate and have huge cultural differences matters a lot. Not to mention the issues around totally inadequate funding for social care impacting on health.
Finally we can note that because funding streams are separate there are fewer incentives to cooperate, and even some perverse incentives to compete for funding. If local authorities invest in better housing then health improves but it is the NHS that gets the gains. We have the current situation of one public body imposing fines on another – which should be a ludicrous idea but which has a twisted logic in the current fragmented set up.
So does change require a reorganisation?
The reality is that in many parts of the country the local authorities and the NHS are already working together – and where it works best is where the local relationships are good, informal arrangements are made and they ignore the complexities of governance and just do it. That can be built on and encouraged but each locality has to be left to find its own way.
We could start by a few simple measures:-
- give Health and Wellbeing Boards the responsibility to sign off Clinical Commissioning Group plans (now rests with NHS England) – and to monitor delivery
- and sign off on social care budgets and commissioning plans
(both plans must explain how they took the other into account)
- make a joint commissioning framework (and policies) mandatory as with Joint Strategic Needs Assessment and the area Wellbeing Strategy
- strengthen governance of CCGs by having non executive directors to prevent conflicts of interest so that all of primary care (including GPs) can be brought into their local remit (currently with NHS England)
- set financial limits above which agreement from the LA would be required (~£5m)
and in a longer time frame
- make CCGs and LAs coterminous (many CCGs are smaller than their Local Authority)
- integrate commissioning and other support functions
- pool the whole budgets.
None of that requires any major whole system reorganisation. And it should not be done through top down imposition; each locality should be left to find its own way at its own pace so long as it delivered improving and better integrated care.