Public funds and commissioning need to be in the hands of those who are elected, accountable and representative
This article first appeared in the Health Service Journal.
There are three main reasons why local authorities ought to also have the strategic responsibility for the planning and commissioning of health services:
- it brings the democratic accountability we rely on for (almost all) other public services;
- it allows total public funds for an area to be allocated to best overall advantage and for strategic investment decisions − population based decisions; and
- it allows for economies of scale − especially in management, administration and support functions
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: it’s one reason why we have democracy.
Only those who are accountable through a democratic process should be allowed to make decisions about how public funds are allocated and priorities set. For most of the lifetime of the NHS, public money flowed to the providers of healthcare based on history − just roll over what was used the previous year plus or minus 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 proper measures of value for money.
Two decades of commissioning by various flavours of NHS bodies has 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. The biggest inefficiencies in our NHS are arguably no longer in providers being inefficient in delivery, though they are, it is that we allocate spending on the wrong things.
A new set-up
Because the funding stream for health is 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 it 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. 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 groups’ commissioning plans, which currently rests with NHS England, and to monitor delivery.
- Make a joint commissioning framework and policies mandatory as with the joint strategic needs assessment and the area wellbeing strategy.
- Extend the scope of needs assessment to embrace resources available to meet needs and extend also to housing and education.
- Strengthen governance of Clinical Commissioning Groups by having non-executive directors to prevent conflicts of interest, so that all of primary care can be brought into their local remit, which currently with NHS England.
- Set financial limits, for example £5m, above which agreement from the local authority would be required.
And in a longer timeframe:
- make CCGs and local authorities coterminous (many CCGs are smaller than local authorities);
- integrate commissioning and other support functions; and
- pool the whole budgets.
None of this requires any major whole system reorganisation. Nor should it 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. CCGs can retain most of their role through having delegated responsibility.
We have a clear choice. We leave major decisions about how our public funds are allocated to those who are unelected, unaccountable and unrepresentative − and who have a track record of failure. Or we trust democracy, where at least we can find out what is going on and can get rid of those that fail. Democracy is far from perfect, but it is better than the alternatives.