Could local authorities be about to regain a proper role in the governance of the NHS?
The juxtaposition of last week’s local government white paper and the Public Finance/Deloitte health round table begs a fascinating question about the future control of Britain’s health provision. It is just possible the government has put in place the first building block of a renewed local democratic influence over the NHS.
Although ‘joined-up government’ has become something of a cliché, the notion that local schools, health provision, social services, the police and the criminal justice system should work together is plain common sense. Sir Michael Lyons’ concept of ‘place shaping’ itself risks becoming over-used, but again he is right to point out that only elected local government has the legitimacy to bring the full range of local services together to deliver seamless and consistent public provision.
The new white paper is clear that Local Strategic Partnerships, using resources brought together within Local Area Agreements, are to be strengthened and made more effective. Non-local government partners, including health trusts, will be required to take part.
Although Local Government Secretary Ruth Kelly’s document didn’t quite make the point explicitly, Whitehall’s weak and silo-dominated approach to public service provision can only be made rational at the local level. The Department of Health cannot be forced to work consistently with, say the Home Office. But clever local officials can, by force of argument and cunning, get local health providers and the police to bend their priorities towards greater consistency within their area.
Of course, there are many problems with LSPs and LAAs, not the least the limit to their political accountability. A semi-official partnership of different public bodies is an awkward institution for the public to understand or to hold to account. Having said that, many NHS bodies are only faintly accessible to the electorate, answering to ministers and Parliament.
The white paper makes it clear that council leaders and portfolio-holders must provide democratic legitimacy, though others may chair the LSP. An effective local authority will become first among equals within the LSP and should, under the white paper proposals, be able to create a bridgehead into the budgets of a number of services. In the short term, the government does not plan to put all public service budgets into the LAA, but in the longer term, anything is surely possible.
The PF round table revealed exasperation at the complex and erratic policy signals given to local health bodies. Hospital trusts are funded by an unstable tariff system. Pay bargaining and other supposedly devolved decision-making are subject to national intervention. Parts of the service are, as a result of Richmond House diktat, to be provided by particular kinds of providers.
Might a radical evolution of the new LSP/LAA model provide an opportunity to break with the chaotic, centralised past? If the government really wants ‘joined-up’ local decision-making, shouldn’t the Local Government Association argue for virtually all local NHS funding to be placed within the scope of the LAA? Indeed, the same argument could be made for other services such as the police.
In short, the local government white paper makes a clear case for moves towards what might be called a ‘Single Local Budget’. Such a pot would include virtually all the resources of the state to be used for local service provision within an LAA area. In the first instance, each of the contributing partners would probably have to continue to answer to Whitehall (or, in the case of the council, to local taxpayers) for the resources in the ‘SLB’.
However, the scale of public resources available at the local level would become immediately clear. While it is possible to imagine the LGA arguing for such a radical decentralisation of government budgets, there would probably be suspicion in the NHS. However complex and inconsistent the existing funding arrangements may be, many within health would probably prefer to keep ministers as their accountability point. LSPs would be just too, well, local.
The white paper suggests that Kelly and her DCLG colleagues would like to tilt the state towards a greater degree of devolved control. Local government would lead such a process. But the pace of change signalled is slow. Reluctance within key service departments puts a sharp brake on any proposal for serious devolution.
Localists must take the government at its word and lobby hard for the most radical of the various options — including greater local control of health provision. However limited the white paper’s proposals, they must be grabbed and developed.
