By Andy McKeon
15th May 2009
Comprehensive Area Assessments should help improve the nation’s health by focusing on local partnerships. But, argues Andy McKeon, the notoriously parochial NHS will have to look beyond its narrow objectives to achieve this
Primary care trusts have a lot to worry about at the moment: the consequences of their World Class Commissioning assessments; preparation for swine flu; separating out their provider arms into arm’s-length or stand-alone organisations; and anticipating the effect of International Financial Reporting Standards on Local Improvement Finance Trust capital schemes.
And then, of course, there’s the money. Growth rates of over 5% in cash for 2009/10 and planned for 2010/11 sound cosy. But words like ‘austerity’ and ‘thrift’ are becoming increasingly popular, alongside notions of ‘Armageddon’. Through it all, PCTs need to keep a clear focus on improving the health of their population and the services that are purchased on their behalf. The health challenges continue to be formidable.
Teenage pregnancy is on the rise again, obesity rates are increasing, alcohol misuse is of growing concern and health inequalities seem stubbornly resistant to change despite the extra resources spent in deprived areas over the past decade. Making progress on these kinds of problems with perhaps little or no growth in resources will be a critical test.
Of course, health issues shouldn’t just be a worry for PCTs. Tackling childhood obesity, for example, is as much or more of a local authority and schools issue as it is a PCT one. Any interventions also have to be directly geared to the local circumstances.
Comprehensive Area Assessments address all these points. The focus is on local partnerships working together to produce improved results that matter to communities. Previous assessment regimes have focused on the individual institution and have looked back at past performance. Those for NHS bodies have also focused on performance against a national set of targets or standards, leaving little room to address locally chosen priorities and virtually none to consider joint action by a PCT and its partners.
The CAA regime will take a different approach. At its heart lies an area assessment that will address the quality of life for local people, how the local statutory bodies are working together to bring about improvements and what the prospects are for success. It will therefore look at whether the individual institutions working together are more than the sum of the parts. It will focus on what matters to local people and whether local priorities and actions meet the needs of the communities. And it will be forward rather than backward looking.
There will also be a major difference in reporting. Area assessments will not be scored and there will be no league table. Instead, there will be a narrative report based around some major themes and a system of flags. Red flags will signal an area of concern. Green flags will identify good practice from which others might learn. A new website will enable local people and professionals to review the assessment and make comparisons with other areas, including, for example, listing green flags on a particular topic or theme.
A different assessment system will mean a different way of working for the inspectorates involved. The Audit Commission, Ofsted, the new Care Quality Commission and inspectorates of probation, prisons and constabulary will be working to gather information and make joint assessments. There will not be a single inspection ‘event’, more a continuing dialogue with the local strategic partners. The commission and the inspectorates will also draw on their work with individual local organisations. This is one example of the Count principle – ‘count once, use many times’. In partnership with the Department of Health, we will look to ensure that the World Class Commissioning assurance framework for PCTs takes note of any relevant information from the CAA and vice versa. We have already successfully done with this year’s ‘use of resources’ assessments.
The CAA should boost Local Strategic Partnerships’ ability to focus on and improve the health and wellbeing of their communities. PCTs should regard this as a major opportunity, not that their partners have needed much bidding. As part of Local Area Agreements, partners have already prioritised issues such as teenage pregnancy, childhood obesity, alcohol misuse, smoking cessation and health inequalities more generally.
But the NHS is a notoriously parochial institution, rarely looking beyond its borders unless it thinks others will help meet its objectives – and I speak as one who has worked in it and with it for the past 30 years. However, the CAA will challenge the NHS as President Kennedy once challenged his fellow Americans to ‘think not what America could do for them but what they could do for America’. In this case, the question is what the NHS should do for the wider community, not just what should the local partners do for the PCT.
There are several areas where the NHS can and should do more to help the local community’s endeavours. One is sustainability. Climate change affects us all and the NHS has its part to play in helping to tackle it. Many Local Area Agreements include a reduction in carbon emissions as one of their chosen priorities. But the NHS itself is a significant contributor to CO2 emissions. It also has its own recently announced sustainability strategy, but it clearly needs to work with its local partners to help bring about change and make its own contribution to local targets.
A further area is the local economy. All public sector bodies have a duty to seek to limit the impact of the current recession and help their local economy recover. The NHS will often be the largest single employer in town, with all that that implies for recruitment, training and skills development. It can also have a direct impact on economic welfare, for example by helping people on Incapacity Benefit or in danger of experiencing long-term illness. This was one of the arguments for the introduction of cognitive behavioural therapies on a much greater scale, for problems such as anxiety and depression.
Both these areas are matters for hospital trusts, which are larger employers and have bigger carbon footprints than PCTs. Indeed, it is an irony that PCT use of resources assessments include a specific section on sustainability, whereas trust assessments do not. But, although the focus of the CAA is on the PCT and its partners, an area assessment will inevitably have to take account of the actions (or inactions) of the wider NHS, particularly where it has corporate social responsibilities.
This is the first year for the CAA. The first assessments will be in November. They will make more explicit and transparent the impact of local statutory bodies’ joint working and whether those partnership meetings and discussions really do result in improvements for local people on things that really matter to them. If information is power, particularly when given by an authoritative source, it should greatly increase the power of local communities through its reporting.
We expect the CAA and its reporting tools to develop. The recession has already highlighted a particular aspect – that of the local economy – that perhaps wasn’t in the spotlight when ministers commissioned the inspectorates to develop a new approach to assessment. And, although value for money has always been an important element, it will now become more acute as public expenditure tightens. Indeed, the Treasury’s Operational Efficiency Programme, published with the Budget, recommended the development of a ‘Total Place’ programme. This would map total public expenditure in an area and identify the efficiencies that could be found through better collaboration between public sector partners. Ten further pilot sites have been added to the two original ones.
So, we are into the first year of a different approach to assessment that focuses on the local partnership and the results being achieved for local people. It offers a real opportunity for the NHS. But in doing so it really brings into question how far the NHS stands aside from its local community when the issues aren’t absolutely fundamental to the achievement of its own objectives.
Andy McKeon is managing director, health, at the Audit Commission
