The government’s reform plans for the NHS are attracting a great deal of anxiety and opposition. Given the untested nature and the content of the reforms this concern is not surprising. Indeed, the degree to which the hostility has hitherto been relatively muted might be more surprising. Because of the political, professional and public backlash the government has now announced 'a pause' for reflection and review of the policy.
A major worry is the lack of transparency and accountability for the GP-commissioning arrangements. Another is the potential impact the reforms could have on joint working between local authorities and other local agencies in the community and voluntary sector, and the wider public sector. These issues should be addressed together.
The factors that have driven local health services, local authorities and the community and voluntary sector close together remain as pertinent today as they ever have. The benefits of joint commissioning, pooled and aligned budgets, shared staff teams and integrated services are well documented. At a time of severe budget pressures and cuts in both local authorities and the NHS, it is essential there is more joint working - not less.
Before the government’s policy 'pause' many local authorities were already engaged in positive dialogue with GP colleagues – with joint plans for the Health and Wellbeing Boards and joint work already in place or in well advanced stages of planning.
As currently proposed, Health and Wellbeing Boards could enable constructive co-operation between local government and the health service but these arrangements could result in confused accountabilities. The current review of the policy provides an opportunity for a genuinely radical and democratic solution to enhance local democratic accountability.
The Health and Wellbeing Boards be should be given an explicit and direct responsibility for strategic NHS commissioning in their areas - accountable through local authorities to the electorate for their decisions, and thereby securing some real and tangible ‘local’ accountability. The boards are already being given responsibility for joint-needs assessments and the strategic objectives that should drive local health commissioning. They could ensure that primary and public health, children’s and adult social care services are fully aligned - and resources deployed effectively across the agencies to secure common objectives. Having an overarching strategic commissioning role would make much sense and bring the NHS and local government closer together.
These proposals are at a ‘high level’, and considerable attention will need to be given to the detail: for example, the composition of the Health and Wellbeing Boards to ensure clinician representation with an effective and solid voice; the relationship between local boards and local authorities to ensure clarity over where ultimate accountability lies, avoiding confusion over the roles and expectations of the national Commissioning Board and of the Department of Health; and how finance would be allocated to the boards. There is scope for representation of staff and, most critically, service-users/patients, on these boards which should be subject to locally accountable scrutiny.
This approach should be pursued during the period of “pause”. It has the potential to offer better and more accountable solutions than appointing a small number of councillors and/or council officers to a local Commissioning Board which is still NHS-dominated and controlled; or placing hospital and other health providers on such boards – an approach guaranteed to lead to conflicts of interest and undermine the principles of strategic commissioning.
The medical professionals, and GPs in particular, may initially find this proposed ‘localist’ approach threatening, and it is vital that common cause between the GPs, wider NHS professionals and local government is found. Accordingly council leaders and their senior officers must work quickly and genuinely to develop good relations and a common cause.
With that latter point in mind, local government and its representative bodies should use the 'pause' to raise the issues of local accountability, and a greater local government role and responsibility for local health services and health outcomes. They should urge that ultimately the logic of Community Budgets and Total Place leads to the prime responsibility for health commissioning being placed with elected local government working with their health colleagues.
The current stalling of the government reform programme, however temporary and however real or unreal, provides a brief opportunity to re-open the debate about local government’s legitimate interest and potential role in local health commissioning. My proposals may be not find universal favour or their way into the Bill before parliament but they should reignite a debate leading to a much strengthened local government role and accountability.
John Tizard is director of the Centre for Public Service Partnerships
