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Health: ripe for whole place plans

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Eric Pickles’ ‘50 ways to save’ is an eclectic mix of ideas. These range from the almost inconsequential but populist, to things that local authorities are enthusiastically implementing, and one or two ideas that are really powerful but difficult to achieve. I will declare an interest here: removing me - not by name - is number 24 on the list.

Number two on the list is community budgets, which tops my own list of powerful good ideas, but which has massively under-delivered against its potential.

Community budgets is not a new idea. It most recently arose when local strategic partnerships first looked at expenditure by all public agencies in one locality. This became Total Place under the last government, and after being put on hold for a while after the election, the same ideas have come back through community budgets, social investment, payment by results and the troubled families initiative.

In a report, Whole Place Community Budgets: A review of the potential for aggregation, commissioned by the LGA, Ernst & Young concluded there was an opportunity to save up to £20bn over five years, dependent partly on the “ability of government to unblock the potential”, which “will determine … what could be achieved”.

The Department for Communities & Local Government report, The Cost of Troubled Families, identifies similar scope for reducing duplication and realising savings and better outcomes.

But you will not find any blueprints for achieving these goals in these reports. These savings do not feature in Treasury funding forecasts or even in local authority budgets, despite their massive potential. No one has yet found a way to achieve the revolution in systems needed to scale up pilots to a point where directors of finance are happy to add them to the savings schedule.

The key issue is leadership and governance. There has to be a collective commitment across agencies at a local level to new ways of working, a willingness to challenge professional boundaries and subjugate organisational sovereignty in the name of the greater good.

This should be coupled with an acceptance from national bosses that local priorities and methods can supersede central imperatives, policies and standards. It is an almost impossible task.

Many pilot programmes achieve fantastic results and prove the general thesis. There are very few where mainstream provision has been shaped by a whole place approach and benefits (savings and better outcomes) are being achieved systematically. Typically, the pilot operates separately from the mainstream.

Birmingham did succeed when it pooled budgets for learning disability and mental health with local primary care trusts. The partnership was underpinned by a binding contract. It was therefore inoculated against paralysis in dealing with difficult choices or shifts in government policy. Expenditure was cut by £51m (15%), while performance improved.

The lesson for community budgets is: be focused on objectives; simplify negotiations by only including essential players; and use the law to put backbone into partnership working.

Healthcare should be a community budget priority. Strip away ringfenced education grants and other restrictions on expenditure, the core business of unitary and county councils is social care for adults and children.

The major opportunities for joint working are all with health - for example joint commissioning of adult social and medical care (commonplace in most of Europe).

Who leads health in localities? Clinical commissioning groups are in their infancy; the local units of the NHS Commissioning Board and Public Health England still don’t have all their staff in place; the powerful acute trusts often seem focused on their businesses rather than health outcomes; and local authority scrutiny and Healthwatch are variable in their effectiveness. It feels like a primeval governance soup from which one hopes clear leadership will emerge.

It is also astonishing to see the low-key way in which the Francis report was received. A hospital is reportedly responsible for 1,200 avoidable deaths, and others are being investigated. Compare that with the urgent response to Victoria Climbié’s death: the whole world of local authority children’s services was revolutionised.

Perhaps we need something radical to increase health’s accountability and strengthen its leadership, to deliver the benefits and cost savings that are clearly there. What about a health equivalent of a police and crime commissioner - a highly visible elected leader to take a grip of the local health agenda? It is worth a debate.

Stephen Hughes, chief executive, Birmingham City Council

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