“Our proposals for the new NHS offer a great, and indeed a new, opportunity for a partnership with local authorities” – the words not of Andrew Lansley or Jeremy Hunt but former health secretary the late Sir Keith Joseph in 1971.
Thirty five years on, continuing efforts to configure the right relationship between these two great institutions of public service reflect persisting differences in governance, culture and history.
A particular flashpoint is getting a better alignment between organisational and planning boundaries, with local government usually playing catch up with the changing architecture of the NHS. The latest iteration is the evolving arrangements for the 44 sustainability and transformation plans across the country.
NHS England has acted quickly to allay initial concerns about the low profile of local government in the initial planning guidance. Four of the 44 STPs are headed up by senior and respected local authority figures. But the timescales are forbidding and most of the footprints are too big to be truly local. Genuine attempts to build good bottom-up plans may be crowded out also by top-down pressures driven by Whitehall worries about the NHS deficit.
Local authorities too face unprecedented financial pressures, especially in adult social care where the inadequacy of the £382m generated by the new social care precept – against a funding shortfall of at least £1.2b – will take their toll as the year progresses.
With organisations edging closer to their own particular financial and service delivery precipice, evidence suggests that places with a history of good working relationships will seek collaborative ways of managing the pressures rather than seeing them as a trigger for conflict and cost-shunting.
As the NHS moves tentatively towards place-based systems of care, local government begins a different kind of localist trajectory in which councils will eventually depend wholly on locally raised revenue. This will deepen further the differences in how the NHS and local government is funded. The integration pioneer and vanguard sites are showing what can be achieved locally. STPs have potential too, if given time. If only national policy could be as joined up.
Richard Humphries, assistant director, policy, The King’s Fund