I do not have a chip on my shoulder about the NHS.
To the contrary, I sympathise with NHS colleagues who have to work in such a heavily centralised and bureaucratic management system.
As they have worked more closely with local authorities, I believe NHS staff increasingly recognised that the sorts of transformation programmes which local authorities have undergone have simply not been matched within the NHS.
A good part of the reason may be the health service’s centralised system which, through its historic emphasis on short-term planning and fire-fighting, has held back longer-term thinking. To that extent local government can probably give a qualified welcome for the NHS Long Term Plan.
I would not dispute the description, given by Health Service Journal editor Alastair McLellan on LGCplus.com, of the “benighted” reforms by former health secretary Andrew Lansley. I also agree that swerving around obstacles will only take you so far. If the long-term plan is genuinely about change, then early evidence is needed of the promised ‘shared decisions’ between commissioners and providers to show this is the case.
There also must be reality about finances. It will not be only a local government observation, but the idea that the long-term plan is somehow going to achieve financial balance for the NHS, even with accountancy adjustments which auditors can accept, is straining credulity. The plan talks about hundreds of millions of pounds to be saved. The obvious question: how and why, if not before now?
Turning to public health, if the reference in the long-term plan was flying a kite, it was a clumsy intervention. Jim McManus, vice president of the Association of Directors of Public Health, has undertaken a comprehensive demolition of the intervention and the Local Government Association has provided further evidence to similar effect. But local government can press further.
A worthwhile review of public health funding needs to broaden the horizons. If testing opinion on a stronger role for the NHS in commissioning public health services really is a cunning plan to extract more money for local government to be spent on frontline public health, let’s give the Treasury another option. Have a good hard look at Public Health England and the value of its regional offices: there has to be scope to give more responsibility to local government.
We can see a familiar mindset. Having been involved post-2010 in working groups formed by the then Department of Health, I remember how sudden the creation of Public Health England was in the run-up to the final legislative process. Every indication was that this was a concession to the health establishment.
That mindset resurfaced in the introduction of the Better Care Fund, backed up repeatedly by a burdensome performance management regime imposed from the centre. The regularity with which fund’s guidance, allocations, and so on are delayed is another illustration of the tensions still at the centre, which really doesn’t want to let go of health-related funding.
In this we can probably bracket the health department and NHS England. Together with the Ministry of Housing, Communities & Local Government – no doubt a junior partner in their eyes – they are now reviewing the Better Card Fund to ensure the fund meets its goals, or more likely theirs. Note also the lack of contribution from local government to the review.
There is an already well-rehearsed line in the long-term plan: the emphasis on adult social care funding not imposing any additional pressures on the NHS. That can be read as the NHS looking after its own, perhaps in Mr McLellan’s eyes, ‘doing something right’. What it does not do is to persuade everyone that NHS England is lined up alongside local government in pressing for a fair allocation for adult and children’s social care funding in the spending review.
The current picture certainly shows that NHS leadership has out-performed its local government equivalent – whatever that is – if lobbying success is measured by financial settlements. Whether the short-term funding for social care and whatever bonus might come in the next years is mainly attributable to the efforts of NHS leadership is at best a dubious claim. Adass for one must feel it has been wasting its time.
Since sustainability and transformation partnerships first came on the scene, if you look beneath the headline of integration – accountability having conveniently disappeared – in practice the concept too often results in local government having to dance to the tune of the NHS centrally. Apart from anything else, it does not make it easy to develop local partnerships.
The NHS is indeed everything Mr McLellan and the likeminded claims it to be in terms of national and international reputation. But those who oversee it could usefully show partners like local government more respect. Until then, no-one should be surprised if local government continues to push back.
John Sinnott, chief executive, Leicestershire CC