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Richard Humphries: Turf wars are adding to local systems’ woes

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The NHS Long Term Plan, published in January, attracted a mixed reception in some local government circles.

Excoriating it as “a mind-bogglingly complex list of unconnected solutions”, New Local Government Network director Adam Lent slammed the “hierarchical, status-obsessed culture of the NHS”. This earned a swift riposte from Health Service Journal editor Alastair McLellan: local government has a chip on its shoulder about the NHS and should learn from it, not criticise it.

A different starting point to understand what the plan means for local government is to acknowledge the realpolitik of health spending. At one level the plan can be viewed as a thank you letter from the NHS to the Treasury for its present of an extra £20bn over the next five years.

As the Institute for Fiscal Studies has pointed out, this means that the path for over half of day-to-day public service spending has been largely decided, thus pre-empting the outcome of the spending review.

This was never likely to endear the NHS to local government, with sibling rivalry inflamed by the suggestion in the plan that the government and NHS might consider playing a bigger role in commissioning some public health services currently commissioned by local authorities.

The path for over half of day-to-day public service spending has been largely decided, thus pre-empting the outcome of the spending review.

What is clear is that this is a plan written by the NHS for the NHS, not for the whole health and care system, since the funding settlement excludes public health, social care and education and training. Although it has much to say about prevention and population health – key to the future sustainability of the NHS and social care – the plan sees substantive progress as relying on action elsewhere. Thus the footprint of aspiration is much smaller than that of the earlier Five Year Forward View.

Much of the responsibility for the Long Term Plan’s omissions ought to be attributed to the government’s dismal failure to deliver joined-up policy-making, rather than to NHS England. Continuing cuts in local authority public spending undermine the plan’s ambitions for prevention and health improvement.

There is still no sign of the five-times delayed social care green paper, with fears that social care has fallen off the domestic policy radar and, much like Brexit, lacks any kind of deal to take it forward. Helpfully the plan states “the government is committed to ensure that adult social care funding is such that it does not impose any additional pressure on the NHS over the coming five years” – useful ammunition in spending review representations.

It would be churlish for local government to ignore the unprecedented support by NHS leaders for more social care spending, instrumental in securing an extra £2bn in the 2017 Budget. But the absence of a sustainable funding settlement for social care leaves the risks with councils, much of which will be exported to an already fragile provider market, overstretched family carers and the NHS.

Social care accounting for two-thirds of all non-school council spending is having dire consequences for other services critical to health such as housing, parks and leisure services. The possibility of a fiscal boost to stimulate the economy in a post-Brexit emergency Budget might offer the faintest glimpse of a silver lining in the clouds of continuing austerity.

Yet despite its omissions, there is some real meat in the plan that local government can welcome. The prioritisation of primary care and community services rather than hospitals for extra resources, including better NHS support for people in care homes, echoes calls from the Local Government Association and the Association of Directors of Adult Social Services for more investment in care closer to home, and should help some of the pressures in adult and children’s social care.

The expansion of the personalised model of care to the whole country owes much to the pioneering success of personalisation in many local authorities. If implemented effectively and at scale it will align the NHS more effectively with social care.

Despite its omissions, there is some real meat in the plan that local government can welcome.

And arguably the most striking feature of the plan from a local government perspective is the evolution of sustainability and transformation partnerships into integrated care systems across the whole country by April 2021. The plan makes clear local authorities will be key partners in developing place-based approaches to improving population health and that through the ICSs councils will work more collaboratively with providers.

Our work at The King’s Fund on existing ICSs identifies effective engagement of local authorities as a key enabler of progress. Localists will welcome the plan’s sensible rejection of top-down prescriptions for how social care and clinical commissioning group budgets should be aligned in favour of local agreements.

There is still much to do in thinking through how councils can be a true partner in ICSs given profound differences with the NHS on governance, funding and lines of accountability. One question is how far these can be addressed through locally agreed workarounds without legislative change.

Another is how can a system that excludes council spending on public health, social care and other health-creating services improve place-based population health. And where does the important role of health and wellbeing boards in tackling population health fit with the larger geographies of ICSs?

Tensions within some of the emerging ICSs also reflect softer issues about local culture and politics, especially in places where progress is held back by a history of poor relationships between local leaders and their organisations.

The plan marks another milestone in the twists and turns of local government’s relationship with the NHS since 1948. But the political and economic climate has rarely been less auspicious, with deep uncertainty arising from Brexit, including its impact on the economy, public finances and the public service workforce, and the continuing failure of central government to deliver a coherent joined-up policy framework.

In this daunting context, if local government and the NHS are serious about a shared commitment to improving the health and wellbeing of local populations, throwing rocks at each other, fighting turf wars or just walking away will only add to the woes of local systems.

Instead, learning the lessons from the early days of STPs, local authorities need to be centrally engaged in the production both of local five-year ICS plans and in developing the plans’ national implementation programme, for that will take account of the spending review outcomes for public health, social care, capital and workforce. As ever, the success of these partnerships hinges on the ability to manage difference without compromising the achievement of shared purpose.

The NHS Long Term Plan will not work without the full involvement of local authorities. In securing a better funding settlement the NHS is a powerful ally that local government cannot afford to lose. Locally and nationally, they are truly in it together.

Richard Humphries, senior fellow, policy, The King’s Fund

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