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Testing the Big (Healthy) Society

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The three core bills involving health and social care, localism and education will fundamentally change the relationships between central and local government and the communities we serve.

All three will affect the ability of communities to shape education, health and other services delivered locally. But just how much does the Health Bill embrace localism?

On the face of it, its intent is to promote greater responsiveness for clinicians to patients, more choice and greater local accountability. But part of its complexity is the apparent wider ambition to transform the National Health Service into a brand or unifying concept, rather than an inter-connected public body - the Big Healthy Society, perhaps.

While the bill is being debated, the NHS is changing already. As widely anticipated, present organisations are regrouping into a more centrally driven organisation to manage the scale of management savings needed and sustain a core strategic commissioning capacity.

While councils understand the rationale behind the clustering of PCTs, there is understandable concern by those councils that already have integrated arrangements in place about dismantling these precipitously, particularly where emerging GP consortia support continued integration. This is a central/local test for the new arrangements and one that will be watched for signals about the style of the National Commissioning Board.

We do not know yet what consortia will look like or how enthusiastically GPs will engage with them locally. A pattern is starting to emerge with half the country covered by shadow consortia. This may, however, reflect the NHS truism that the first wave gets the best deal.

We do not yet know what the phrase that consortia and the Board “must have regard to” local plans means in the bill. Public health proposals also test localism in action.

The headline intention is to transfer responsibilities for the public health function in PCTs to councils. So far, so good. Why though, councils ask, does the Bill give powers to the Secretary of State to direct who is appointed (and more importantly who is not delivering) and to require councils to co-operate with national public health activity?

Directors of Public Health have concerns about the independence of their role analysing, protecting and advocating for good health locally. They may fear undue influence by councils in what they might need to do to address national strategies or approaches.

The Health Bill approaches the issue of the general power of competence differently from the Localism Bill. It constrains the power of the Secretary of State to intervene in the day to day running of the NHS. He will give the National Commissioning Board an annual mandate for achieving key health outcomes. These will set the framework for commissioning locally.

A key test of all three major reforms is Government knowing when to hold on to control and when to let go. If the health reforms are to gel locally, local players have got to feel they can take a few, well judged risks and not be constrained by any of the major bills in achieving this.

As the bills progress in the months ahead we must ensure that in their totality the reforms are not incongruent for the implementers on the ground.

Rob Whiteman, managing director, Local Government Improvement and Development

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