What are the advantages, opportunities and risks of the localism the government wants for services and how will ‘citizen leaders’ manage their roles? Phil Kenmore looks at the implications
We are in the days of the Big Society and place-based leadership. The government is promoting a new localism across the public sector. But what does localism actually mean, how well have its implications been thought through and what demands will it place on local leaders of health services?
The Localism Bill is about giving communities greater control over resources, priorities and decisions: this is intended to boost citizen engagement and deliver the services that local communities need or want.
The most obvious example is creating commissioning consortia to lead NHS commissioning. Localism also implies more joining up of services across sectors within a community. It will also allow a greater plurality of organisation types, such as social enterprises.
There has been very little central guidance about the form that localism should take. The coalition argues that this is the point - giving local leaders the freedom to decide how best to allocate resources and organise services in their area. Others find the lack of direction and control unhelpful at best - and terrifying at worst.
With budgets being slashed and difficult decisions about rationing having to be made, it feels to some like the government is passing the buck just when the buck is maybe something you really don’t want.
There are a number of implications to consider from this for local leaders of services or commissioning, and in fact for local “citizen leaders” taking roles in new organisations.
Capabilities and skills
Whole new sets of skills and capabilities will be required from groups that take over local commissioning or provision. Roles and structures will be different. Leaders will have to be more entrepreneurial and understand how to collaborate effectively to drive performance while reducing costs. Many leaders have never had to do this before and will have to develop or buy in these skills fast.
A big challenge will be how to gain meaningful engagement of communities effectively. The Localism Bill aims to give people a much stronger influence over this area and service.
If localism is to work, however, communities need to “own” the difficult decisions made about prioritising and rationing services. The foundation trust model shows how this can be done more effectively than
in the past - although it still has some way to go to deliver engagement at the level required.
Popularism vs professionalism
This is something that leaders already know well. There is always tension between the professionals’ view of what should be done and the popular view - what local politicians and the electorate would like to see. For example, evidence may suggest that centralising maternity services across two areas improves quality, but lack of support from communities may make this impossible for any MP or GP commissioners to support.
How far will this pressure increase? How will commissioning consortia cope with making unpopular decisions about decommissioning inefficient healthcare services when the populace demands they are provided locally?
The Localism Bill also gives communities new rights to not only take over assets and services but also to challenge council tax increases which could place further pressure on local government funding and indirectly on health services.
How do local organisations and communities avoid the replication of central bureaucracy with a worse local one driven by the need to engage, consult and gain the support of multiple local stakeholders - especially when there are unpopular resourcing decisions to make?
There is potential to actually increase the complexity of relationships and processes to the detriment of service users.
Localism will create complex partnerships. The ability to operate in an environment of high ambiguity, with diverse stakeholders and interest groups, will test leaders to the utmost.
The Total Place pilots showed some of the benefits of joining up services.
However, the pressure to collaborate across different services in, say, back office functions, presents complex challenges. These could distract organisations from their core roles.
With the focus on cutting expenditure, there is a risk that individual organisations or small communities will focus on going it alone. Each local service can establish its own governance, objectives and remit - rather than joining with others for whole community gain. Instead of creating a joined-up Big Society of more efficient, integrated services, the result could be greater fragmentation.
Scarcity of resources
The pressure across all public finances is severe, with the NHS also facing significant efficiency savings.
The result could well be conflict between commissioners and providers as services seek to deliver their own savings. The NHS may face added pressure from social care due to its “protected” status. This may create strain on relationships as people struggle to deliver more with less.
The structural and cultural changes required to bring about localism will also require substantial upfront investment, and economies of scale from central management could well be swallowed up.
Having said all this, the opportunities of greater localism are there to be grasped. Creating greater efficiencies across services in local areas is essential. Shaping a vision for local communities about all their public services is important. Genuine local flexibility will mean an increase in the so-called “postcode lottery” of services - but that is the point if you want local people to drive the provision of the services that matter most to them and their unique local conditions.
Top tips for localism
- Encourage the development of entrepreneurial leadership in your own and other local organisations
- Take time out early on to think creatively about establishing meaningful local engagement
- Anticipate early on popularist issues which differ from the evidence base and the views of professionals
- Keep a firm focus on minimising the creation of local bureaucracy
- Work quickly to create innovative, flexible and responsive models of local partnership working
- Maintain the values of community gain to avoid organisational “individualism” under pressure