Is there really room for localism in the Big Healthy Society?

The complexity of the Health and Social Care Bill became evident as MPs delved into its hundreds of clauses during the committee stage. At the same time, MPs have also been getting to grips with the localism and education bills. All three will fundamentally change the relationships between central and local government and the communities we serve, and 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 NHS into a brand or unifying concept, rather than an interconnected public body – the Big Healthy Society, perhaps.

While the bill is being debated, the NHS is already changing. Organisations are regrouping into a more centrally driven organism to manage the scale of necessary management savings and sustain a strategic commissioning capacity. While councils understand the rationale behind clustering PCTs, those councils that already have integrated arrangements in place have understandable concerns about dismantling these precipitously, particularly where emerging commissioning consortia support continued integration.

This is a central/local test for the new arrangements, and one that will be watched for signals about the future shape of the national commissioning board.

In the committee’s early evidence stages, MPs have been testing the localist credentials of the bill. For example, what powers will health and wellbeing boards have to shape the commissioning plans of the NHS Commissioning Board and commissioning consortia? What teeth will they have if commissioners ignore the board’s joint strategy? How will councils develop meaningful relationships with consortia and new types of health providers? How will councils manage their role in scrutinising major changes to NHS services, particularly if they impact locally while aiming to enhance the quality or safety of services across a region?

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 virtually the whole country covered by shadow consortia. However, this may reflect the NHS truism that the first wave pathfinders get the best deal.

We do not yet know what the phrase in the bill that consortia and the board “must have regard to” local plans means. We know that financial plans must be signed off by the national board, but will concerns raised about the adequacy of planning for child health or the healthcare of homeless people, for example, trip referral back?

That would, admittedly, be a failure of local joint planning, but it might also reflect genuine concerns about the priorities a commissioning consortium had considered. Although the present system has complexities, so too may the new one, only they will be different.

Putting localism to the test

Public health proposals will also test localism in action. The intention is to transfer responsibility for public health from PCTs to councils. This has been well received by local government, because of the opportunities it offers for concerted local action to address the wider determinants of poor health and inequalities. But why, councils ask, does the bill give powers to the health secretary to direct who is appointed (and who is not delivering) and to require councils to cooperate with national public health activity? Councils are used to having duties to carry out, but not prescription of how or who they choose to do them.

The drafting probably addresses another fundamental issue with localism and the NHS. Directors of public health are concerned about their independence in analysing, protecting and advocating good health locally. They may fear undue council influence in what they must do to address national strategies or approaches. The answer is in national and local discussions, guidance and best practice examples – not central prescription – because councils are used to understanding statutory responsibilities while articulating community priorities.

A key part of the Localism Bill is the general power of competence, which would give councils the power to do anything that would be legal for an individual. This is augmented by new opportunities for community groups and local organisations to play a greater part. The bill then attempts to put some potential constraints on this general power, as the government comes to grips with defining “guided localism”.

The Health and Social Care Bill approaches the same issue differently. It constrains the health secretary’s power to intervene in the day to day running of the NHS. He will give the Commissioning Board an annual mandate for achieving key health outcomes. These will set the framework for commissioning locally.

A vital 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, local players have to feel they can take a few, well judged risks and not be constrained by the bills in doing so. As the bills progress we must ensure that the reforms are congruent for the implementers on the ground.