Why the reforms need to avoid penalising NHS and local government relationships

With the government agreeing to pause, listen to and reflect on concerns that have been expressed about the health reforms we will be hoping that they do indeed take stock of some of the finer detail contained within the reforms and the impact they will have on areas that have built up strong cross-sector relationships.

This is, we believe, crucial to maintaining the modernising reforms already underway across many local public services, which offer the best chance to improve health outcomes through effectively addressing the social determinants of health.

Viewed from a central perspective, the current reform processes within the health sector may appear to be producing uniformly elegant solutions for sectoral reform management. But not all of this is taking full account of the evidence for the kind of full public services system change that is required to deliver improved health outcomes.

As the Marmot report has shown, population health outcomes are driven by all public policy decision making and resource application. Population health is not simply the outcome of NHS spend, which the NAO showed last year  “can only influence 15-20 per cent of inequalities in mortality rates”. ¹

In Blackburn with Darwen we have a unique partnership between the council and the care trust plus which has helped us meet the government’s stringent cost saving targets and at the same time improve the effectiveness of health commissioning across the local NHS and the social care sector.

We were the first area to have a fully integrated senior management team across both organisations which has already delivered £2m savings on management costs which can be redeployed to frontline services. We have also been proactive in establishing our health and wellbeing boards, ensuring the local community is fully involved in the development of new structures.

Unfortunately, however, this work threatens to be undermined by the desire within the Department of Health to push the clustering agenda with very little scope for devolved decision making or the impact the changes will have on those areas that have been proactive and have already developed strong local partnerships across the NHS and local government.

It has been suggested that there are two reasons requiring the need for clustering. The first is to ensure continued capacity in PCTs as staff leave because of the demise of those organisations. This may be the case in some areas but is not the pattern where local authorities are in joint arrangements with PCTs as the local authorities provide both support in terms of management and commissioning capacity but also are an area of stability in a changing world.

The second argument is that by moving PCTs into clusters, this gives the opportunity for GP clusters to move into that space and be developed with support from the clusters. 

This is also not a tenable position as in the integrated care trusts/local authority health management model normally they are relating to single or small groups of GP consortia, and therefore it is organisationally simple to support the development of a GP consortia. The proposed clusters will have to liaise and support anything up to 14-15 GP consortia with a very significant geographical spread.

The implications of this are that where there has been joint commissioning arrangements for social care these can be left isolated in the larger clusters as the joint arrangements are not common across the larger cluster footprint. Also many local authorities only agreed section 75 agreements on the basis they would operate with a shared management arrangement.

It is possible that local authorities would see clusters as a breach of the agreement and would not wish to continue with it given the wider and more diluted health focused governance. It is also likely on the broader integrated issue that shared posts and shared costs would be dissolved with additional costs to both health and local government.

The real health benefits of the integration of not only social care but the wider health determinants of housing, leisure, enforcement, neighbourhood support services are being pulled apart.  What we are facing is a centrally driven initiative which ignores some parts of the Department of Health’s own guidance and which will cause disruption to successful models of integration and add cost and uncertainty. It also seems to favour “managing the transition” over securing evidenced based health outcome delivery systems.

It is on the basis of this understanding that we see that a  solution to this issue would be for care trusts or PCTs/LAs (with integrated arrangements) to be part of clusters but to retain the role of chief executive as the accountable officer for the business of the integrated functions. 

This would allow these organisations to delegate into clusters those functions that make good business sense and allow the sharing of capacity where this is required. However, crucially, it would maintain integration of management and back office functions which could then potentially provide the basis of support for GP clusters and avoid disruption and additional costs.

Locally integrated public services developing a “single public sector offer” to the public with primary care aligned with “health relevant” local government services are the only way we will be effective at improving health outcomes.

This is not just the view of Blackburn with Darwen. Such evidence based models of effective health improvement have long been apparent to the World Health Organisation who as long ago as 1978 in the Alma Ata Declaration said that primary care:

“involves, in addition to the health sector, all related sectors and aspects of national and community development, in particular agriculture, animal husbandry, food, industry, education, housing, public works, communications and other sectors; and demands the coordinated efforts of all those sectors” (VII:4) 

It is hard to see how any non flexible approach to PCT clustering will move public service delivery nearer to the form demanded by its clear function of “radically improving health outcomes”.

Let’s hope the government is both listening and looking at the evidence of effectiveness - otherwise NHS reform will be one step forward and two steps back.

1. NAO, (2010). Tacking inequalities in life expectancy in areas with the worst health and deprivation