Published: 11/08/2005, Volume II5, No. 5967 Page 23 24
Local area agreements are being touted as a fast, less bureaucratic way to get things done at community level. Colleen Shannon meets the people who are making them work
Imagine getting all of the top talent in your locality together in one place - not only senior executives from the NHS but also, say, the chief constable, the university vice-chancellor, the council leader and chief executive from the local authority and the head of the chamber of commerce.
Once the diaries are co-ordinated, imagine getting them all to agree on priorities for the area and convincing each person to sign up to some very tough targets. Then envisage winning a consensus on how much money should be spent and persuading everyone to hand over some of 'their' cash. Now, imagine there is a window of five months in which to get this done.
It sounds impossible, but that is exactly what has happened in 21 pilot sites around England which now have local area agreements in place.
Another 66 localities have entered the second wave and the ambition is for universal adoption of LAAs across England in the next few years.
LAAs are seen as the next advance in partnership-working between local government, the NHS and myriad other partners. They are similar to existing local public service agreements, but are more binding, contract-like arrangements.
In simple terms, LAAs provide a means of sharing objectives, targets and resources. The aims are to simplify the number of additional funding streams from central government going into any one area, join up public services more effectively and allow greater local flexibility.
'LAAs bind all the partners into a way of working that ensures commissioning and planning is integrated, ' says NHS Confederation policy manager Jo Webber. 'It does have major implications for the way that primary care trusts work with their partners in the future.
'People have quite a lot invested in LAAs from the policy point of view, so I could see them as being the way forward. It makes sense because it gives a consistency across partnerships locally that previously people have found a bit difficult.'
The new LAAs can also be a way to improve dialogue vertically as well horizontally, according to Andy Buck, chief executive of North Sheffield PCT. He has been the NHS lead on Sheffield First, one of the first-wave LAA pilot sites.
'It is a vehicle for enhancing partnership and joint action, and It is also an opportunity to develop the relationship between Sheffield and government, ' he says. 'So you can see it in those two dimensions: what is happening locally through our partnership and how we collectively as Sheffield, negotiating with government, are securing some of the freedoms and opportunities to deliver services.' Mr Buck also sees an opportunity to cut back on bureaucracy. 'At the moment too much time can be distracted by the need to manage multiple funding streams and different routes of accountability. That effort ought to be devoted to delivering outcomes, not managing inputs.' Many people who have worked on LAAs see them as an opportunity to get health objectives into a wider agenda and to access resources that have traditionally been outside NHS control.
'It is a real opportunity to get a lot of other parts of local civil society signed up to health objectives, ' says Dr Gabriel Scally, regional director of public health for the South West. 'You can have cross-sectoral agreements and targets on, for example, alcohol and drug abuse which can have enormous implications for the NHS.' He adds that physical activity for young people is another instance in which the NHS can do 'little or nothing' on its own, 'but will have to cope with the ill-health effects in due course if we do not do something about it'.
Effective joint-working is 'absolutely central' to achieving the fully engaged scenario outlined in the Wanless report on public health, and LAAs are a good mechanism for this, Dr Scally believes. Another possibility is the contribution that NHS hospital trusts could make to LAAs, in view of their role as important local employers as well as healthcare providers, he adds. One of the roles of PCTs is to co-ordinate the contribution of other NHS bodies to the LAA.
Reading the runes in policies such as the public health white paper Choosing Health and adult social care green paper Independence, Well-being and Choice, there does seem to be a determination at the top to move the boundaries of the NHS and local government closer. This impression was reconfirmed when the government declared that PCTs should be rationalised to be coterminous with local authorities (news, page 5, 28 July).
The idea of coterminosity between the NHS and local authorities might be popular with some.
In a recent NHS Confederation survey of PCT chief executives, those in London said coterminosity has worked greatly in their favour.
A review of the LAA pilots commissioned by the Office of the Deputy Prime Minister and published in June raises other issues. The authors of A Process Evaluation of the Negotiation of Pilot LAAs found 'considerable enthusiasm for the overarching principles' when interviewing people involved at local level. However, some were less confident and 'felt they were being asked to play a game whose rules were opaque and constantly changing'. In some cases, the researchers say, partnerships need fewer rules, not more. They should be freed from the constraints of centrally prescribed 'blocks' of activity and allowed to define their own work themes. The reviewers also say the regional government offices need clearer roles and more authority, additional resources and more expertise in setting targets and developing indicators.
Many governance issues remain unresolved at a locality level, the report says. Project development, appraisal, commissioning, monitoring and audit have not been addressed yet in most pilot localities.
The next wave of pilot sites will need to be well prepared, with high-level leadership, strong partnerships, good co-ordination and excellent communications.
As for central government, the researchers conclude, there is evidence that 'some in Whitehall' underestimate the difficulties of partnership working - thus also underestimating the magnitude of the task and the progress that has been made.
CREATING A SUCCESSFUL CITY
Sheffield welcomed the opportunity to become one of the first 21 LAA pilots as a way to build on existing partnerships and move them to the next stage.
The Sheffield city strategy for 200205 aimed to achieve 10 features of successful cities:
a strong economy;
a well-educated workforce;
a vibrant city centre;
attractive, successful neighbourhoods;
a healthy population;
good transport systems;
a good cultural and sporting offer;
cosmopolitan and exclusive;
well-run, sustainable and wellregarded.
These broad strategic objectives aligned well with the main priorities for the LAA pilots.
Many aspects of the Sheffield First agreement, the city's LAA for 200508, will involve and further the work of the NHS.
a broad public health programme, with four trailblazer communities earmarked for priority early action;
a commitment to integrated neighbourhood children's services;
improvements to services for older people;
Tackling drug and alcohol misuse.
Reducing inequalities is a common thread running through all these initiatives. 'The city has a very robust commitment to closing the gap between the better off and more deprived neighbourhoods, and the LAA is now an important contributor to that, ' says Andy Buck, chief executive of North Sheffield PCT and NHS lead on the city's LAA.
The Sheffield partnership substance misuse programme is one area where simplifying funding streams could have clear benefits for the service.
There are at least 15 streams directed at substance misuse, based on a national template of assumed need.
Some services are struggling to find enough money, while others could spare some resources - if this were allowed.
'There would be significant advantages in bringing everything together in a single funding stream, ' says Mr Buck.
'In light of that, we will be agreeing with government which targets we will seek to deliver using that resource, developing a single plan for that and agreeing a single performance management accountability mechanism back to government.' His advice to others in the NHS who might be entering the LAA process is clear: 'See this as an important opportunity to further enhance local partnership-working and to secure from the government rationalisation and simplification of funding streams and accountability mechanisms.'
Kent entered the first wave of the LAA pilot scheme with great enthusiasm and a determination to achieve a radical improvement in public services and the quality of life for everyone in the county.
Kent Partnership, an affiliation of public, private and voluntary organisations, will oversee delivery of the LAA and was already well developed when work began. This has proved to be a distinct advantage: relationships were in place and many common priorities had already been agreed.
Kent's existing strategic priorities were a good fit with the LAA thematic 'blocks': stronger and safer communities, children and young people, and older people and healthier communities. Following a public consultation exercise, the Kent Partnership had already agreed nine overarching themes, which have been embedded into the 'Vision for Kent'.
economic success shared by all;
learning for everyone;
modern social and healthcare services;
a better environment;
communities that feel safe and secure;
keeping Kent moving.
The LAA has provided excellent opportunities for the NHS in Kent, and public health is one example, says Mike Daly, assistant director of partnerships and strategic planning for Kent and Medway SHA.
'We have tried to think of ways to add value to things we are already working on, for example Choosing Health. It is something that can only be delivered in partnership with local government and others.' There are 18 high-level local public service agreement targets to be met and one of these is promoting health and reducing health inequalities. Kent public health network, which is sponsored by the PCTs, co-ordinates this area of work.
Public health outcomes that will be measured at PCT and county level are ambitious and include:
reducing the number of people who smoke (four-week smoking quitters and mothers smoking during pregnancy);
reducing the risks associated with obesity;
improving sexual health and reducing teenage pregnancy (48-hour access targets for genito-urinary medicine clinics, reducing teenage conception rate);
Reducing substance abuse (increasing the number of people in treatment and improving access to services);
Improving mental health and emotional well-being (improving postdischarge follow-up and reducing suicide rate).
Mr Daly says the timetable was the most challenging part of the exercise, but that the effort has been worth it because of the benefits for local people.
AT A GLANCE THE ABC OF LAAS
Partnerships include local authorities, the NHS, police, the voluntary sector, business, education and community groups.
21 pilot sites approved in October 2004.
20 LAAs signed on behalf of the government by John Prescott. In Peterborough, negotiations were still continuing.
66 further pilots approved in June 2005.
LAAs are negotiated between local partners and regional government offices, which act on behalf of central government.
LAAs specify a range of agreed outcomes with associated indicators, targets and funding streams.
Additional freedoms and flexibilities in terms of funding, performance management and service organisation can be negotiated.
The first wave of pilot sites concentrated on safer and stronger communities; children and young people; older people and healthy communities.
Find out more
Office of the Deputy Prime Minister: www. odpm. gov. uk
Local Government Association: www. lga. gov. uk
NHS Confederation: www. nhsconfed. org
Twenty-one sites in England have piloted local area agreements, which are contract-like arrangements.
LAAs are intended to simplify funding by reducing the number of fund ing st reams d i rected at specif ic areas.
Supporters say LAAs cut through red tape and allow access to resources usually outside NHS control.