The health service has a long history of joint working. To build on this, it must recognise local need as a bigger priority than targets and keep decision makers close to communities
Last autumn for communities and local government secretary Hazel Blears asked me to join her as policy adviser. I sensed that the new team prime minister Gordon Brown had put together was serious about joined-up government and I wanted to play a small part in making it a reality.
I have not been disappointed. Communities and Local Government, which is co-ordinating the local area agreement process with the prime minister's delivery unit, had been pushing hard to reduce the number of targets set across government. After challenging negotiations with all departments over the winter, 198 targets have been agreed. This is a huge reduction on previous years.
Through its primary care trusts and others, the NHS has long been an enthusiast of partnership working. There is an honourable history of successful joint endeavours, particularly with social services for children, elderly adults and people with mental or learning disabilities. The Department of Health is able to bring reassurance to other Whitehall departments that are more wary of the benefits that partnering can bring.
So far, the signs are positive. I have seen a genuine wish to keep the number of targets to a minimum. Trading between departments is not uncommon, as it is recognised that goals can be achieved via another's efforts. There is an acknowledgment that not everyone can be a priority.
This is of course all fine until later in the year when a department comes under the spotlight for lack of progress or an embarrassing system failure. Then the accountability strings will tighten, partners will be sidelined and investments targeted directly at the short term "problem" not the "solution".
The NHS is familiar with these scenarios and despite PCTs' commitment to joint investment and joint systems, many NHS priorities have been only marginally influenced by local need. Equally, the NHS's love affair with institutional care has left some PCTs with relatively little scope to secure long-term health improvement.
Understandably, the NHS remains nervous about delegating the choice of priorities or measurements of progress to anyone outside of its accountability framework. However, there is abundant evidence, including that from NHS modernisation reviewer Sir Derek Wanless, that in order to sustain continuous improvement in the health of the population, bigger and bolder partnering than we have witnessed to date is required.
Hopefully, all Whitehall departments will see themselves writ large enough in the local area agreements to stay attached long enough to reap the benefits.
In it for the long term
Why is joint working so important? How have we arrived at separate health and social care systems and who thought this was a good idea? The historic and cultural differences that exist between the NHS and local authorities make it, in my view, essential that leaders in these jobs must be able to demonstrate a deep understanding of work in both sectors and, at best, experience in them.
The public recognises the local authority by its town hall and identifies the NHS by its hospitals and GP surgeries. In contrast, NHS commissioners have changed their names, headquarters and leaders with alarming frequency. The public expects commissioners from both agencies to be in it for the long term. They expect that in order to reduce obesity and improve antisocial behaviour or poor parenting, partners will display loyalty and show determination to work in harmony. This is very challenging at best and even harder if regularly interrupted by organisational change.
Commissioners should be able to draw on local resources and people in a way that can only be achieved if the decision makers are close to the communities they serve. If along the way they integrate their workforces, buildings and back-office services, then even better.
Health improvement investments must be protected from attempts to siphon them for use in other parts of the NHS. Centrally there has to be a genuine understanding that money cannot be spent twice. It is disingenuous for national leaders to use the expression "locally determined priorities" while at the same time continuing to demand centrally driven results.
GPs understand this is a long and complex game. Their roles as community leaders, albeit on a small scale, are well understood by their patients. Their new role now as practice based commissioners is taking time to bite and they still remain outside of many local partnerships.
However, I am hopeful that they will head off PCTs from creating "community provider trusts" and instead work with their local authority partners to build a new coalition of provider services.
The public does not want increased choice if it means more of the same from bright, shiny buildings that fail to connect with other essential parts of their lives.
Partnering to deliver long-term health improvement is a priority for all commissioners, but this has to be achieved at the same time as finally securing a reliable and safe treatment sector. Some PCTs have made strides in driving up efficiencies in the acute sector, although some would argue that these improvements were achieved largely by the trusts themselves as they aspired to meet foundation trust criteria, under the watchful eye of Monitor.
Commissioning is as much about ensuring the safety of the services as it is about system redesign or value for money. The public will not be interested or support the medium term plans of their commissioner if they feel day-to-day services are not up to scratch.
Quality assurance is the day job of PCTs alongside national regulatory bodies. PCTs must be confident enough to check and challenge what is going on in their organisation and make sure they have the right workforce to do it. The public has never been more worried about its safety in NHS institutions and needs to be reassured, even if the evidence suggests people should be confident about safety.
As a student, one summer I worked in a cake factory that produced cakes for many famous high street stores. Despite the grand scale and positive reputation of the factory, one of these stores insisted on employing its own separate quality assurance workforce. We called them the "ladies in green".
This shop would not risk its reputation by relying solely on the use of contracts and written standards as its method of assurance, as all its competitors did. It wanted to check the quality for itself and could not contemplate being associated with system failures that were preventable.
At a time when disability or sickness renders us at our most vulnerable, it would be good for the public to expect that the NHS valued its reputation enough to employ a few green ladies, too.