In their article on who should run the NHS in last week’s The MJ, emeritus professors George Jones and John Stewart argue that the NHS should formally become part of devolved local government’s remit in preference to social care becoming part of an NHS-led National Health and Social Care Service.
I am a fan of local government. Having worked close to it for many years of my career, I have a deep-seated respect and admiration for its community leadership role and, in particular, its local democratic accountability.
Councils – just like the health service, police, courts, fire service and education – are everywhere. They have an important universal presence in our daily life and, in their local elected representative role, they inhabit a unique place in the public service landscape. So I agree with a lot of what professors Stewart and Jones say.
Local government offers an inherent line of sight to local people – service users, taxpayers, patients, communities – which enables electoral ‘come back’ when things go wrong. It also confers an important legitimacy, though higher electoral turnout rates would boost this further.
I also agree that cutting council budgets is unhelpful. For the past couple of years our refrain at NHS Providers has been that ‘when you cut social care, the NHS bleeds’.
The last few months’ A&E performance has shown that the cuts have gone pretty deep and it is hard to stem the blood flow. And the professors are right that the current arrangements for NHS commissioning and delivery – the Lansley reforms – have left the NHS far too fragmented.
They argue for a substantial and important role for local government in health service provision. But, to my mind, that is very different from saying the NHS should become a formal part of local government’s remit.
The professors assert that the NHS cannot innovate. They are wrong. The NHS always has innovated and continues to innovate – witness the current development of new care models, the growing use of telemedicine and the wholesale shift of mental health provision from an institution-based model of care to a community-based one.
Change may take longer than we might like but that is more due to the nature of healthcare than hierarchical structures.
Healthcare is complex, high risk, safety critical and therefore, highly regulated. Change needs to be evolutionary, not revolutionary, balancing risk and innovation.
Councils have been impressively ingenious and flexible in responding to the substantial cuts to their budgets and their legal obligation to live within their means. They have transformed and realised significant efficiencies. But they’ve also had to reduce service eligibility, reduce access (eg shorter opening hours), increase charges and decommission some services altogether, often with significant impact on the public.
So, yes, it is striking that NHS trusts have incurred deficits where councils could not. But NHS trusts are required to meet much more tightly defined service standards and they are constitutionally unable to make many of the generic service changes outlined above that local authorities have made.
They are also picking up increased demand displaced from a number of the service changes which councils have been forced to make.
How we fund public services will always be a vexed issue. However, moving the NHS into local government is not a magic key. It won’t, by itself, deliver the efficient, high quality, seamlessly integrated health and care services we need. It also won’t speed up the reform of local government finance.
Fifteen years ago I worked on the reform of local government finances. Nobody budged then and there is little sign of them budging now.
Just as the centre wants to keep its hands on everything NHS-related because it is so cherished by the public, so it fears granting local tax raising powers and, by extension, letting go of local control. Shifting the NHS into the local government orbit won’t change that.
True, much needs to change. But advocating a wholesale organisational shift from one part of the public sector to another is not the solution.
We must ensure local government and the NHS work together effectively. But one side taking over the other, either way round, is not the answer. If nothing else, it would be a massive organisational distraction just at the point when we need to concentrate on improving services for our citizens.
There are three things we need to do: move, for the first time, to population-based, needs-focused, integrated strategic service commissioning. Take the issues of local, single place-based, culture and leadership seriously. Where these are good and effective, the boundaries between local government and health are slipping away in any case. Remember that context is everything. What was right 34 years ago does not necessarily apply now.
Oh, and a bit more money wouldn’t go amiss
Saffron Cordery is director of policy and strategy at NHS Providers
This article is a response to George Jones and John Strewart's Put local government in control of the NHS
