Guest editorial Tuesday 12 October 2010: Liberation from the Empire – the Local Government Association take on the White Paper

Irwin Brown of the Socialist Health Association looks at the bid by the Local Government Association’s bid for a prominent place in the post-White Paper future

The responses to Equity And Excellence are now in.  Support for the aims but almost universal agreement that the proposals will not deliver the aims, at least not without high risk, as argued with great authority by the Kings Fund.

The most significant and most interesting response must be that from the Local Government Association, the body which represents the views of local authorities.  This looks like the start of a long-overdue bid by local government to play a far more significant role in health for the top tier authorities (the 80 odd which already commission social care).

Local government should be responsible for public health, as a natural part of their overall responsibility for population well being.  They argue for adequate funding to support it, but they don’t agree with ring fencing on principle.

They want the whole role and see no need for some re-badging of the Department of Health into a Department of Public Health telling them what they should do, or how to do it.

If councils need some national dimension, to link local to national priorities, then they will set it up their way.  They want control of resources; they don’t want to have to accept lot of staff from the NHS; and they do not need to be told who should be appointed Director of Public Health.  In fact, leave us alone.

Commissioning – more than co-ordination
Then on commissioning, they appear not to be impressed by some coordination or promotional role.  They suggest they are best place to directly lead commissioning of a long list of services; including long-term care, mental health, learning disability and children – which would appear to mean £30 bn - £40 bn flowing through them, not through GP consortia.

They point out local authorities have a track record in commissioning this kind of complex cross-organisational stuff,  as opposed to GP consortia , who don’t. (Not to mention not even existing yet).

They see no role at all for any involvement of National Commissioning Board or any need for leaving services out of scope as is proposed for maternity.  They will form their own networks to deal with specialist services, and may have regional and even supra regional structure if necessary.

A hold on consortia
On GP consortia (GPC), they accept the role for GPs in commissioning, but to ensure the authorities have overall strategic control they have the responsibility to agree the GPC’s plans.  They do this within a wider framework of an annual published integrated commissioning plan they draw up based on the Joint Strategic Needs Analysis they also draw up.

So they have strategic control over what GPCs can do, and so then in some sense must follow GPCs being accountable to deliver against their agreed plan.

They like the idea for health and wellbeing boards (HWB); but in a very different sense to what the White Paper envisages.  For local authorities, these are not talking shops where interested parties get together, but an executive part of the local authority with members and lead officers in place.  

They also point out that the functioning of the HWB has to come under scrutiny, and they simply suggest existing arrangements through health overview and scrutiny committees (HOSCs) are slightly adapted to scrutinise the HWBs, as well as the GPCs.  Rather than being abolished HOSCs get stronger powers.

Then with respect to resourcing, they suggest that GPCs should come to them to share the infrastructure of commissioning especially since they already have all the necessary stuff in place.  Not really sharing notice, just allowing the GPCs to buy into what local authorities already have – big savings.

So in summary.

Local authorities lead on needs analysis and draw up the annual integrated commissioning plan bringing health and social care together, linking to other services, which contribute to public health.  They lead commissioning of a broad range of more complex services and oversee the commissioning of the rest by GPCs.  (They would also from the risk pool to protect vital services should GPCs fail.)

They determine their own resources and do not need DH guidance or templates to tell them about partnership working, stakeholder engagement, consultation, scrutiny, governance or how to commission.

The end of Empire
At a stroke, they will have pretty much ended the six-decade long dominance of the DH Empire.  Health will become a properly democratically accountable service alongside the rest.

They have replaced the SHA outposts of the Empire, with their own regional groupings (supra and sub as necessary).  They use their existing commissioning expertise and infrastructure to replace what was provided by PCTs.  They form the support and performance management functions for GPCs.

This is pretty radical stuff - and in its way represents a change in the NHS as significant as the White Paper itself.  It does, however, flow far better with the themes of localism and the replacement of quangos by more accountable bodies.

Many have long advocated that it is clearly wrong for public funds to be allocated other than through elected representatives, and especially not by quangos.  They see the DH or even the NCB or the DPH as part of the problem, not as part of a solution.

If the LGA could lobby hard enough to get its demands met then the risks in reform will be reduced and some of the obstacles to integration of care will have been removed.