Plans to scrap PCTs and bring in GP commissioning consortia could jeopardise links between health and local government if the Government persists with the Bill, warns John Tizard
The Government’s reform plans for the NHS are attracting a great deal of media, political, professional and public interest – hardly surprising, given the significance, scope and likely impact of these plans.
One potential consequence of the proposals currently before Parliament which seems to be receiving rather less scrutiny and discussion is the negative impact which the new NHS commissioning arrangements could have on joint working with local government and other local agencies.
Typically, local authorities have developed good and sometimes very effective relationships with their local primary care trusts (PCTs). We have seen a growth of joint commissioning; the care trust plus initiative; shared management arrangements in a number of places; joint director of public health appointments; and much more.
In truth, PCTs have been critical partners around local strategic partnership board tables, and in practical ways. Often, these relationships have taken years to develop, with both the NHS and local government investing time, money and people in making sure these relations have been sustained. Strong personal commitment by key leaders from both partners has typically ensured that their organisations have worked effectively in tandem for the benefit of local people.
The factors which drove local health services and local authorities close together remain as pertinent today as they ever have and, indeed, the Marmot review identified once again that many health determinants often rest more within the remit of local government than the NHS.
This is why the Government has wisely agreed to move responsibility for public health to local government. Of course, it yet remains to be seen if this transfer will be adequately funded, and whether the Department of Health will truly allow ‘local choice’ and ‘local discretion’. If it to work, this has to be a local government controlled function, and not simply local authority hosted.
The benefits of joint commissioning, pooled and aligned budgets, shared staff teams and integrated services are well documented. At a time of severe budget pressures and cuts in both local authorities and the NHS, it is essential that there is more joint working – not less. There is a need for more such approaches – not less. And although this is generally accepted across local government and the NHS, there remains a deep cause for concern.
Sadly, previous periods of budget constraint and cuts have tended to result in less pooling and joint working, with agencies becoming inwardly protectionist, resulting in a combination of unintended and deliberate ‘cost shunting’.
Many PCTs are going through massive change in advance of their demise, with key personnel moving or being uncertain about their personal positions. And the introduction of GP-led commissioning brings a new dynamic to relations with local authorities and, indeed, other local agencies.
Not all GP commissioning consortia will be co-terminus with local authorities – a situation which could lead to some authorities working with many groups of GPs where previously there was just one PCT.
While there are many GPs who will wish to contribute to wider local social and economic goals, this may not be universal. And, inevitably, most will have less experience of working with professionals and politicians from local authorities than their PCT colleagues.
This places a significant responsibility on local government to build relationships, encourage GP consortia to see local authorities as natural allies and important partners – and offer the consortia practical and meaningful support. This could include the provision of support services, infrastructure for the commissioning activity; joint commissioning and procurement; common approaches to supporting the community and voluntary sector; joint public engagement/consultation; and the sharing of premises.
The new health and wellbeing boards can undoubtedly be powerful forces for progressive co-operation between local government and the health service. It is to be hoped they can ensure some form of local accountability.
They will have responsibility for joint needs assessments and the strategic objectives that should drive local health commissioning. They can ensure that primary and public health, children’s and adult social care services are aligned, and resources are used effectively across the agencies to secure common objectives.
Whether an area is a designated pathfinder or not, this work should already be under way – and if it is not, it needs to start now. This should begin with agreement on a vision for health and welling for the locality; protocols on key joint working; radical solutions and best use of scare resources; and on the format and membership of the new boards.
In their role as ‘place shapers’, local government leaders will wish to influence health planning, commissioning, resource utilisation and service delivery in their areas. In seeking to achieve this end, they must take care not to frighten away or threaten to take over their natural allies – the GPs.
Good local authority leaders are well experienced at influencing and working with others to secure outcomes for their communities when they do not have control or formal leverage.
In the case of health, they will have the formal structure of the local health and wellbeing board and, hopefully, shared objectives with their local GPs – so there really is little excuse for failing to achieve effective collaboration. There may be a need for some independent facilitation to secure optimum approaches.
While this has to be locally driven and secured, it is equally important that ministers and the Department of Health send clear signals to GPs and the wider NHS that co-operation with local government is a good thing, and mutually beneficial. n
John Tizard is director of the Centre for Public Service Partnerships
