Written evidence from the Local Government
Group (COM 72)
ABOUT THE
LOCAL GOVERNMENT
GROUP
1. The Local Government Group (LG Group)
works on behalf of councils to support, promote and improve local
government. The LG Group is made up of six organisations:
— Local Government Association (LGA);
— Local Government Improvement and Development
(LGID);
— Local Government Employers (LGE);
— Local Government Regulation (LGR);
— Local Partnerships; and
— Leadership Centre for Local Government.
2. Within the LG Group, the LGA is a voluntary
membership body and our 422 member authorities cover every part
of England and Wales. Together they represent over 50 million
people and spend around £113 billion a year on local services.
They include county councils, metropolitan district councils,
English unitary authorities, London boroughs and shire district
councils, along with fire authorities, police authorities, national
park authorities and passenger transport authorities.
3. The LG Group is pleased to submit this
written response to the Health Select Committee's inquiry on commissioning
and would welcome the opportunity to give oral evidence.
INTRODUCTION TO
THE LG GROUP
RESPONSE
4. We welcome the Committee's inquiry into
Commissioning given the significant number of questions that the
health White Paper Equity and Excellence: liberating the NHS raises.
Taken together, we believe that the proposals in the White Paper
represent a major restructuring of not just health services but
also local government's role in health improvement and the coordination
of health and social care. It is therefore an area of reform that
we are deeply interested in.
5. The LG Group is working closely with
our member authorities, and partners throughout the health and
social care world, to dissect some of the more complicated issues
surrounding the White Paper's various proposals. As such our response
will continue to evolve as we seek clarification to a number of
questions that our work to date has raised. Some of these are
shared in this submission—not to ignore the questions posed
by the Committee but rather to illustrate how our thinking is
developing.
6. Underpinning our work on the White Paper
are five questions, which we believe the government should apply
to all the proposals to test for consistency. They are:
— Do the proposals build on existing experience
and good practice?
— Do they support an area-based approach?
— Do they promote a person-centred approach?
— Do they ensure accountability to local
communities?
— Do they ensure that public resources
are directed to the areas of greatest need?
7. Owing to the fact that this area of work
is very much a "work in progress" our submission does
not adhere strictly to the Committee's lines of inquiry and instead
provides the latest LG Group thinking. Given our remit and interest
this submission naturally focuses on issues of accountability,
integration, public health and transition.
KEY POINTS
8. Local government has real expertise in
commissioning and invaluable experience of operating in, and developing,
mixed economy markets. As such we are eager to see local authorities:
take a lead role in commissioning particular services where councils
have the practical service knowledge and experience to do so;
work closely with GP consortia in the commissioning of other services;
and support consortia on the infrastructure and systems associated
with the commissioning process.
9. We have some concerns that GP practices
do not have such commissioning experience and are more used to
operating as a small business, unlike local authorities which
oversee multi-million pound budgets and are expert across the
full commissioning spectrum; from data analysis and procurement
planning to contract and financial management.
10. Councils are ideally placed to take
a central role in the commissioning process because the goal of
improving public health and wider wellbeing is about more than
just health and social care services. It includes the services
and activities provided by housing, leisure, and transport departments
to name a few.
11. Councils have a central role in all
these areas and can therefore provide the much needed broader
infrastructure within which GP consortia will carry out their
proposed functions. This is crucial because working across services,
and indeed organisations, is part of the process that develops
more innovative and personalised services.
12. Central to the commissioning process
must be the Joint Strategic Needs Assessment (JSNA) to effectively
plan for a population's needs. There are good examples of councils
and PCTs working positively on JSNA and coterminous organisational
boundaries are often cited as helpful in strengthening partnership
arrangements between local government and health.
13. Looking to the future it will therefore
be important that the scope of the JSNA covers the local authority
area, and is not defined by where GP consortia choose to form
themselves. This could lead to a cross-boundary scope, which would
complicate care pathways.
ACCOUNTABILITY
NHS Commissioning Board
14. An independent NHS Commissioning Board
will be responsible for allocating NHS resources to GP-based consortia
and supporting them in their commissioning decisions. We believe
this represents a centralisation of decision-making in the health
service. Consequently, we think it is essential that the Board
represents local decision-making at the national level, whilst
allowing local commissioners the flexibility to adapt services
to local public services.
15. This "subsidiarity principle"
underpins our views on the Commissioning Board and we prefer to
see commissioning led by GP consortia in close partnership with
local government. We are therefore keen to understand more about
the government's plans for the nature of local government involvement
and engagement in the Commissioning Board's structures and work.
16. We have further questions on the role
of the Board at regional and sub-regional level—particularly
in regard to arrangements for commissioning and primary care,
dentistry and pharmacy contracts for example. Again, we are eager
to know how such arrangements will relate to councils.
17. We believe there is a risk that the
creation of the NHS Commissioning Board and Public Health Service
at a national level, and the roles of GP consortia and local authorities
at a local level, may lead to a division between healthcare and
public health. This has the potential to detract from a coordinated
approach linking interventions across the spectrum from prevention
to health treatment.
18. We are keen to know what the commissioning
scope of the Board will be and how this will relate with GP consortia
and Health and Wellbeing Boards.
Health and Wellbeing Boards
19. We fully support the creation of Health
and Wellbeing Boards to provide local leadership and a strategic
framework for coordination of health improvement in local areas.
This must be based on the local health needs of an area as identified
by the Joint Strategic Needs Assessment.
20. We envisage HWBs being the senior strategic
partnerships body comprising officers, elected Members, GP commissioners
and community/patient representatives. They will drive forward
needs assessment, agreement of local priorities and the development
of commissioning plans to improve the health and wellbeing of
local people. In dialogue with the public, stakeholders and service
users they must identify gaps in service provision and help GP
commissioning consortia take decisions about investment and disinvestment.
21. We support the proposal for HWBs to
be a statutory requirement for all upper-tier local authorities,
although they will need the flexibility to join together to work
in sub- and supra-regional groupings to address health and wellbeing
issues affecting larger areas. They will also need the freedom
to devolve powers and responsibilities to smaller areas—district
councils, parishes and neighbourhoods—to engage more directly
with local communities.
22. GP commissioning consortia will need
to consider how they can best align with HWBs and we believe they
should be required to develop their commissioning plans in partnership
with the Boards based on the local health needs identified in
the JSNA. We further believe that HWBs should have authority for
signing off GP commissioning plans and should be required to publish
an annual joint commissioning plan in partnership with GP commissioning
consortia.
Health Watch
23. We support the government's commitment
to giving patients and the public a voice and profile in the development
and review of health and social care services. However, in order
to give HealthWatch the best possible chance of succeeding we
need to ensure that it is built on strong foundations. We therefore
strongly recommend that the government undertakes an evaluation
of Local Involvement Networks (LINks) so the lessons from that
structure of patient and public involvement can be captured and
shared.
24. Moreover, we seek urgent clarification on
funding provision for interim patient and public involvement arrangements.
LINks' funding ends in March 2011 yet the White Paper proposes
that Health Watch will be operational from April 2012. This potentially
means a whole year of no funding for a crucial element of the
health and social care review and development architecture.
25. A local Health Watch will not be the
only local body that is concerned with engaging the public in
developing and reviewing health and social care services; at a
local level a number of bodies may exist that can effectively
capture the views of users and the general public. We therefore
believe there should be more clarity on the proposed role and
boundaries between a local HealthWatch and other local bodies.
Health overview and scrutiny
26. We have sought the views of all councils
on our developing positions on the Health White Paper and on the
issue of overview and scrutiny the sector is unanimous; councils
value their health scrutiny functions and see them as an effective
means of holding the executive to account for decisions affecting
the health and wellbeing of local communities.
27. The Health and Wellbeing Board as proposed
in the White Paper is clearly an executive body with wide-ranging
commissioning responsibilities and cannot, therefore, hold itself
to account. The roles, powers, membership and accountabilities
of HWBs and health OSCs will therefore need to be clearly defined
and distinct from each other. Fundamentally, arrangements for
the scrutiny of local health outcomes, and Health and Wellbeing
Board performance, needs to be separate from the Boards.
Directors of Public Health
28. The White Paper proposes that Directors
of Public Health (DPH) will have dual accountability to local
authorities and to the Secretary of State through the Public Health
Service. We question the need for joint accountability and believe
that DPH should be accountable to just their councils in the same
manner as other chief officers.
INTEGRATION
29. The LG Group strongly supports the further
integration of health and social care services, particularly given
the unique funding environment that public services will be operating
in over the coming years. Joint commissioning represents a big
opportunity to further embed integration and build on existing
good practice between councils and PCTs. There are many examples
across the country of local government working constructively
with health to develop local services that best address local
need.
30. Our preferred approach is that all commissioning
should be undertaken at the local level unless there are compelling
reasons (such as financial or clinical) for it to be done at a
regional or national level. Even in the event of commissioning
taking place at the national or regional level we would expect
ongoing coordination with local commissioners.
31. We will support councils to engage with
emerging GP commissioning consortia to develop joint commissioning
plans and we are committed to supporting GPs. This may mean, for
example, councils taking a lead role in commissioning services
where GPs have limited experience in services that councils understand
well, such as:
— Drug and alcohol dependency;
— Free nursing care (currently paid for
by PCTs).
32. Local authorities will also be able
to offer GP commissioning consortia support with the provision
of "back office" functions such as HR, payroll, IT support
and performance monitoring. We strongly recommend that GPs give
consideration to working with councils to join up commissioning
infrastructure and support.
PUBLIC HEALTH
33. Local government has a central role
to play in promoting public health and health improvement and
we strongly support the proposals to transfer responsibility for
improving the public's health to local authorities.
34. Taking on this additional responsibility
must be accompanied with additional resource. We are pleased the
government recognises this point but do not believe that the imposition
of a ring-fence is right; this runs counter to the place-based
approach advocated by the LG Group and we believe the ring-fence
should be removed to enable councils to use resources to greatest
effect. Experience from the Total Place pilots shows that ring-fenced
funding can be a barrier to adopting a whole-systems approach.
35. Indeed, far from protecting resources
for public health, a ring-fence may have the opposite effect and
be seen as the totality of resource to funding public health and
health improvement. Other services, such as housing, transport
and leisure all make a significant contribution to public health
and we do not want to lose this coordinated, joined-up approach
which the ring-fence may threaten.
36. It is not clear how public health interventions
will be evaluated. We do not want to see a return to a centralised
or rigid approach to evaluation, which could run the risk of replicating
previous National Indicators and an unhelpful focus solely on
what can be measured.
37. A number of issues require further clarification,
including:
— What the division of responsibility will
be between the national Public Health Service and local government
and how the respective priorities of each will be balanced to
ensure local priorities are not undermined by national ones.
— What percentage of NHS resources will
be transferred to local authorities for public health?
— How will GPs and health providers engage
with the public locally and how will the NHS Commissioning Board
engage with the public nationally?
TRANSITION
38. The proposals in the White Paper represent
a major restructuring of both health services and local government's
role in health improvement and the coordination of health and
social care. Achieving the objectives of the White Paper will
therefore mean a fundamental shift from focusing on structures
and systems to how people and patients experience services and
commission them for the best outcomes. It will also require a
significant change in emphasis from working to achieve centrally
imposed process targets to the setting of local health outcomes
based on local health needs.
39. Such a dramatic change in emphasis must
be supported by the right behaviours, which will not straightforward
given the numerous stakeholders involved in the White Paper's
reforms will have different cultural perspectives. GPs may have
limited experience of working with elected Members, and vice versa,
for example. At both the national and local level, discussions
on reform of health commissioning and the coordination of health
improvement must be underpinned by the question: what is the most
effective way of securing the best health outcomes for all local
people?
40. As strategic leaders of health improvement
local councils are committed to working with partners in primary
care to ensure a smooth transition. It order to do this it will
be necessary to transfer some key commissioning support from PCTs
to councils for a transitional period to develop the capacity
of GP commissioning consortia.
41. We support the principle of the lead
for commissioning being as close to patients as is possible and,
in general, we agree that this role sits naturally at the primary
care level. We do, however, have some concerns that for a significant
number of people—including those with mental health problems,
learning difficulties and drug and alcohol problems—their
care and support needs are primarily met by social care and other
council services, rather than primary care services. In such cases
we believe that the local authority should take a lead in commissioning.
October 2010
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