Despite being 18 months away from taking over responsibility for public health, local government has already had its first clash with the NHS. It illustrates the cultural chasm the two will have to bridge if they are to make their new relationship a success.
The spat with the NHS leadership at the Department of Health is over how much money the NHS will hand over locally for the public health budgets. Chief executive Sir David Nicholson asked councils to sign off their local primary care trust’s calculation of how much money should be transferred. Most have responded by deluging the DH with objections and concerns. The DH was clearly taken aback by this independence of thought, not behaviour it encourages.
The health reforms will bring local government closer to the NHS than at any time since 1948. As well as taking over public health, councils’ health and wellbeing boards will work with the clinical commissioning groups on a joint assessment of local need and agree an overall health and wellbeing strategy.
The dispute highlights how GPs, NHS clinicians, and managers – particularly those involved in commissioning – could get tangled up in the health reform’s conflicting lines of accountability. While the NHS is used to looking upwards to its Whitehall leadership (foundation trusts notwithstanding) it will now also be held to account locally through the clinical commissioning groups themselves and through the council.
So not only will councils be running clinical services – immunisation programmes and some sexual health services are two of the most prominent – but the grubby art of local politics will be brought to bear on clinical services.
In early October, the Society of Local Authority Chief Executives and Senior Managers discussed the relationship between the NHS and local government at its annual summit. It said afterwards that “it is time for more honesty about the differences in culture between the NHS and local government. After more than a decade of “partnership” between the two, there is still too little shared understanding or integration of services.”
Councils understand what clinicians offer; few clinicians appreciate what councils have to offer. This means local government will be the suitor in the fledgling relationship, because they are the ones who have to prove their value. As one councillor said recently: “It is extraordinary the hoops you will have to go through [with GPs] to gain respect and influence.”
The success of the relationship will primarily depend on two factors: the ability of councils to make a success of public health by integrating it with other services such as social care, housing, education, early years and leisure; and the extent to which the council and clinical commissioning groups are united on tough decisions on service reconfigurations.
Councils must not become the rallying point for opponents of decommissioning acute hospital services. Service reconfigurations need strong political backing. This is where canny GPs will play the politics game shrewdly by drawing councillors into their decision making, involving them fully and using their community links to have long overdue conversations with local people about why moving services out of district general hospitals to regional centres or the community can often be the right thing to do.
Commissioners who get the relationship with local government right will have a strong hand – clinical expertise, local knowledge, and community and political support for difficult changes. Hertfordshire County Council’s support for major hospital changes in Welwyn Garden City is a powerful example of what can be achieved.
If the relationship fails, the clinical commissioning group will have trench warfare with local politicians to add to its list of problems.
Richard Vize is a journalist and communications consultant. He was the editor of the HSJ 2007-2010. He edited the Guardian supplement for the NHS Confederation conference.