After all the talk that has been around the NHS reforms since the Health and Social Care Bill was first published at the beginning of the year, the Government has now responded to the report from the NHS Future Forum and have indicated that they do after all recognise the need for a number of key changes.
Integration of services
Many of the changes will affect local government, and for the most part these are likely to be viewed by councils as positive. Certainly if the majority of the changes contained within the Patient Involvement and Public Accountability section of the report are accepted, councils’ main worry, about a reversal in the attempts to bring together health and social care, should be averted. Simply accepting the wisdom of the Forum’s recommendation about the necessity for the boundaries of the clinical commissioning group to match those of local authorities, with any departure clearly justified, makes the process of that integration much more achievable.
The NHS Future Forum recognised (and the Government has accepted) that the original Bill’s proposals around commissioning and competition would have directly affected that close integration between health and social care which many councils have spent considerable time and effort to achieve.
The Forum members who dealt with these issues, many of whom were from the local government sector, say that they approached the Listening Exercise through the lenses of “ensuring that the NHS delivered patient-centred care that is defined, designed and accountable to people and their communities” and with three priorities:
- integrated care for patients and communities
- the voice of patients and the public embedded in our health services, including children, vulnerable adults, carers and those who are often excluded
- effective assistance of accountability and government.
The key to achieving these recommendations is strong support for the integration of services by making the local system, both NHS commissioners and local authorities, jointly accountable for setting, delivering and monitoring the outcomes sought for their communities. As part of this, the Forum recommended that those areas which have already implemented joint commissioning with a fully integrated approach to delivery of services should be supported as demonstration sites for other communities.
The role of local authorities is recognised as crucial to this integration, and there are significant implications for councils. Central to the achievement of the integrated system around health and social care is the effective setting up and operation of the Health and Wellbeing Board (HWB), where councils are set to be the controlling element. This comes through two parts. Firstly, the HWB itself - it is clear that these are now intended to be integrated into councils as they will be operating their executive functions in these areas, that they should operate as equivalent executive bodies do in local government, and that it will be up to councils to insist upon having a majority of elected councillors on the HWB.
These proposals seem to be intended to strengthen significantly the influence that councils will have, as shown by the intention for the clinical commissioning groups to have to involve the HWB as they develop commissioning plans. Whilst the changes do not go so far as to give the HWB a veto should the plans not meet with approval, the HWB will have a clear right to refer plans over to the all powerful NHS Commissioning Group if they are not satisfied.
There is also a strengthened role provided for scrutiny, as the HWB, as a whole, will be subject to the existing overview and scrutiny functions of local authority executive functions and the greater discretion to exercise those powers which is contained within the Localism Bill. There is, however, much still to be sorted out about how this will work.
Drawing up arrangements around the HWB that get the balance right, get the accountability right, the liabilities and duties right and, increasingly important as shown by the number of recent high profile judicial reviews, the consultations right, is not impossible but it will not be easy. It is likely to be made more difficult in a situation where the different parts of the delivery mechanism are under different funding streams, with different expectations about financial restrictions, and with different statutory duties. Local authorities are political bodies, with members elected on political mandates, very different from the way in which the clinical commissioning groups will be governed.
Elections can of course change things. And how does the position of an elected mayor, possibly at odds with the elected councillors, affect this? Local government will also need to get used to the role of Monitor and how that particular regulator chooses to exercise its duties about the support of integrated services. And finally, they will have to develop a much closer relationship and understanding than most can realistically claim they have with the Acute Trusts and FTs in their area, who will have to be included and integrated within what is intended to be a far more holistic system.
What should local authorities do now?
There is time to think it through, and the Coalition Government and their advisers will no doubt be relying heavily on their civil servants to get the final delivery of these plans, well, deliverable. But now they have that steer, it is not too early for councils to start thinking about how the approach can best be put into effect for their community, and what they will need to do and how they should work to achieve the outcomes their communities will want to see.
Some places are more ahead than others, but everywhere has made a start; and councils have an outstanding advantage - they are, unlike the clinical commissioners, already there. Councils should make that count.
Bevan Brittan is one of the market leading law firms working with local authorities and our practice is now recognised as one of the country's few full service local authority practices in the country. If you would like any advice on the issues raised in this article please contact a member of our local government team.