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    Chipping Barnet CLP notes that access to contraception is a fundamental human right underpinning equality, impacting on the health, structure and prosperity of both society and families. The 2012 Health and Social Care Act disadvantaged women, separating much of the funding for contraceptive care from the NHS by moving the responsibility for commissioning into Local Authorities, with NHS providers competing for contracts. As a result, the commissioning of contraception is now separate from the commissioning of other aspects of women’s health, including abortion. From both a woman’s and a clinical perspective, this is illogical. Compounding this, the impact of austerity on Local Authorities has led to a reduction in services, reduced access and to a postcode lottery for contraception in England.

    Chipping Barnet CLP believes that contraceptive services need to be fully funded and accessible in all areas of the UK, with co-operation replacing competition. It welcomes the commitment of the Shadow Health Department to abolish competitive tendering for these essential services, and to work with clinicians to establish centres of excellence alongside regular accessible clinics to which women have free and easy access to confidential care.

    Chipping Barnet CLP calls on the Labour Party to resolve to deliver fully funded contraceptive services in all areas of the UK, setting up a working group whilst still in opposition, composed of experienced clinicians and commissioners, to write a blueprint for delivery which will be implemented within the first year of the Labour Government.

    Published by Jean Hardiman Smith with the permission of Sarah Pillai ( Chipping Barnet CLP )

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    I can’t recommend this film – which focuses mainly on older political activists campaigning for the NHS – too highly.
    (Statement of competing interests: I feature briefly in the film)

    Pensioners United

    Directors: Phil Maxwell, Hazuan Hashim

    Country: UK

    Running Time: 75′

    Year: 2018

    A potent account of a passionate group of pensioners who unite together to fight for a better life for themselves and those who will follow them. Starring Jeremy Corbyn, Harry Leslie Smith, the late Tony Benn, and thousands of inspirational pensioners from across the UK.
    ~ Allyson Pollock

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    You may find this video of a meeting held in Birkenhead Town Hall on September 27 of interest. The meeting set the current situation in Wirral, of an accountable care system at a fairly advanced stage, in its national context.

    The meeting began with a short contribution from a local GP, Dr Mantgani, who has in the past worked closely with Virgin; he expressed his concerns regarding the threatened closure of five walk in centres.

    I then spoke – about 12 minutes into the video – about the historical and current context of NHS cuts, rationing and privatisation.

    After a very interesting Q and A, there was a contribution, starting 56 minutes in, from Yvonne Nolan, a former director of social services in Manchester who now lives in Wirral. Yvonne described her work in Manchester, which in effect involved a long period setting up the de facto accountable care organisation which now operates across Greater Manchester. She related this to the current situation in Wirral.

    This was followed by further questions and comments; all in all, a fascinating session

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    Can I appeal to everyone, individuals and organisations, to get solidly behind the judicial review as loudly and forcefully as possible.

    I’d like to see all of us highlighting and publicising the judicial review in our various communications and campaigns. We are trying in Wirral.

    If the review succeeds entire awful council/CCG edifices of pooling and dissembling come tumbling.

    If the review doesn’t raise the required £18k we’re all doomed no matter how vocal our local and national campaigns!

    Come on! The price of a few glasses of wine/beer/flat white.


    Kevin Donovan


    Dear chums

    As you may have heard the Wirral Clinical Commissioning Group (CCG) has announced that it wants to close five local NHS clinics because Wirral residents “were confused about where to get help with urgent care”. The CCG, which is the local arm of NHS England, says it wants to “move care closer to home”.

    Are YOU confused? Will YOUR care be closer to home if they close centres which are used by THOUSANDS of Wirral residents every week of the year?

    Eastham Clinic; Victoria Central, Wallasey; Miriam Medical Centre, Birkenhead; Parkfield Medical Centre, New Ferry; Moreton Medical Centre

    All these are due to close. Will a proposed ‘urgent treatment centre’ at Arrowe Park be closer to YOUR home?

    You can find a petition from Defend Our NHS here:

    Please sign and share with friends.



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    The introduction of Accountable Care Organisations – or whatever they are called this week – brings a lot of talk not only about integrating health and social care, but also about local accountability.  The accountability seems to be more about accountants than about democracy, but in principle local elected councillors could have a voice in the working of health services  which they haven’t had for many years.  We asked our members how health had featured in their local election campaiogns.

    Of course we were looking mostly at how local Labour parties dealt with health – but some of our members reported that the Green Party had more to say about the NHS than Labour.

    Enfield Labour Party

    Their manifesto said they had  IMPROVED HEALTH:

    • Increased fitness with 12 outdoor gyms and outdoor playing spaces
    • Opened a world class sexual health clinic
    • Cut smoking prevalence by 6% since 2012
    • Helped cut the life expectancy gap between the rich and poor and cut teenage pregnancy rate in the borough

    and pledged that they would:

    • launch a Borough Poverty and Community Fairness Commission
    •  tackle discrimination based on sex, race, disability, age, sexual orientation, gender reassignment, religion or belief, marital status, or pregnancy and maternity
    • oppose Tory policies that drive division and disadvantage in our community and tackle the causes of childhood poverty giving every child a good start in life
    • develop our holistic approach to adult social care meeting needs in housing, advocacy and support
    • continue to oppose the privatisation of our NHS
    • campaign for more GPs and better surgeries
    • put public health at the heart of policies for improving the quality of life of residents by promot-ing healthy lifestyles and physical activities
    • continue to subsidise leisure facilities and services for older people
    • give mental health the same priority as physical health
    • support increased integration between the NHS and Adult Social Care to meet residents’ needs and cut bureaucracy
    • reduce air pollution through clever design and screening of roads
    • crackdown on illegal tobacco and cigarette selling
    • ensure food safety standards and hygiene in business premises

    Hertfordshire Labour Party

    Hertfordshire leaflet

    Colchester Borough Labour Party

    reported they had redesigned two outdated sheltered housing schemes to provide fully accessible 21st Century older persons’ apartments.

    Manifesto commitments:  A Labour-led council would improve the health and wellbeing of the Borough and its residents by:

    • Continuing to question whether the merger of Colchester and Ipswich Hospital Trusts is in the best interests of our residents and communities;
    • Demanding a greater say in the NHS Sustainability and Transformation plans and programmes for our area, which means objecting to one Clinical Commissioning Group run from Suffolk;
    • Involving the Borough Council in the integration of health and social care provision;
    • Lobbying the government to significantly increase spending on the NHS;
    • Providing more sheltered, supported and extra care accommodation by working with a range of partners across all sectors;
    • Campaign on easy accessibility for all public buildings – especially the Work Capability Assessment centre;
    • Instigating more Changing Places toilets.

    Manchester Labour Party

    Put Health and Social Care at the front of their campaign – as perhaps is appropriate when Manchester is said to be leading the way.

    Manchester people made caring for those most in need in the City their number one priority so it is the number one priority for Manchester Labour. By taking control of our health and care services we will protect our NHS and help Manchester people live longer, healthier, happier lives.

    We will:
    ● Increase pay for homecare workers to at least the Manchester Living Wage
    ● Employ more people to support vulnerable residents to stay in their own homes using the 1.5% Council Tax increase raised for adult
    ● Begin construction of at least 200 homes for older people at social rents as part of our extra-care schemes
    ● Invest to improve local access to community mental health services

    1 Comment

    Alan Hall

    Speaking the truth to power is always a risky business.  No more so than when considering how millions of pounds of public money should be shovelled into developments and contracts.

    Local government overview & scrutiny has been with us since the Local Government Act 2000 and the advent of the cabinet system and executive mayors. In the case of executive mayors –  a single politician making the decisions to spend millions of pounds of public money albeit with the advice of officers and an appointed cabinet – it is easy to see how local councillors could feel disempowered if they are not allowed a proper say on the decisions taken. Overview and scrutiny committees can provide a proactive, pre-decision mechanism for proper political involvement and public engagement. This scrutiny system improves and refines decisions, weeds out poor proposals and advances evidence-based policies.

    Good council scrutiny can also allow for challenge to government too. Following the roll-out of austerity and public spending cuts led a review of the London Borough of Lewisham’s emergency services which reported in 2013.

    The review showed that significant funding cuts had put services under severe strain, with an impact on preventative services and areas like probation too.

    The process allowed for proper scrutiny of these changes both by the council and external public agencies and, during the review, Lewisham Council successfully challenged Jeremy Hunt, secretary of state for health over the proposed closure of Lewisham hospital’s A&E department.

    An example of proactive scrutiny came after the tragic Grenfell Tower fire. All housing authorities rightly reviewed their housing stock and hopefully their policies. As a matter of urgency, I wrote to Barry Quirk the then chief executive of Lewisham council to ask that a fire and risk assessment be made of all tall buildings and I invited the borough’s fire commander to address us to give the public and the council the assurances it needed.

    Party politics will, of course, play a part in any local government setting and it is naive to think that elected politicians forget their party in scrutiny. But, as a recent Communities & Local Government Select Committee report on local authority scrutiny says, council leaderships have a responsibility to foster an environment that welcomes constructive challenge and debate. I have always held that scrutiny meetings can provide a platform to explain and publicise good policy initiatives and challenge assumptions or ‘group think’.  Let’s imagine the alternative – complete, untrammelled power of the executive.

    Instructing scrutiny members how to vote and threatening them with the whip does not foster the constructive challenge we need. Scrutiny committee members need to be able to hold their cabinet colleagues to account.

    But if proper scrutiny is to play a full part in effective local government, we will need a culture shift.  The scrutiny process – sometimes seen as the trainspotting of the council world – needs to be valued every bit as much as executive decision-making. This parity of esteem should mean getting access to the resources needed to do the job – including professional and independent advice.

    The Financial Reporting Council and the Institute of Chartered Secretaries & Administrators advise that a company’s board should make funds available to their audit committee to enable it to take independent legal, accounting or other advice when the audit committee reasonably believes it necessary to do so. However, scrutiny committees have no such right. Indeed I have requested independent legal advice in the past and an eminent QC has given an opinion supporting a refusal of this request. I believe this change would help proper scrutiny when a council’s legal officers are advising the executive on hugely complex and controversial developments and contracts. It would solve an inherent conflict of interest.

    Meanwhile, the government has responded positively to the select committee’s recommendations that overview and scrutiny committees should report to their full councils and not just the executive and that officers should provide impartial and professional advice. That after 18 years of local government scrutiny these recommendations need to be made at all is telling. There is a long way to go before there is anything like parity of esteem between the executive and scrutiny functions.

    I helped pilot scrutiny arrangements in Lewisham in 2001 and more recently I am pleased to have had the endorsement of Lord Kennedy – and, somewhat to my surprise a government minister Lord Young – when I led the questioning of a compulsory purchase order around Millwall Football Club’s ground in South East London. The lesson I have learnt is that scrutiny is best when gathering evidence from beyond the usual officers and paid advisors. In the words of an Ofsted inspector who I gave evidence to recently: “Triangulate – don’t only listen to your officers.”

    Council scrutiny is a crucial part of our local democracy. It benefits councils and residents alike, contributing to better decisions, better use of public resources, better public engagement and – ultimately – better services.

    this article was originally published by The Fabian Society

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    In recent days there has been a storm about the recently announced 2016/17 local government grant settlement from central government. The creation of a new £300m relief fund will mainly be used to help Tory-run councils, like David Cameron’s Oxordshire County Council, with Labour leveling the accusation that this is to buy off Tory MPs.

    I will leave it to others to form a view on whether this is fair or not. But this whole storm did get me thinking about the scale of the cuts not just for this year, but over the past few years, since the Tories came to power.

    So I grabbed hold of the 2011/12 figures for “council spending power” and compared them to the recently announced 2016/17 figures and worked out the percentage cut in spending power for each council. I picked 2011/12 as a base year this was the first full council financial year the Tories were able to fully influence after being elected.

    I decided to look only at the 152 County Councils and Single Tier Councils (e.g. London Boroughs, Unitary Councils, Metropolitan Boroughs etc) as they make up over 93 per cent of all council spending. There are 201 district council but they make only about 7 per cent of total council spending. Hence looking only at the “Upper Tier” councils as this made the analysis more focussed.

    The thing I wanted to test was the theory that the most deprived councils were worst hit. So I took a trip over to the Office of National Statistics (ONS) English indices of deprivation for 2015 website. Here I got the Index of Multiple Deprivation (IMD) average score breakdown by council areas and then  used the rank of the average IMD score to plot percentage change in revenue spending power using versus the IMD average score rank.

    Below is the very telling plot of this data. Note councils with low ranks on the IMD (those plotted to the left) are the most deprived and those with high ranks on the IMD (those plotted to the right) are the least deprived.

    Upper Tier Council Cuts versus IMD

    This graph shows a strong and clear relationship that the councils that are serving the most deprived communities have suffered the largest cuts over the past five years. This very strong relationship is evidenced by the high R2 value (or coefficient of determination) of 0.81. A value of 1 would indicate a perfect fit on the line of best fit, and a value of 0 would mean the data does not fit the line in any way. A value of 0.81 shows a strong and clear fit/relationship.

    So there you have it: the numbers don’t lie. The poorest and most deprived have suffered the largest percentage council cuts. The poor have been robbed to subsidise the rich.

    If you want to check the data and my calculations you can download it here.

    First published on Ravi’s own blog More Known Than Proven

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    Integration. Prevention. Personalisation. The buzzwords that indicate the reforms our health and care system needs are as widely recognised as they are overused. So too are the problematic features of current service provision: fragmentation, barriers and silos. The challenge is not one of rhetoric, but of moving beyond words to practically forge a system that works for people – and enables us all to live healthier, happier lives.

    The context is a challenging one  – on this there is also widespread consensus. People are living longer, and many more with long-term, complex conditions. The medical advances and increased life expectancies we can all celebrate mean that demand for services has evolved from the point when the National Health Service was first established in 1948. A hospital-based model set up to treat illness when life expectancy was 65 is now being required to tackle challenges it was not designed to cope with. Pressures are created as a consequence of this: A&E wards are struggling to cope with too many crises that could have been avoided if appropriate care was in place, and hospital beds are over-relied upon because community based infrastructure is insufficient. The funding cuts to local government of 40 per cent over the last parliament have had an inevitable impact on social care provision: the coalition government’s approach to salami-slicing Whitehall budgets without reform exacerbated the situation.

    Against this backdrop, the announcement that responsibility for health and social care would be devolved to statutory organisations in Greater Manchester was certainly a bold move. The circumstances of the announcement months before the general election distracted from much of the substance of the proposed framework, which was to enable joint decision-making on integrated care to support physical, mental and social wellbeing. The intervention also exposed some of the fault lines that exist in debates over health and care reform: between centralist and localist perspectives, and between the medical profession and the local government sector.

    As a consequence there are a few myths around the content and the implications of the Memorandum of Understanding which set out the terms of the devolution deal in Greater Manchester that need to be addressed, prior to a realistic appraisal of the measures. Some media coverage referred to the agreement as a local government “takeover” of the NHS. In fact, the frame – work was developed between Greater Manchester partners together  – 12 NHS clinical commissioning groups (CCGs), 15 NHS providers and 10 local authorities  – and each will retain their existing statutory responsibilities. The parties to the agreement are the Greater Manchester CCGs and local authorities (collectively known as GM), and NHS England. The mischaracterisation of the approach reflects precisely the obsession with professional hierarchies and sector-based territorialism that true integration needs to break through for new arrangements to be more than the sum of their parts.

    Fears have been expressed in some quarters that the measures herald the end of the “N” in the NHS. However, the first principle of the agreement is clear that “GM will still remain part of the National Health Service and social care system, will uphold the standards set out in national guidance and will continue to meet the statutory requirements and duties, including those of the NHS Constitution and Mandate”. The charge that the creation of new models of inclusive governance and decision-making would equate to the dissolution of a national system is ill-founded. The NHS has always been delivered in practice by local units such as primary care trusts, which lacked strong public accountability or visibility but worked within geographic and bureaucratic boundaries to make decisions about resource allocation and service provision. When considering the ‘N’ in the NHS, we need to be clear how this fits with the aspiration to craft a system suited to whole person needs, which are by definition different. What balance should be struck between national ‘one-size-fits-all’ rigidity on the one hand, and responsiveness to the needs of people and places, on the other? A public service reform discussion about the role of the national and the local very often quickly alights upon the phrase ‘postcode lottery’ in the negative  – this is interestingly most often used with respect to local inputs rather than variations in outcomes nationally. The postcode lottery that people living in Greater Manchester should be most concerned about is the fact that they can currently expect to live nine years less than the average person in England. This is the motivating force behind the new framework being created by GM partners: tackling the existence of some of the worst health outcomes in the country  – outcomes which have emerged and persist under a centrally-accountable national system.

    The devolution agreement, while not in itself an automatic shift to positive outcomes, presents real opportunities for transformation beyond the existing baseline. Taking the starting point of making an analysis of whole population health needs across Greater Manchester, partners can work towards the twin objectives of closing the health inequalities gap – moving from having some of the worst health outcomes to having some of the best – and aligning provision to prevent ill health and promote well-being, from early age to later life.

    For the first time, strong democratic accountability puts local people at the heart of the emerging new framework. Where previously decisions would be taken by remote bureaucracies or distant Whitehall departments, they will now be taken involving democratically elected representatives. This can inject a new responsiveness to the local system which will be driven by stronger direct incentives to evolve to meet people’s demands: good access to high quality, joined up services which provide the right care at the right time. GM partners are already focussed on ensuring early, tangible benefits for people which also begin a shift to wider systemic reform, such as proposals to offer seven days a week GP access by the end of the year and a Greater Manchester-wide plan to join up fragmented dementia services.

    While the devolution deal does not bring with it any more or less funding – the £6bn package identified refers to existing resources – a more strategic approach across Greater Manchester can seek to make the best use of these by allocating them more efficiently and effectively. Full place-based commissioning and delivery can ensure public investment is committed on the basis of shared intelligence and is geared to provide the right balance between medical intervention and social support. The GM framework is an opportunity to develop a more coherent long-term strategy to ease pressure on hospitals, while building up services in the community that bring health and social care closer to people’s homes. This will mean removing funding ring fences to make sure funding goes where it is needed locally, identifying duplication caused by service silos, and strengthening formal collaboration between providers. New budgeting models such as year of care funding can be developed, which begin to engineer a system-wide shift away from a focus on single episode and crisis treatment towards longer term preventative care. This can all create space for precisely the innovation and adaptation healthcare systems need: a research, innovation and growth strategy is a major strategic thread through GM partners’ joint work and they are prioritising the early implementation of an academic health science system.

    Creating a preventative whole-system approach that shifts from treating illness to promoting wellness involves recognising individuals not as patients but as people. In a different relationship with statutory services, individuals have responsibility for their own health outcomes but are also given the right support. Traditionally, building-based health services like hospitals and GP practices focus on treating illness and operate largely in isolation from wider provision that impacts on good health outcomes such as employment and housing. There is now a real opportunity to align priorities across services and within communities. For example, poor health is too often a barrier to sustained employment, so another early implementation priority from the GM partners is a new programme to help people with mental health conditions get back into work.

    Stakeholders in Greater Manchester are continuing to develop the relationships, trust and mutual respect between the professions and services involved. Nonetheless, there are real risks to the new approach which will need to be recognised and managed as the process evolves.

    First, the funding context within which the GM partners operate is something of a burning platform. It won’t be until the new Conservative government’s first comprehensive spending review that partners will have confirmation of what resources they have to work with, and how longterm a settlement they can predicate their plans on. A strategic business case will be developed by the end of the year which will need to find a way to bridge financial gaps, which will be no small challenge in the context of further austerity.

    Second, the huge ambition set out in the early Memorandum of Understanding was matched by an extremely tight timetable for the translation of these principles and framework into action and outcomes. Partners are already part-way into a ‘buildup year’ ahead of full control of health and care budgets in GM by April 2016. While a roadmap and delivery plan are to be developed and agreed between the partners and wider stakeholders, governance arrangements will be agreed in parallel. A careful balance will need to be struck between moving forward where possible while also ensuring that effective system-wide leadership is forged. Governance arrangements will need to simplify accountability rather than add to complexity. They must be robust enough to realign accountability for the use of public resources sufficiently to meet the huge ambition of the framework.

    A priority within all of this is to ensure constant and substantive public engagement and involvement: both in the process of devolution itself, and on an individual level in relation to health needs. There will be a new responsibility for local politicians to articulate the ambitions of the GM partnership and ensure that public dialogue focusses not simply on institutional arrangements but on health outcomes. The latter must remain a driving force for partners as well as a measure of their success. Public engagement shouldn’t happen solely through democratically elected institutions but that a new transparency and accountability is created across the whole health and care system so that people have greater opportunity to become genuinely more involved and engaged in decisions which affect their lives.

    GM partners are not complacent about the scale of the challenge they face. As the business case is developed they will need to identify the risks and ensure plans are in place to mitigate and overcome them. There is a shared recognition that they have a unique opportunity to move beyond traditional ‘vertical’ organisational silos and pioneer the development of ‘horizontal’ arrangements across a place which have more potential to tackle demand pressures and create more responsive services. The ultimate prize motivating all involved would be to overturn the trajectory of health inequalities which a centrally accountable system has failed to. Then words like ‘integration’ and ‘prevention’ would move from being just aspirations to standard practice.

    This was first published by the Fabian Society

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    The Chancellor of the Exchequer has announced a £200 million in year cut to the public health budgets in England and the Department of health is holding a snap consultation over the summer how to axe the budgets.

    Councillor Alan Hall, who sits on the governing body of London’s Kings College Hospital and also chairs Lewisham Council’s public scrutiny function, said: “This is a cruel conjuring trick that will directly damage public health services. The Chancellor has slashed them to the bone and now he’s cutting through the bone itself.

    “Because he’s transferring the services from the NHS to local authorities he thinks that we won’t notice. But they are still the same services and public health will suffer.

    “We have had scarlet fever in children at record levels this year and this is the work of public health clinicians locally. Most of Lewisham Council’s health budget is tied up in NHS contracts and axing £1.5 million in this financial year will affect services.

    “He’s cutting preventative health care and so will inevitably put greater strain on the NHS. This damages not only the poorest communities but it damages all of us that benefit from preventative health services. It’s a cruel con-trick that will backfire on all of society”

    The Public Health budget was directly run from the NHS but transferred to local councils in 2013 with child health service budgets transferring this year. The public health budget  funds many direct NHS services such as sexual health clinics in local hospitals, health protection, drug and smoking healthcare and children’s health programmes like promoting vaccinations and breast feeding.

    Local authorities up and down the country are waking up to the consequences of the announcements by the Chancellor of the Exchequer on 4th June 2015. The Department of Health launched a four week consultation on 31st July what it describes as a technical consultation on how to cut £200 million in year from England’s public health budgets previously agreed for this financial year 2015-16.

    The consultation document called: Local authority public health allocations 2015/16: In-year savings reveals that Lewisham is earmarked for an ‘in-year’ cut of £1.5 million pounds.

    This was first published on Alan Hall’s own blog.


    The transfer in 2013 of significant public health responsibilities and funding for the over fives was, rightly, heralded as one of the best local government-related decisions of the last Parliament (although, to be honest, there weren’t that many to choose from). And since that time we’ve been working hard to negotiate the follow-on 0–5 healthy child programme, included within it the Coalition Agreement priority of an enhanced Health Visitor resource, personally mandated by the PM.

    At an otherwise pretty grim time for councils, we celebrated the “coming home” of responsibilities that had, more than 150 years ago, first defined local government as being principally about the health and wellbeing of our citizens and their communities. Indeed, we even took in our stride the otherwise anathema-like criterion of the money being subject to a ring-fence.

    And we lauded this progressive change not just for its potential to enable all our functions to be redefined and reworked in the light of these new “health of the public” duties, but we loved the unexpected and increasingly rare opportunity to salvage something of our commitment to prevention and early intervention which was being undermined by the swingeing reductions being made to other key sources of “early help” revenue (notably the DfE’s “hot knife through butter” approach to the EIG).

    So, the recent announcement by the Chancellor that £200m is to be swiped in-year from our grants, just a few months before the 0–5 transfer, has left us – and apparently the Department of Health and Public Health England – deeply troubled. The sense of disbelief and, amongst the more melodramatic, outrage wasn’t just because we thought we might have balanced our books in 2015-16; no, it was because we picked up a rumour that the cut was to be made both deliberately against non-NHS activity and also specifically against this grant. Local government, and only local government, must take the hit. Whether or not the latter is true, it is clear that the former is accurate – protection for the NHS is to be ensured.

    Or is it?

    As we work our way through the likely implications locally with our health colleagues (possibly £6.4m for Birmingham, by-the-by) – who are equally bemused and angered – what is clear is that pretty much all of the 2015-16 allocations are tied up contractually. And large numbers of those contracts are – you guessed it – with the NHS, notably Community and Mental Health providers.

    So, this cut has three consequences attached to it: it will, as seemingly intended, permanently reduce the DH’s DEL as it pertains to the public health grant and, consequently, further impair councils’ ability to invest in upstream interventions. But it will also put more pressure on the NHS at a time when it least needs it.

    Why would the Government want to do this? Well, we know that deficit reduction is the fig leaf for an appetite to shrink local government, so perhaps there is no real surprise in yet another cut – although, clearly, the rules of the funding game are that there are no rules and, if this is the case, we should expect further in-year reductions to play havoc with our attempts to plan and set budgets.

    But what councils and their partners really don’t get is why it makes sense to anyone to introduce this kind of cut when it clearly undermines the otherwise ferocious determination to protect the NHS. Maybe, along with much else that we are seeing in the early legislative programme of the new government (for example, in the Housing Bill), decisions are being implemented that were never intended to get this far. Obviously, it is bizarre that anyone would bring forward ideas that they wouldn’t really want to put into practice in the first place; but this is not as strange as then seeing them through anyway. Let’s hope that this is just an early phase of cognitive dissonance and that, as Parliament progresses, there will be no more cutting off of noses to spite faces.

    For now, however, it does seem that a paradise only recently regained is to be a paradise lost.

    This was first published on Mark’s own blog.

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    Public funds and commissioning need to be in the hands of those who are elected, accountable and representative

    This article first appeared in the Health Service Journal.

    There are three main reasons why local authorities ought to also have the strategic responsibility for the planning and commissioning of health services:

    • it brings the democratic accountability we rely on for (almost all) other public services;
    • it allows total public funds for an area to be allocated to best overall advantage and for strategic investment decisions − population based decisions; and
    • it allows for economies of scale − especially in management, administration and support functions

    Arguably, there is one further reason: local authorities are better managed than health services (in terms of procurement, sharing services, service integration, commissioning). They are many years ahead on the “best value” journey. They are also far better at resisting vested interests and conflicts of interest: it’s one reason why we have democracy.

    Only those who are accountable through a democratic process should be allowed to make decisions about how public funds are allocated and priorities set. For most of the lifetime of the NHS, public money flowed to the providers of healthcare based on history − just roll over what was used the previous year plus or minus a bit. Long waits and restrictions on access balanced the books. There was no planning, no sense of public involvement in decision making and no proper measures of value for money.

    Two decades of commissioning by various flavours of NHS bodies has not managed to change things much, and we constantly hear (for example) that the priority attached to acute care is detrimental to developing community care. The biggest inefficiencies in our NHS are arguably no longer in providers being inefficient in delivery, though they are, it is that we allocate spending on the wrong things.

    A new set-up

    Because the funding stream for health is separate, there are fewer incentives to cooperate, and even some perverse incentives to compete for funding. If local authorities invest in better housing then health improves but it is the NHS that gets the gains. We have the current situation of one public body imposing fines on another, which should be a ludicrous idea but it has a twisted logic in the current fragmented set-up.

    So does change require a reorganisation?

    The reality is that in many parts of the country, the local authorities and the NHS are already working together − and where it works best is where the local relationships are good. That can be built on and encouraged, but each locality has to be left to find its own way.

    We could start by a few simple measures:

    • Give health and wellbeing boards the responsibility to sign off clinical commissioning groups’ commissioning plans, which currently rests with NHS England, and to monitor delivery.
    • Make a joint commissioning framework and policies mandatory as with the joint strategic needs assessment and the area wellbeing strategy.
    • Extend the scope of needs assessment to embrace resources available to meet needs and extend also to housing and education.
    • Strengthen governance of Clinical Commissioning Groups by having non-executive directors to prevent conflicts of interest, so that all of primary care can be brought into their local remit, which currently with NHS England.
    • Set financial limits, for example £5m, above which agreement from the local authority would be required.

    And in a longer timeframe:

    • make CCGs and local authorities coterminous (many CCGs  are smaller than local authorities);
    • integrate commissioning and other support functions; and
    • pool the whole budgets.

    None of this requires any major whole system reorganisation. Nor should it be done through top-down imposition; each locality should be left to find its own way at its own pace, so long as it delivered improving and better integrated care. CCGs can retain most of their role through having delegated responsibility.

    We have a clear choice. We leave major decisions about how our public funds are allocated to those who are unelected, unaccountable and unrepresentative − and who have a track record of failure. Or we trust democracy, where at least we can find out what is going on and can get rid of those that fail. Democracy is far from perfect, but it is better than the alternatives.

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