Opinion: Health & Social Care Bill – a local government perspective

Media coverage and comment so far since the Bill was published last week has been largely about GP commissioning, and the abolition of Primary Care Trusts and Strategic Health Authorities. Naturally there will be risks associated with such an enormous transfer of financial responsibility, but we should most certainly not overlook the underlying localist and patient-centred philosophy, and the opportunities for GPs to become more engaged with a wider health and wellbeing approach in every locality.

GP practices operate in local communities, and councillors are elected to represent those same communities. How should we work with them more closely in the future, demonstrating our role as local leaders? A couple of years ago, Richard and Erica Kemp wrote a booklet (Cabinet Member for your Ward) about the principles of all councillors doing this, which is available on the LGA Lib Dem website. More recently, Richard and I have had meetings at the LGA with national representatives of the various GP bodies, and have discovered there exists a great deal of common ground about the opportunities set out in the Bill. We have published a joint statement which sets this out.

But for me, and indeed councillors of all parties across the LGA, the central issue for councils is the proposal for greatly enhanced local democratic legitimacy. Health and Wellbeing Boards – bringing social care and the NHS, including GPs, closer together – are to have a statutory basis, but with maximum local freedom as to their composition. Whilst their strategic role will clearly be closely associated with decisions to be made by a local authority’s Cabinet about service delivery across a city or county, we have also won a significant victory in relation to the non-executive councillor’s role. Health scrutiny will be retained. Public Health responsibilities are to return to local government, their historic home, after forty years in the wilderness – and again the Health and Wellbeing Boards will have a co-ordinating role, whilst the powers can be integrated with virtually everything else a council does: transport, lifelong learning, culture, leisure, etc.

So instead of upward accountability to the Secretary of State, with all the attendant national targets for this that and the other, we shall have a much greater degree of local accountability. The Joint Strategic Needs Assessment for each area, an existing mechanism of variable quality around the country, will form the basis for commissioning the necessary services for the local population. Where health inequalities exist in specific parts of the area, local discretion can be called into play to address the needs of those individuals, families, or communities.

LGA Liberal Democrats were never convinced by the silo suggestion of a separately elected local health board, given that people (and especially older people in our rapidly-ageing society) often need both health and social care. The model proposed in the Bill to my mind has the potential to be much more effective, both in relation to meeting those needs and with regard to local accountability. This Bill shows very clear signs of Lib Dem principles coming forward in Government, and I believe we have Care Services Minister Paul Burstow to thank for that.

Cllr David Rogers is the Lib Dem chair of the LGA’s Community Wellbeing Programme Board and is a county councillor in East Sussex.

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  • Thinking about the fundamentals of this madcap scheme ….

    What we’re used to is public bodies spending public money by funding private company providers. Broadly, this works. The public body is charged with obtaining value for money and should be capable of preventing profiteering. Also, the public body can respond flexibly to inputs from elected councillors, whether their directions are to minimise costs, or to insist on quality at high cost, or something in between. Public bodies such as civil service departments can of course become subject to the Yes Minister disease and end up under the thumbs of the private providers they are supposed to be controlling, but, there should be enough checks and balances to prevent gross mismanagement or massive fraud.

    But what is now being proposed is to have private bodies (the so called “GP” commissioners) spending public money, with a different set of private companies as the providers. That means a private sector “client” dealing with a private sector “provider”, all funded by the taxpayer.

    So, if you are Easyhospital Inc, and you are trying to sell your services to DoctorCrippen NHS Commissioning Ltd, how will you bid to outsmart your competitors? You could of course try to minimise the price or maximise the benefits you are offering, but why bother? It is DoctorCrippen who you have to sell to, not the public. DoctorCrippen is bound to be asking “what’s in it for us”? So, you might as well charge the public purse a nice high price and make a good solid profit, and then find some clever way to feed back some of the money into DoctorCrippen’s pockets, so as to win the contract. Just go for complexity, like Enron did, so that nobody can work out what sort of tricks you are playing.

    Why does the Coalition think this is a remotely sensible business model?

    Well, they don’t, of course. Hence the masterstroke to call the private commissioners “GPs”. Hey presto, wrap yourself up in the warmth of the bedside manner of dedicated medical professionals. Distance yourself from the hard-headed commercial organisations that will actually be doing the commissioning.

    GP commissioning is, of course, about as logical as asking the ice cream vendors to run the Brighton Tourist Board. They might be prepared to do it, of course, once it was pointed out to them that they had an interest in getting people to visit Brighton and that they could get paid to do the job. But, rather than set up laptops in their vans and juggle taking B&B bookings with serving ice lollies, they would assuredly engage somebody else to do the tourist stuff. Which is just what the good doctors will do. You can’t do doctoring and hospital purchasing at one and the same time. You might as well try to stick a broom up a convenient orifice and sweep the surgery while you’re about it!

    Enough of the comedy. Passing off a special form of privatisation as “GP commissioning” is not funny. Sure, the profits will not be made by charging the end customers directly. It’s worse than that. The profits will be made by encouraging private commissioners and private suppliers to team up at the expense of the public funder.

    Oh, and by the way, they won’t do anything but pay lip service to what elected councillors might want them to do. They’ll make sure to keep councillors in the dark. They won’t want anyone spoiling their profitable opportunities.

  • David Rogers 25th Jan '11 - 8:02am

    Buch and Allen appear not to have read the Bill. The “any willing provider” model may indeed mean that patients have more than one choice in their area for a particular procedure, but the choice available will not be price-based. As to the powers of the Health & Wellbeing Boards, their overall responsibility for commissioning – based on identified population requirements in the Joint Strategic Needs Assessment – will be real. And that’s then where the enhanced local democratic accountability comes in, the central element of my article. Board membership will include elected councillors, and local government officers employed by those councils. Moreover, non-executive councillors engaged in the scrutiny process will be able to “follow the NHS pound”, whether it’s being spent by GPs, Foundation Trusts, social enterprises, or private providers – an enhancement of the current situation, and further evidence that this is to be a localist system not a centralist one.

  • Depressed Ex Lib Dem 25th Jan '11 - 9:17am

    “There seem to be many people who want to keep the Brighton Tourist Board firmly controlled from Whitehall! ”

    That’s absolute nonsense and you know it.

    The policy the Lib Dems fought the last election on was based on locally elected health boards taking over the responsibilities of PCTs. The principle of elected representatives on PCTs was accepted in the coalition agreement. Now the Lib Dems have voluntarily dropped that policy in favour of putting the power into the hands of GPs.

    The choice has nothing to do with localism versus centralism. It’s a question of whether the organisations that are in charge are elected (or at least partly elected) or whether they are, in effect, groups of completely unaccountable local businessmen. (Or, rather, as John pointed out on the other thread, businessmen accountable to their consciences!)

    Until recently I would have had no doubt about which side of that argument Lib Dems would have been on. But now?

  • Depressed Ex Lib Dem 25th Jan '11 - 9:24am


    “As to the powers of the Health & Wellbeing Boards, their overall responsibility for commissioning – based on identified population requirements in the Joint Strategic Needs Assessment – will be real.”

    That’s actually rather a confusing statement. You say that as to the _powers_ … the _responsibility_ will be real.

    I have no doubt that the bill gives the boards _responsibility_, but the question is whether they have any real _powers_.

    If you’re claiming they do have real powers rather than an advisory role or a role of liaison, clearly it would help your case to tell us what those powers are. (Obviously we’re talking about powers over the activities of the GPs in relation to health service commissioning, not the public health role.)

  • I see no Iceberg 25th Jan '11 - 9:40am

    It’s blindingly obvious that the Conservatives think localism is simply another word for trying to shift the blame away from central government. It won’t work. Stafford shows us that any local disaters will quickly become national ones when this marketisation gathers speed.Expect more of the same catastrophes as the bungled and overpriced I.T. systems and confusion inherent in this deliberately tangled web of private contractors and complex ever shifting accountability is implemented.

    If this was a well thought out set of reforms that would benefit the patient and those who work in the NHS, then why would the B.M.A. and R.C.N. be warning of the dangers they pose ? Why shouldn’t we believe that they have the NHS and patients best interests at heart instead of those eager GPs who see a business opportunity ? Why should we believe the spinners from the coalition instead of respected organistations of people who work in the front line of the NHS ? And who do the Ministers, trying their best to ignore this looming disaster, think the public will believe if it does start to cause chaos and misery in a life and death service ?

    Here is an excellent artical that covers many of the salient points.
    This is a phony revolution, driven not by patients or clinicians, but by business interests.
    “The coalition has ignored the concerns of the British Medical Association and the Royal College of Nursing. This is a phony revolution, driven not by patients or clinicians, but by business interests. Less of a cure, I would say, more like second dose of the same poison.
    In the white paper, Lansley makes no mention of the involvement of Mars, Unilever and Diageo corporations – specialised in the sale of confectionary and alcohol – in public health discussions and planning meetings since September last year. No mention either, is made of hundreds of thousands of pounds in donations to the Conservative Party from private health companies.
    The prime minister and the health secretary insist that we need these reforms now, but where is the evidence that private contractors in the NHS improve care? I have certainly never seen it in practise, or in print. In fact, the work of Allyson Pollock, Professor and Director for the Centre for International Public Health Policy at the University of Edinburgh demonstrates painstakingly that privatisation within the service damages patient care.”

  • David Allen 25th Jan '11 - 9:45am

    John Rogers

    “David Allen tries to paint GPs as evil, gullible, Enron driven, private profiteers who are only interested in “what’s in it for us”!”

    Oh no I don’t. The vast majority of them are not. (Though of course, even dedicated hard-working professionals have been known to appreciate a good deal when they can get one…)

    It is the private companies, who will move in to “partner” GPs in their commisioning role, who will be the problem. The new system almost invites greedy and rapacious organisations to go for this role!

  • I see no Iceberg 25th Jan '11 - 9:59am

    Having spent time writing an informative piece and see it disappear I am wondering how many other contributers to this site give up after what appears to be deliberate censorship. Deeply Saddening.

  • David Rogers 25th Jan '11 - 4:41pm

    1. I made clear in my original article that Lib Dems in local government were not impressed with the silo suggestion of a seperately-elected local health board, and indeed argued against it privately and publicly;
    2. I am indeed claiming that there are real powers in the Bill for Health & Wellbeing Boards, the full content of which is of course available on the DH website, so anyone interested in further details can read all or any of it for themselves. I sincerely trust that these will not be diluted by the Parliamentary process, as they are central to the local democratic legitimacy element of the proposals;
    3. On your final point, these strategic powers will influence both GPs and public health (and other functions), enhancing the integration of service delivery for individuals and communities which is also a central aim.

  • David Allen 25th Jan '11 - 6:21pm

    John Brace

    “an example locally as to what the Lib Dem/Con council/govt has done well”

    Yes – a good example of a public body using private providers effectively and gaining the benefits of their open competition. Better than the Old Labour all-state solution with a monopoly state provider.

    Also better, I submit, than the NewConDem idea of having a private sector customer dealing with private sector providers.

    Let’s suppose your Council outsources its purchasing function to EasyCouncil Inc next year. Then no doubt, a new contractor may come along and enquire how they might win the work away from Colas. What are EasyCouncil Inc going to suggest? That they try to win it on low price and quality of work? Or, that maybe they can strike some sort of private partnership deal with EasyCouncil Inc, to their mutual benefit, and at the taxpayers’ cost?

  • Depressed Ex Lib Dem 25th Jan '11 - 7:13pm

    David Rogers

    “I am indeed claiming that there are real powers in the Bill for Health & Wellbeing Boards, the full content of which is of course available on the DH website, so anyone interested in further details can read all or any of it for themselves.”

    Well, looking at the bill, section 179 is on the Board’s “Duty to encourage integrated working.” That outlines the Board’s roles of encouragement, assistance, advice and support. And then there is section 180 on “Other functions of Health and Wellbeing Boards,” which deals mainly with the Board’s exercise of existing functions of local authorities.

    That is all I can see. Of course the bill is quite long and there may be more I have missed. But I really do wonder what the “real powers” you referred to are. Perhaps you could overcome your reticence and give us a hint.

  • David Rogers 26th Jan '11 - 1:24pm

    This is an extract from the Explanatory Notes to the Bill: “Chapter 2 deals with the health scrutiny functions of local authorities and makes provision for the establishment of health and wellbeing boards in each upper tier local authority area. It sets out their role in preparing the joint strategic needs assessment, the joint health and wellbeing strategy and in promoting integrated working between NHS, public health and social care commissioners.”
    The words themselves are very clear, that this role goes well beyond “the exercise of existing functions of local authorities”, which would be social care alone; the role is local leadership of the JOINT (that is, social care and health) strategic needs assessment, and the JOINT health and wellbeing strategy – both of which will have a major influence on commissioning decisions by GP consortia and others. Adding in the public health transfer, the enhanced scrutiny powers, and the reference to promoting integrated working, the significance of this additional local democratic legitimacy becomes obvious (to me, at least).

  • Depressed Ex Lib Dem 26th Jan '11 - 3:00pm

    Well, I don’t claim to be an expert on this, but I think if you read the bill itself rather than relying on the notes, you will see that this does indeed relate to the exercise of existing functions of local authorities:

    “180(1) The functions of a local authority and its partner commissioning consortia under sections 116 and 116A of the Local Government and Public Involvement in Health Act 2007 (“the 2007 Act”) are to be exercised by the Health and Wellbeing Board established by the local authority.

    “181(1) Subsection (2) applies where a Health and Wellbeing Board is (by virtue of section 180(1)) preparing—(a) an assessment of relevant needs under section 116 of the Local Government and Public Involvement in Health Act 2007, or (b) a strategy under section 116A of that Act.”

    Under the 2007 Act, joint strategic needs assessments for health and social care were prepared by each local authority and its partner PCTs. The present bill simply amends that so that they will be prepared by the new boards instead. As the boards will be made up of representatives of the local authorities and the new GP consortia (and possibly others) this confers no additional power on the representatives of the local authority that isn’t already there. Previously they prepared a plan jointly with the PCTs. Now they will prepare one jointly with the GP consortia – through the new board.

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