Over the last couple of weeks I have been posting about how the way in which the frame of the NHS long-term plan has been set influences what it can achieve. I have suggested that the structure of the NHS at the top – quangos taken out of a Department of State – has inevitably led to the frame being non-political.
The fact that it spends such a large and growing proportion of public expenditure means that the plan is inevitably political, but at the moment the NHS is being allowed to frame its own politics for its own plan. As I have tried to explain this is not a disaster (although any conflict locally or nationally is likely to need ‘politician type’ politics as well) but it does mean that while certain things are foregrounded by the NHS others drift into the background. This ‘drifting into the background’ doesn’t mean that it’s unimportant – it’s just not part of the NHS frame that defines what’s in focus.
And my point today is that if three or four local government leaders get together to talk about the future of the NHS one of the things that tends to drift into the background, is local government.
It is in the long-term plan, but it’s a hazy presence rather than being at its core.
And that’s a great pity because over the last few years it’s become clear to many NHS staff on the ground that local government has to be a major part of healthcare – because of social care – but crucially not just because of social care. This winter, on the ground in some places, local government is front and centre of the picture and without that hospitals would fill within days.
So why isn’t local government front and centre in the NHS long-term plan?
I usually start this explanation by getting people to look at a bit of history.
The main reason that local government isn’t front and centre for the NHS is indicated by the obvious words defining each sector. Local government is LOCAL and – yes you are right – the National Health Service is NATIONAL.
One of my unfunny historical joke reminds us that the Anglo Saxons ran Britain as a series of localities and within a couple of decades after 1066 the Normans gave that idea a real bashing and ran things nationally.
The two things really are very different. Anyone who works in the NHS knows that nationally the organisation sees itself as being run in a command and control method of working. In that there really are people who believe that central plans make things happen in localities. (Although as I have said before there is rather more command than control). It’s not that command and control actually works, but it is the main mode of expectation and operational management.
In local government the idea that the national centre could tell every local authority how, for example, it should deal with winter would be laughed at. It’s not just that there is a recognition that winter in Cumbria is different from winter in Cornwall, but the very structure of the ‘local’ in local government means that everyone in the sector knows that governance is based on local differences NOT national direction.
Local authorities are expected to define themselves locally – and they do.
This is of course reinforced by the fact that councillors are elected locally and that within each authority there are even smaller localities (wards) where the elected representatives think that wards matter much more than the whole local authority.
All of which means that often, when 3 or 4 NHS leaders get together, if they remember local government at all, they think of it as being a bit weird, as different local authorities in their patch create the problem of ‘not agreeing with each other’ – almost as if the purpose of locality was to do away with itself by agreeing with all the neighbouring localities.
Now magnify that within the writing of their long-term plan. There really is a lot to think about in creating that plan. Get three or four NHS leaders together and they will have to think a lot about planning before they get to thinking about local government.
So local government is in the plan – but not front and centre.
And that’s a great pity – not just because of social care and transfers of care – but for all the remaining aspirations of the plan. As I’ve said in many posts, you can try and improve cancer survival rates without improving late presentation of cancers and… well good luck with that.
But the reasons for late presentation derive from people’s lives beyond the NHS and a locality-led campaign about our cancer mortality rates being much higher than the national average – and what are we going to do about this? – would have much more traction than one led by the hospital.
So even if local government involvement is rather vaguely defined in the writing of the long-term plan, when it comes to implementation – if it’s going to work – it has to be front and centre.