Posted on Monday 7th February 2011
Written by: Catherine Staite (Director of Organisational Development)
David Miliband said in his speech in the House of Commons on Monday 31 January 2011 that the Bill is not a 'curate's egg' with some good bits and some bad but rather is wholly bad. But is he right?
Most of the debate about the government's planned changes for the health service has focused on the abolition of PCTs and the creation of GP Commissioners. Concerns are being expressed about disruption and the loss of expertise currently residing in PCTs as well as the ability of GP Commissioners to predict need and to manage complex budgets and contracts with diverse providers.
The transfer of responsibility for public health to local authorities may not have made the headlines but it heralds a very significant change. Public health covers a very wide variety of functions from disease control to behaviour change, as demonstrated by the recently published draft outcomes framework for public health. Most public health outcomes can only be achieved by close partnership working between public health and local authorities. This means the change makes sense. However, although estimates vary, the ring fenced public health budget which is being transferred to local authorities would appear to be about half of the current spend. This will make the transfer challenging.
Health and Wellbeing Boards are also being created by the Bill and the Department of Health is inviting local authorities to set them up now. Local authorities are being given a statutory duty to 'hold the ring' between GP commissioning, public health and adult social care, all of which will be represented on the Board. This is a classic example of local government having to make sense at local level of those issues which central government has failed to resolve at a national level. For example, children's services are not included even though children and families should be at the heart of any strategy for improved health and wellbeing. The Health and Wellbeing Boards will produce a joint needs assessment for their area and a strategic plan to meet that need. However, GP commissioners will have most of the money and local authorities will have few levers to ensure GPs invest in prevention and improvement. If all the GP's money is spent on acute care there won't be much left over to spend on preventing the sorts of behaviours – such as smoking and poor diet - and problems which contribute to the need for acute care.
Health and Wellbeing Boards will need to have a very good grasp of the inter-relationship between public health, acute care and adult social care. The consequences of choices made in one area will be felt elsewhere in the system. Falls prevention helps keep older people out of hospital. Reablement and good home support gets them out of hospital sooner. If part of the system malfunctions everyone suffers. Increased personalisation and individual budgets as well as the need to encourage new providers will make commissioning ever more challenging. If the 'Big Society' is to take up the slack, by creating more community capacity, then local government will have to help establish and maintain new forms of mutual care, such as the Southwark Circle - a big ask at a time when local government is implementing major cuts as a result of a reduction in central government funding.
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