How do you scrutinise health services across a large area?

By Ketan Sheth

Many members of health overview and scrutiny committees will feel that their role is a complex one. In my experience, this area of scrutiny becomes even more demanding when there is a joint committee, involving a number of local authorities, to scrutinise health services across a large area.

I sit on the North West London Joint Health Overview and Scrutiny Committee (JHOSC) alongside seven other local authority representatives which was set up in 2013 to review Shaping a Healthier Future – the NHS transformation programme across north-west London. This year it was confirmed that Shaping a Healthier Future was no more, so you might be thinking that there would never be such a complex issue for a joint health committee to review. You’d be wrong.

A major change is afoot, but this time it’s more on the commissioning side of health services. On the back of the new NHS Long Term Plan, there’s now active consideration of a proposal to merge all eight of the clinical commissioning groups (CCGs) covering north-west London into one body. This would create a body commissioning health services for about 2.2 million people across eight boroughs. It’s linked to an intention in the Plan, for Integrated Care Systems linked to single commissioning bodies. Parts of the machinery for just one CCG have been around in north-west London for a while. The CCGs, a while ago, set up their ‘collaboration’, which has a joint finance committee, and there’s nothing new about co-commissioning among a number of CCGs. I don’t want to dwell here on the pros and cons of the proposal – we’ve had one JHOSC meeting to focus on it and shortly we’ll have another. But what interests me is reflecting on the challenges for members sitting on a joint committee who have to review such a large-scale project.

The first obvious point is that this is an enormous topic and the implications are profound. To my mind as a scrutiny member, the only way that you can start to understand the proposal and prepare for the all-important committee meeting is by breaking down the topic into smaller chunks. One way to do this is to look at the published NHS papers and ask some obvious questions based on: how, when and why.

The ‘how’ is key. According to NHS England guidelines for merging CCGs a “merger should not unduly distract the existing CCGs from business as usual, including delivering core performance standards and achieving financial balance.” So, straight away there’s one interesting line of enquiry here – how will the CCGs manage this process, if it goes ahead, and how will they be able to run existing services effectively?

The ‘when’ is interesting. The NHS Long Term Plan describes an intention that by April 2021 all of England will be covered by an Integrated Care System, involving a CCG or CCGs working together with partners. But in London, things are moving quite a bit faster and the intention at the moment is to have a single CCG for north-west London by April 2020. Again, this raises an interesting question: what are the risks of this pace of change?

Let’s look at the ‘why’. It would be unfair to say there was a single reason. But the NHS Long Term Plan says by “by 2020/21, individual CCG running cost allowances will be 20% lower in real terms than in 2017/18 and CCGs may therefore wish to explore the efficiency opportunities of merging with neighbouring CCGs.” This brings up more lines of enquiry such as will the cost-savings be achieved and what happens if they are not?

So, it will still be a big, demanding topic to look at in committee. But already, I think as a scrutineer I can feel more on top of it, and better prepared by working through it layer by layer.

ketanKetan Sheth is Councillor for Tokyngton Wembley and Chair of Brent Council’s Community and Wellbeing Scrutiny Committee.

 

 

 

All views in this blog are those of the author and do not represent those of INLOGOV or the University of Birmingham.

 

 

 

 

 

 

 

 

Monitoring visit to Armenia by the Congress of the Council of Europe

Bryony Rudkin

Arriving at Norwich airport at 4am is quite an achievement on a Sunday morning when it’s still dark and the road signage is poor.  Needs must however and last month this is where I set off from for Armenia as part of a team from the Congress of the Council of Europe where I’m a member of the UK delegation.  The Congress is made up of locally elected representatives of the 47 member states of the Council of Europe (so wider than the EU).  Part of its remit is to uphold the principles of the European Charter of Local Self-Government so monitoring visits are carried out to member states by local representatives from other countries along with an academic expert and a senior member of the Congress secretariat.

This was my first such visit.  The journey was something of a sensory overload taking me from Norwich to Yerevan via Moscow.  Norfolk is a long way geographically and culturally from the oldest Christian nation, but by late morning the next day I was listening to the Mayor of Yerevan explain his ambition for a new transport system and better housing for his residents.  Plus ca change.  Mayor Marutyan was elected in October 2018 following the ‘velvet’ revolution in April of the same year.  An actor, comedian and film producer by trade, he is one of the new politicians coming to the fore throughout the continent.  Shaky 20th century infrastructure and other unresolved issues have left him with enormous challenges.  Yerevan is a very green city, but as choked with traffic as most capitals.  It might have been even greener had it not lost thousands of trees when the Soviet Union crumbled and the state could no longer supply it’s people with fuel.  The Mayor’s response to our questions showed the same commitment to improvement and change I’ve seen in towns and cities round the UK and the same frustration with central government when it came to getting things done.

The following day brought contrast with a visit to a stunning village which sat alongside the remains of a collective farm and still proudly used the House of Culture from the same era – children proudly showed us folk dancing and karate with all the zeal and joy of any contestant on Britain’s Got Talent.  Here local representatives work alongside members of a huge diaspora who have returned to support the communities their families fled at the time of the Armenian genocide.  Again, some exceptional challenges alongside the mundane, but this village is doing well.  A daily bus takes its young people to the university in Yerevan and they have a free, strong Wifi signal, the like of which rural Norfolk would give its back teeth for.

So a visit of contrasts.  Evidence that some institutions and behaviours had changed little from the time when instruction came direct from Moscow, but we did meet bright, capable young people in the civil service and NGO’s – the staff of the Ombudsman who defends human rights were exceptional.  We also saw what might be identified as ‘Big Society’ in action through the work of a super-diaspora.  Clear policy objectives in local planning showed mayors and councillors were ambitious for their people.  A privilege indeed to have been part of the team.  My next task?  To get Norfolk County Council to improve the signage on the new airport distributor road…

bryony talkingBryony Rudkin is a PhD student at INLOGOV, Deputy Leader of Ipswich Borough Council and Portfolio Holder for Culture and Leisure. Bryony also works with councils around the country on behalf of the Local Government Association on sector-led improvement, carrying out peer reviews and delivering training and mentoring support.

 

All views in this blog are those of the author, and not those of INLOGOV or the University of Birmingham.

Parallel lines? The issue of coterminous boundaries

Mark Sandford

A persistent feature of local public administration in England has been the use of different definitions of geographical areas for different functions of government. Elected local authorities use one set of boundaries; un-elected health authorities another; Local Enterprise Partnerships another again. Centrally-driven initiatives, such as the Work Programme or Community Rehabilitation Companies, use boundaries based on those of local authorities but they differ from one another. Each set of boundary patterns has some commonalities with every other set, but this is as much chance as intention.

This diversity reflects two connected features of English political culture. One is that, as Brian Hogwood’s Mapping the Regions noted in 1996, regional and local government structures in England have always been concerned with the delivery of functions rather than the management of territory. The purpose of boundaries is purely to define efficient administrative units. The other is that, with a small number of exceptions, England contains very few localities that display either consensus over boundaries or a distinct sense of local identity.

Coterminosity banned?

Debate on English sub-national governance have occasionally proposed that boundaries should be reformed so that they are more coterminous – i.e. that local bodies should, wherever possible, adopt the same boundaries as one another. In the spirit noted above, this idea is presented as a route to improved public administration. Coterminosity is not a term that attracts affection: the Local Government Association included it on a list of ‘banned jargon’ in 2008. But it plays a significant, sometimes overlooked, part in proposals to improve local administration.

Many recent think-tank reports claim in passing that local public services would benefit if the agencies delivering them used the same boundaries. Examples include the IPPR’s Rebooting Devolution; the IfG report Joining Up Public Services around local, citizen needs, which refers to “misaligned geographies”; Reform’s Vive la devolution; ResPublica’s Devo 2.0: the case for counties; and an LSE report on city-region devolution in England. The implication is that this makes partnership working easier and more efficient – and critically, that it improves accountability. That concern can be seen in the Government’s proposal to align local authority and Local Enterprise Partnership boundaries in a 2018 consultation paper.

It seems intuitive that public services would function more effectively, and fragmentation between them would be reduced, if they covered the same geographical area.  But there is actually little definitive research evidence about the effect of coterminous or non-coterminous boundaries on the economy or efficiency of public administration. This may partly explain why there has never been a consistent drive to harmonise administrative units in England.

The challenges of change

Altering local boundaries to align with one another would be time-consuming. First, local actors would have to agree on a common boundary. This might be more challenging than one might expect. This is visible from an interactive map produced by the National Audit Office in late 2017. In some of the examples in that map, different boundaries used by different services are simply historical accidents. But in others, there may be valid criteria – based on scale, user populations, or geographies – underlying the differences. As an example, most bodies operating in Greater Manchester use the same boundaries; but the NHS Clinical Commissioning Group boundaries include Glossop, from the High Peak district of Derbyshire. The town is far closer geographically to the Manchester conurbation than to other towns in Derbyshire, and is surrounded by sparsely-populated countryside.

There is, again, an intuitive logic to boundaries that incorporate neighbouring urban areas in preference to following historical boundaries. The idea that boundaries should reflect the pattern of settlement is supported by a 2016 report from Shared Intelligence, Learning the Lessons from Local Government Reorganisation. This report suggested that ‘underbounded’ cities, where parts of a continuous urban area are located within a separate authority, face particular service delivery challenges. The implication is that future redesigns should avoid or correct these difficulties.

But the strength of feeling concerning historic boundaries should not be underestimated. Local authority reorganisations in England have frequently attracted legal action to prevent mergers. Public opinion research carried out as part of the 1992-5 restructuring in England found strong support for the return of historical boundaries in certain parts of England.

The Shared Intelligence report also identified issues relating to scale. In English local government, this normally relates to the population covered by an administrative unit, and the economies of scale in service delivery that can be achieved as a result. Widely-differing scales are used for local units in England. For instance, there are 20 Work Programme contracts (employment support) and 16 Community Rehabilitation Companies (probation). Could these functions operate at, for instance, the scale of county councils and urban authorities (implying some 40 units)?

Low-profile boundaries can be aligned more easily. During the 2000s, a number of executive agencies altered their boundaries to align with those of the standard regions used at the time. Examples include Natural England, the Highways Agency, the Housing Corporation, and the Arts Council. Staff were frequently relocated to the same city or office as a result. More recently, in 2014 the Williams Commission recommended better alignment of various public body boundaries as one element of a wider programme of local government reform in Wales.

Joining up: a victory for place?

Aligning local boundaries often appears as one element of an enthusiasm for ‘joined up government’. This has enjoyed periods of popularity in the last 30 years. In a nutshell, it implies reversing the practice of governance noted by Brian Hogwood’s 1996 report: focusing on the governance of a ‘territory’ rather than individual functions of government. There have been occasional steps in this direction: the most recent example was the community budget programmes (later ‘Our Place!’) piloted by the Coalition government, which followed the similar ‘Total Place’ programme under the 2007-10 Labour government. These initiatives were lauded but have left little mark on the governance or local geographies of England. Any comprehensive move of this kind would need to address the functionalism and lack of ‘local identity’ that underpins the governance of England.

Mark SandfordMark Sandford is a senior research analyst in the House of Commons Library, specialising in local government and devolution within England. He has published a number of recent papers and blogs on local government finance and English devolution. Previously he was a research fellow at the Constitution Unit, University College London (2000-05) and head of research at the Electoral Commission (2006-07).

 

All views expressed in this blog post are those of the author and not necessarily INLOGOV or the University of Birmingham.

Gone Missing – 500 Councillors

Chris Game

I should have been voting this week.  I’m a longstanding Birmingham resident, almost unhealthily fascinated by local politics and particularly electoral politics, and it’s one of the years in our electoral cycle when the metropolitan boroughs, like Birmingham, have elections.  What more to wish for?

A lot, as it happens – but it involves a quick sprint through recent history, starting in 2014.  That was when Communities and Local Government Secretary, Eric Pickles – and a surely coerced Birmingham City Council Labour Leader, Sir Albert Bore – asked Sir Bob Kerslake, chief DCLG civil servant, to review the Council’s governance and organisational capabilities, with a view to increasing its efficiency and effectiveness.

Sir Bob wasn’t impressed, as his report made starkly clear. The Council was dysfunctionally big, visionless and broke, he reckoned, one perhaps secondary but still significant solution to its bigness being to slash the number of councillors from the then 120, giving them even more residents to deal with, and having them all elected in the same year.  Interesting, from an accountant turned career civil servant.

Whereupon the Local Government Boundary Commission piled in, thought it would be fun to have a mix of one- and two-councillor wards, and changed all the boundaries – confusing electors and predictably reducing the proportion of women councillors all in one go.  In case you’re uncertain about the latter assertion, there are currently 27 women councillors in the 32 two-member wards (37%), and just 7 in the 37 one-member wards (19%).

There were protests aplenty, but ministers had spoken, and last May we duly elected our new slimmed-down council.  Which is why Birmingham is the only West Midlands metropolitan council with no elections this week – the other two non-voting mets being Rotherham, which, following its sexual abuses scandal, was required (by Pickles again) to hold all-out elections in 2016 and then every fourth year, and Doncaster, that chose a four-yearly cycle from 2017 to coincide with its mayoral elections.

As you’ll sense, I wasn’t personally terribly enthusiastic about the councillor cull.  But nor did I really, to quote Bob Dylan’s deathless Subterranean Homesick Blues, need a weatherman to know which way the wind blows.  It was blowing, in seemingly increasingly strong gusts, towards ever larger councils and ever fewer councillors. Resistance seems pointless, and the most I can do is to record the trends for the benefit of those who don’t instinctively realise that where Birmingham leads, others invariably follow.

Every local elections season opens, as it will close, with the incomparable analyses of Colin Rallings and Michael Thrasher.  This year, the Local Government Chronicle sub-headlined their preview: ‘The local electoral landscape is undergoing a quiet revolution’.  The scale of that revolution was captured by R & T’s opening statistics: that, whereas four years ago, at the same point in our electoral cycle, more than 9,300 seats were contested in 279 authorities, this week it would be 1,000 fewer seats in 248 authorities.

And the reasons, the causes of the revolution: “some councils being merged or abolished, others having their elections cancelled as they await the same fate, and yet others either moving to a new pattern of elections or having often quite sharp reductions in councillor numbers following review by the Local Government Boundary Commission.”

R & T then went on to their ‘round the grounds’ predictions.  I, more nerdily, thought it might be interesting to count the numbers.  Some of the “1,000 fewer” seats are easily explained – like the 116 contested four years ago in Birmingham, Doncaster and Rotherham.  Others, as noted, are awaiting their fate or changing their electoral cycles. But, by my reckoning, we have actually lost at least 500 seats and councillors – perhaps a dozen councils-worth – since 2014.  The Birmingham councillor culling policy is steadily being rolled out across England, but without anyone bothered even to mention, never mind justify, it to us mere voters.

To emphasise: even without change, our councillors have long been expected to represent several times as many constituents as in other European countries, and now, literally year by year, the multiple is increasing as our councillor numbers are steadily cut – through a combination of council mergers and boundary reorganisations.

500 councillors_Chris Game.JPG

This year sees the election in Dorset of two new unitary councils in place of the former county, two boroughs, five districts, and a unitary – and a cut in councillor numbers of over half: 333 down to 158.  Plus three new ‘super-districts’ in Suffolk and West Somerset, councillors there reduced by a mere third, from 259 to 178. Next year it’s the turn of Buckinghamshire (county council-promoted), Northamptonshire (imposed punishment), and possibly others.

Which brings us to the Local Government Boundary Commissioners, who make all these decisions.  They conduct reviews of English local authorities to improve levels of electoral equality, ensuring all councillors represent approximately the same number of electors.  But theirs is an odd equality: applying only WITHIN individual authorities, with no comparative reference whatever even to neighbouring councils.

And here’s the other thing.  The Commissioners’ statutory criteria include promoting “effective and convenient local government” – but for whom?  Do councillors invariably work more effectively having responsibility for hundreds more residents?  And do these residents always find it more convenient having so many fewer councillors?  Because that’s how it almost always works out nowadays.

This week 53 ‘new’ post-review councils are being elected, like Birmingham last year. In the most recent ‘batch’ of 34 reviews, the councils started with 1,796 councillors.  Rutland increased its councillor numbers from 26 to 27.  The other 33 ended with 217 or 12% fewer – all in the name of more equal, effective and convenient local government.  Interesting!

chris gameChris Game is a Visiting Lecturer at INLOGOV interested in the politics of local government; local elections, electoral reform and other electoral behaviour; party politics; political leadership and management; member-officer relations; central-local relations; use of consumer and opinion research in local government; the modernisation agenda and the implementation of executive local government.

The views expressed in this blog are those of the author and not INLOGOV or the University of Birmingham.

Chance to Shape a Healthier Future

By Ketan Sheth

The announcement that plans to close Ealing and Charing Cross A&Es will no longer go ahead was not a surprise to those of us who work closely with the North West London NHS. In recent meetings in public, they have been very open about the fact that they were reconsidering their plans given the lack of available capital and the context of the new NHS Long Term Plan.

What was a little surprising was the way in which the news was broken. It seemed odd for the Health Secretary, Matthew Hancock, to make the announcement on the 26th March 2019 in response to a parliamentary question from an MP. It was clear on the day that many in the NHS had not been made aware of what Mr Hancock was planning to say. We hear much from the government about the importance of the NHS and local councils like mine working together in partnership to develop plans for services in their area. Most of us are doing what we can to support this. Making an announcement like that over all our heads was not a very good example of such partnership working.

Nonetheless, the NHS decision to shelve those parts of the Shaping a Healthier Future programme that had caused most public controversy does give us a real opportunity to move forward together in North West London. There are major challenges facing health and social care across our eight boroughs and neither the NHS nor local authorities can resolve these alone.

Making sure all of us get the care we need and that the right staff are there to deliver it are matters that should concern us all. If you add in the problems of crumbling buildings and lack of money – the North West London NHS has a massive problem with its estate, with some of our hospitals close to falling down – then you can see there is an agenda where local authorities and NHS leaders should be working together. And government support will be needed too.

It is not all doom and gloom. Despite the lack of money, there are real opportunities to work with local people to improve their health. We should be working together to keep people well, to make sure they don’t keep having to provide the same information to numerous doctors and nurses and to help them navigate a health and care system that can seem very complex. Better support for our children and young people, the frail, elderly and people with mental health issues or long term medical conditions are areas where the NHS and local boroughs need to cooperate closely to have any chance of success.

And if we can make our local residents active citizens – both physically and in terms of helping to shape and improve their local services – then we have the potential to deliver real and lasting change for our residents.

The proposed A&E closures were always a divisive and difficult topic. The local NHS is clear that the decision not to go ahead with them does not mean that nothing will change. The scale of the challenges we face is too great to say that. But while some difficult decisions will still have to be made, we should now see a real opportunity to work together to make our local services the best they can be – and actually shape a healthier future for local people.

ketanKetan Sheth is Councillor for Tokyngton Wembley and Chair of Brent Council’s  Community and Wellbeing Scrutiny Committee.

 

 

 

All views in this blog are those of the author and not those of INLOGOV or the University of Birmingham.

Winter Pressures: Why it’s not just a problem for the NHS

By Cllr. Ketan Sheth

The term ‘winter pressures,’ is a phrase we hear regularly at this time of year as hospitals struggle to meet demand. But what does it mean in practice? That’s what my scrutiny committee wanted to find out when we discussed this issue earlier in the year.

It has, for many years, been commonly perceived that winter pressures are the NHS’s problem. But is this really fair given we serve the same communities and the pressure on health and social care are significant?

In response, Brent Council, Brent Clinical Commissioning Group and London North West University Healthcare NHS Trust have teamed up to address the problem in recent years.

It is no small challenge as parts of Brent are among the most deprived places in London, and Northwick Park Hospital is one of the busiest A&E departments in the capital. Early planning and a co-ordinated cross organisational approach have helped us shape a robust winter plan that maintains patient experience, safety and clinical effectiveness during the most demanding period of the year.

This planning began with lessons learnt during the winter of 2017/18, which were subsequently built into our current plan. It boils down to keeping people out of hospital; ensuring patients who are admitted are treated and discharged quickly (and safely); and provision of adequate home support in the community.

Brent CCG responded by giving patients access to GP appointments from 8am-8pm seven days a week via a network of GP hubs. The hubs play a crucial role in curbing the number of people going to A&E with minor ailments. Their use rose by 42% between Oct-Dec 2017 and the same period a year later. The CCG also provided an enhanced service in care homes, a targeted approach to flu vaccinations and developed a closer working relationship between acute and primary care providers.

The Department of Health provided the council with a one-off payment of £1.3M to support hospital discharges. It ‘purchased’ an additional 15 beds, provided reward payments to care homes that could quickly assess and accommodate patients as well as provide an additional handyman service for home adaptations. It also invested in additional social worker, OT and co-ordinator capacity to boost its Home First initiative to get patients home with the minimum of delay.

Ambulance handover times between crews and A&E staff at Northwick Park Hospital has improved and benefited from an additional paramedic/nurse to assist with triage and advanced assessment triage area.

These plans have helped but under pinning it all is the dedication and hard work of staff on the front line.

The reality is that we face a growing population that is living longer and increasingly troubled by a host of long-term conditions. The only way we can manage this, aside from promoting greater personal responsibility for health, is for the public sector and its partners to develop a healthy working relationship, which recognises this is everyone’s problem.

ketanKetan Sheth is Councillor for Tokyngton Wembley and Chair of Brent Council’s Community and Wellbeing Scrutiny Committee

 

 

 

All views in this blog are those of the author and not INLOGOV or the University of Birmingham.