NHS that involves and listens to local people is in all our interests

Cllr Ketan Sheth

Readers may be aware that the way in which the local NHS is run is likely to see big changes in the months ahead. Part of the NHS Long Term Plan is for local NHS bodies in each area to work in partnership with local councils as part of an ‘Integrated Care System’ (ICS). In North West London, this will mean a huge partnership across eight boroughs, including Brent – my Local borough. It may also mean a merger of the eight clinical commissioning groups (CCGs) across these areas into a single CCG for North West London (subject to a vote of GPs in each borough).

NHS leaders assure us that this is not a change to services, but to how their staff are organised. They say that any changes that are proposed under the new working arrangements will be subject to the same – or more – consultation and scrutiny. We need to hold them to this promise. The biggest concern for me, as a Brent councillor, is that the voice of Brent residents is not lost in a new system covering a huge geographical area (the North West London ICS and the single CCG would be the biggest in the country).

At a recent Joint Overview and Scrutiny Committee, we had the chance to question managers and GPs about the single CCG merger. There were certainly encouraging words about their future approach to involving local people in shaping health services. They have put in place a new programme, rather grandly called ‘EPIC’ (Engage, Participate, Involve, Collaborate), which they say is a direct response to the challenge of maintaining the voices of local residents in a much bigger system.

Working with local patient groups and Healthwatch organisations, they are co-producing an ‘Involvement Charter’ setting out how the public can get involved and setting standards we can hold them to. They have expressed a commitment to strengthening the current approach and involving more people, reaching deeper into our communities than ever before. They have promised to work with councillors and others to reach the most vulnerable and isolated people, who the NHS does not have a good track record of engaging. And alongside this ‘qualitative’ engagement, they have set up a 4,000-strong Citizens’ Panel, representative of local communities, allowing them to test public opinion through surveys and focus groups on a range of issues.

The programme is ambitious and no one could argue with its stated objectives. But as ever, the proof of the pudding is in the eating. The NHS is facing big challenges right now, not least in getting services up and running again in the wake of Covid-19. Getting public engagement right is going to be more important than ever. If this programme really does see a step change in how the local NHS works with our residents – and most importantly, if it acts on what people tell them – it will have my support. My message to NHS colleagues is simple: the goals you have set out are welcome, but we will need swift and tangible evidence that things are really changing for the better. The National Health Service that involves and listens to local people is in all our interests.

 

ketan

Cllr Ketan Sheth

Chair, Brent Council Community and Wellbeing Scrutiny Committee

Social care reform – comprehensive is good, but comprehensible vital

Chris Game

Cllr Ketan Sheth’s recent blog on ‘Local Government and the NHS Integrated Care System’ was, as he explained, timely for him personally – as an elected London borough councillor about to take on a novel scrutiny role in a new ICS.

For us Midlands readers it was timely too, for reasons most easily conveyed by the King’s Fund’s recent highly colourful Map 1 of ICSs so far established – highly colourful, that is, for some parts of England, including Cllr Sheth’s London, but bleak grey for others, like the whole of the Midlands, with merely our at least slightly more localised Sustainability and Transformation Partnerships (STPs).

This blog is not directly about either STPs or ICSs, which have only a late walk-on role. It is, though, about the future of social care and local government’s involvement in, or marginalisation from, that future, and it opens with one of Boris Johnson’s first Prime Ministerial broken pledges, in his very first speech as PM, to “fix the crisis in social care once and for all with a clear plan we have prepared”.

The ‘clear prepared plan’ bit was obvious fiction, and confirmed as such in the Conservatives’ December election manifesto.  60 pages, nearly 1,000 days working on a promised but still undelivered Green Paper, and no sniff of a plan.  One un-costed pre-condition (p.23) – that nobody should have to sell their home to pay for care – and a slightly desperate hope to build cross-party consensus on reform.

But last week, just eight months on, jostling with daily lockdown bulletins and courtesy mainly of The Guardian newspaper, saw a sudden small flurry of tantalising leaks. First came Ministers’ “radical plans for everyone over 40 to contribute towards the cost of social care in later life” – paying more in tax or national insurance, or insuring themselves against “hefty care bills when they are older”.

Broadly resembling the German and Japanese funding systems, it is variously labelled a ‘comprehensive’ and ‘compulsory’ insurance model, both of which, to be effective, it surely has to be.

But an even bigger question, I suggest in the blog’s title, is surely whether it can become a comprehensible and comprehended model, and pretty quickly – because the evidence is that our collective understanding of even the existing system is worryingly low.

With coincidental but near-perfect timing, the New Statesman magazine recently commissioned a poll by Redfield & Wilton Strategies asking a sample of 2,000 GB adults about their awareness of how social care is currently funded and organised. Its findings, for a topic dominating news headlines for several months now, were concerning.

Fewer than one in eight felt they were “significantly aware”, under half even “moderately aware”, and nearly a quarter “not aware at all”. They were then asked which of (1) the NHS, (2) private operators, and (3) my local council, they thought were currently providing community care in their locality.  Being a GB-wide sample, there are no precisely right or wrong answers, and ‘providing’ makes it almost a trick question – which personally I’d have opposed phrasing in this way. Still, there are better and worse guesses.

“My local council”, chosen by 55%, is a decent pick – if, by providing, you mean paying for.  But not, for decades now, if you mean actual care home beds.  As Covid has tragically demonstrated, funding is nowadays effectively separated from extremely fragmented provision, with only some 3% of beds directly provided by councils and at least 80% in over 11,000 homes by for-profit private companies, local organisations and charities.

As for payment – roughly £600 per week here in the West Midlands – just over one-third of residents have their fees met by their local authority; one in eight pay top-up fees, but the biggest fraction must find the full fees themselves.  Which, given our apparently limited understanding of the present-day system, must frequently come as a serious shock.

Exactly half the poll respondents ticked the “private operators” option. However, virtually as many (48%) nominated the NHS, which, note the authors, is nowadays “a very small player” indeed in providing social care.  It’s not totally wrong, but close – and that, in the proverbial nutshell, is Ministers’ social care problem.

The public generally have low understanding of how even the present care home system works, of how literally dis-integrated it has become, with home care provision twice as fragmented and considerably more expensive. But they love, clap for, and think they know ‘their’ NHS.

It was even more starkly highlighted in the crunch question: “Which of three options for the future of social care comes closest to your own view?”  Exactly half the respondents selected the ‘NHS model’ that many had just demonstrated they seriously misperceived: “Social care should be free at the point of use, regardless of whether individuals contributed taxation into the system during their working lives”.

Just over one-third preferred the ‘pension’ or ‘compulsory insurance’ model referenced in the Guardian story – or, rather, first story.  For, the following day, it reported Government plans to in effect merge health and social care services, taking the latter away from local councils altogether and handing them and their £22.5 billion annual funding over to the NHS.

The Department of Health and Social Care issued a routine denial, but the PM’s long awaited ‘plan’ appears, currently, to be that care services would be commissioned by, and funded through, the new NHS regional Integrated Care Systems (ICSs) gradually unrolling across England – although not, as yet, the Midlands, where we’re still in the Sustainability and Transformation Partnership phase.

I conclude with what seems a bit of a personal dilemma. Having worked for over half my life for an ‘Institute of Local Government Studies’, I instinctively deprecate both the fact and implications of elected and accountable local authorities losing a major function for so long integral to their existence.

On the other hand, if that’s what most people reckon they want, and the Government fundamentally misunderstands, distrusts, and already wants to diminish and/or abolish local councils ….   The question is: would the public be prepared to pay the cost of NHS-style “social care, free at the point of use”, largely unaddressed in the New Statesman questionnaire?  But that’s for another blog.

 

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Chris Game is an INLOGOV Associate, and Visiting Professor at Kwansei Gakuin University, Osaka, Japan.  He is joint-author (with Professor David Wilson) of the successive editions of Local Government in the United Kingdom, and a regular columnist for The Birmingham Post.

Local Government and the NHS Integrated Care System

Cllr Ketan Sheth

For those councillors in local government who scrutinise the NHS, it seems to have become an expectation that as one great change ends in our local health services, another begins.

A good few years ago in north-west London we saw the start of the Sustainability and Transformation Plans (later rebranded as Sustainability and Transformation Partnerships) or STPs as they were widely called. Now it seems another change is on the way. By April 2021 an Integrated Care System (ICS) will have been introduced, taking forward much of what was developed by the STPs. And, they are coming at a time of incredible change for the NHS and local government as a result of dealing with the Covid-19 pandemic.

I’m sure many of you are familiar with an ICS. If I had to summarise, I would say they are in essence bringing together health providers and commissioners, along with local government, to plan healthcare based on local population health needs in a defined geographical area. I’ve noticed the term ‘place’ features frequently in the NHS documentation and published reports. I should say as well, that the underpinning and thinking for them is all set out in the NHS Long Term Plan. In a few areas such as Greater Manchester, they started in 2018, and more have been set up to the point where around half of England’s population is now covered by an ICS.

As for my local proposed ICS, this will be cover around 2.3million residents across eight London boroughs in north-west London stretching from Westminster out to Hillingdon, with multiple providers, and community healthcare Trusts as well, and not to forget, the local authorities. At the moment, each borough has its own clinical commissioning group (CCG), but the plan is for one CCG to cover the whole area as well (but that development is best discussed at another time) across the eight boroughs.

So, what I want to address here is this – how does an elected member sitting on an overview and scrutiny start to grips with effectively reviewing and holding to account the development of a ‘system’ of such complexity, and in the constraints of the time and resources we all know elected members face? What should our starting principles be? It’s not easy to answer, but I have a few suggestions.

As an elected member, I don’t necessarily need to worry about being a ‘systems thinker’ but I do like to test the local ICS thinking constructively. I would perhaps ask this – thinking about the ordinary residents in my ward what will it deliver for them? What will an ICS do to make them and their families and children healthier, and be able to live longer and with a better quality of life? Ultimately, for me that’s what organisational systems in our public services should be about. Simply, a means to an end of delivering something better for ordinary people and our communities.

Also, while we talk about ‘systems’ in health services, let’s not forget that when we refer to hospitals in particular we are talking often about important local institutions which command a lot of local pride and attachment; not just because of the services they provide, but because of the outstanding research they do. Also, in my home borough of Brent, they are important local employers. I think this way of looking at the world from the grassroots should not be lost in these changes.

So that’s a few ways we can start to get to grips with such a big change, and complexity. Then it might be time to prepare for the next one, whatever that may be.

 

ketan

Cllr Ketan Sheth

Chair, Brent Council Community and Wellbeing Scrutiny Committee

England’s over-centralisation – Part 2: It IS instinctive

Chris Game

There was much in Jessica Studdert’s recent blog to agree with and applaud, but one sentence particularly struck me – the one opening her fourth paragraph: “The centralised response isn’t just structural, at times it has felt deeply instinctive.”.

So, equally instinctively, I did what even an erstwhile academic does during a lockdown – some heavyweight research, naturally. Like re-watching and content analysing the first 69 Government Covid-19 daily press conferences – one of those crisis features that, like the Thursday evening clapping, lives on because no one knows quite how to stop it.

I exaggerated with the ‘heavyweight’ bit, but I did count – sorry, totalise – the press conferences. So, first question: Which minister, Johnson excepted, was the first to front one?

No, not Foreign Secretary Dominic Raab. As First Secretary of State, he stood in while Johnson was hospitalised, but was actually eighth minister to feature. Surely, then, Health and Social Care Secretary, Matt Hancock. Nope, though he and his permanent pink tie have currently clocked up more appearances than Johnson himself.

Struggling? Chancellor of the Exchequer, Rishi Sunak? Hardly Robert Jenrick, Secretary of State for Housing, Communities and Local Government – for all the considerations touched on in Studdert’s blog. Surely not Home Secretary Priti Patel, despite being apparently the only woman minister capable of reading from a lectern.

They’ve done four, five and three respectively, but the shooting star we are looking for is Environment, FOOD and Rural Affairs Secretary, George Eustice. How short are our memories. His brief includes the so-called food supply chain, and this was late March – panic-buying, pasta-hoarding weekend.

Now the seriously tricky question. How many winning elections to serve as a plain local government councillor – not London Mayor – have all 12 featured Ministers fought between them? Maybe not a huge number? One!

One four-year term of elected local government experience between the lot of them. It was served by then 24-year old Gavin Williamson, now Education Secretary, giving English primary schools his considered judgement on when they should reopen.

It’s easy to mock – really easy – but there are archive pictures of Williamson doing his thing as North Yorkshire County Council’s ‘Champion of Youth Issues’ . Making him, I believe, alone among that TV-trusted Cabinet dozen to have even minimal first-hand insight into how local government operates in the policy field for which he is responsible.

The others can tell you lots, variously, about banking (Hancock), hedge fund management (Sunak), litigation (Raab), corporate finance (Alok Sharma), corporate law (Jenrick), public relations (Eustice, Patel), journalism (Johnson, Gove), marketing (Grant Shapps), Conservative Central Office (Patel, Oliver Dowden).

But actually experiencing what they presumably aspired to do – campaigning, meeting constituents, getting elected, representing people, learning about the provision and funding of public services, the whole government and public administration thing – for some reason never grabbed them or even struck them as career-relevant.

Which today means they know virtually nothing at first-hand about some of the vital stuff local governments do, often to the unawareness of even their own publics: emergency contingency planning, air quality monitoring, water testing, pest control, health and safety at work inspection – oh yes, and communicable disease investigation and outbreak control.

Time for a brief digression on the changing meaning of the word ‘nuisance’. It was one of my mother’s favourite words, applied frequently to my sister and myself, but to almost any usually minor upset to her daily life routine. Mask-wearing and disinfecting supermarket trolley handles would be a ‘nuisance’, not the wretched pandemic itself.

Yet the etymology of ‘nuisance’ is the Latin ‘nocere’ – to harm – and its original 15th Century meaning could quite conceivably be applied to Covid-19 and its capacity to inflict serious and even fatal harm.

The mid-19th Century predecessor of today’s Director of Public Health in Birmingham, Dr Justin Varney, would therefore have boasted the title of Nuisance Inspector – his nuisance agenda including factory air pollution, small-pox and cholera outbreaks, and sanitation, with the first generation of public urinals.

Nuisance Inspectors could not by themselves transform towns and cities, but they played a huge part. As do their modern-day successors – Public or Environmental Health Inspectors. Those successors, however – the ones that have survived the past decade of local government funding and employment cuts – could and should, as Studdert noted, have been doing even more.

The Chartered Institute of Environmental Health reckons there are some 5,000 Environmental Health Officers (EHOs) working in UK local councils. All have job descriptions including responsibilities like “investigating outbreaks of infectious diseases and preventing them spreading further.”

That’s what they do – test, track, trace and treat people with anything from salmonella to sexually transmitted diseases – in areas, moreover, with which they are totally familiar and have networks of contacts. ‘Shoe-leather epidemiology’ is the technical term – seriously.

So presumably, as in other countries – South Korea, Singapore, Germany, Ireland – these EHOs will have been reassigned from other work and spent their time contact tracing?

Rhetorical question – we all know the answers. From early March, contrary to World Health Organisation guidelines, our Government’s big ideas were to ‘delay’ the spread of Covid-19, then develop vital (now less vital) smartphone apps.

This enabled the consequently limited scale of contact-tracing to be undertaken centrally by staff newly recruited by Public Health England – the executive agency of Matt Hancock’s Health and Social Care Department created in the ill-conceived NHS upheaval in 2012.

Insufficient, inexperienced staff doing a job crying out for the skills, knowledge and contacts of council EHOs, who instead were monitoring social distancing rules in pubs, clubs and restaurants.

There are almost always costs in ‘keeping it central’, but, as we have seen, for so many ministers, it must be instinctive. It’s all they and most of their civil servants know at first hand. The alternative would be funding and at least sharing data with pesky local authorities, thereby losing some of their precious control.

Finally, last weekend, all other options exhausted, the Government did allocate a ring-fenced £300 million to English councils to play a leading role, starting immediately, in tracking and tracing people suspected of being at risk of Covid-19.

This time, tragically, the cost of blinkered, prejudiced, self-protective government was paid in lives.

Wider opening of schools during covid-19

Cllr. Ketan Sheth 

Education impacts society and is a measure and driver of our progress as a community.  A good education keeps us physically and mentally strong and plays a key role in the betterment of our socio-economic environment and the communities in which we live. Education is the ultimate pathway of success, providing the support that enables each and everyone of us to keep growing our knowledge and ourselves across the whole of our lives.  That is why education is given the highest status in today’s world. The delivery of our education service, however, has been heavenly impacted at all levels by Covid-19.

We are now starting discussions on easing the Covid-19 lockdown by reopening schools in a bid to restart our economy. The concern is that this might become a breeding ground for a second wave of Covid-19 cases.  Indeed, many parents may decide to keep their children at home, as it is possible that the rate at which the virus spreads may increase when schools open. It is therefore possible that the decline in the number of people infected may be affected. I say ‘possible’ because analysis of international trends suggest there are no definitive indications that opening schools accelerates infection. Schools have not yet been shown to push the reproduction rate (R) above one.

Many of our families and the communities in which we live have actively helped reduce (R) over the last 5 to 6 weeks. As a result the number of hospital admissions of Covid-19, in some communities, has now stabilised. Because of that, the reduction of the reproduction rate has slowed since mid-April, but it is still under 1. This has led to the debate on balancing the needs of the economy and the safety of our communities. In this case, that means our children.

The role of local government is to know and understand its communities and their children. Local government delivers services to local residents every day and is the vital ingredient to finding the best community solution.

As Covid-19 shows, pandemics are not technocratic. They are complex, creating social and behavioural challenges. Parents, teachers, and children are grappling with the threat of contracting the infection, often while dealing with personal loss. Effective management mechanisms between national and local government are therefore critical. We need to strengthen local responses and systems, and respect and build the capacity of local government to manage the policy response from health to the economy, to social protection. Investment in local government will be key to successful recovery and long-term resilience.

Thinking and acting locally will help to ensure that the spread of Covid-19 is curtailed and our communities protected. As far as opening schools goes: this needs to be managed locally and to be responsive to local concerns and needs. A locally crafted step-by-step approach is demanded, setting a code-of-conduct that ensures the highest standards of hygiene, and ensuring all school operations, break times, and classroom divisions meet carefully set social distancing guidelines.

For government to work effectively in the worst of times, it needs to have well-oiled systems, practices and resource flows.  We need to reflect on, and respond to, our population’s needs and changing realities quickly, intelligently, and always with the wellbeing of our communities at the forefront. Anxiety will linger over infection rates, but if we work together at a local level in the communities where we live, we can be agile, and creative, in our services. Together we can do it locally.

 

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Cllr. Ketan Sheth is a Councillor for Tokyngton, Wembley in the London Borough of Brent. Ketan has been a councillor since 2010 and was appointed as Brent Council’s Chair of the Community and Wellbeing Scrutiny Committee in May 2016. Before his current appointment in 2016, he was the Chair of Planning, of Standards, and of the Licensing Committees. Ketan is a lawyer by profession and sits on a number of public bodies, including as the Lead Governor of Central and North West London NHS Foundation Trust.

England’s over-centralisation isn’t just a governance issue now – it’s a public health emergency

Jessica Studdert

The concentration of power at Westminster and Whitehall has long frustrated those of us who engage closely with the structures of governance and compare it to decentralised norms across much of Europe. Now, as with so many facets of the Covid-19 crisis, the pandemic has exposed national vulnerabilities and left us grappling with the consequences. The grip on initiative that rests in SW1 is one such weakness, which is impacting how our system is responding to the virus, in turn perpetuating the public health emergency we find ourselves in.

A degree of national direction is clearly needed in the midst of a serious pandemic. People look to the Government for leadership and reassurance. Those in positions of power certainly feel personal responsibility for leading the response. Measures to implement service strategy nationally, such as through the NHS, or to use national heft for international procurement buying power, are certainly necessary. But time after time during the unfolding crisis, the centralised instinct has clouded decision-making, with terrible results.

The structures for the top-down approach to the pandemic were set early on, when the Government chose not to deploy the existing Civil Contingencies Act which set out clear roles, responsibilities and resources for all local and national public bodies. They instead rushed the Coronavirus Act through Parliament, which gave the Executive a greater level of unchecked power and no defined local role. This has had ongoing consequences for the coordination of an effective response. Leaked findings from an internal Whitehall review found that local emergency planning teams believe their abilities have been compromised by a controlling and uncommunicative approach from the central government machine, which persistently withholds data and intelligence.

The centralised response isn’t just structural, at times it has felt deeply instinctive. There has been a repeated preference for big, bold flashy schemes over smaller, sustained but potentially more impactful measures. In the early weeks of the crisis much media attention focussed on the new Nightingale hospitals, yet we are now seeing tragically how that time and resource could have been better invested in the more targeted shielding of hundreds of care homes. When faced with the need to quickly implement testing for Covid-19, the Secretary of State for Health reached for a high-profile 100,000 target and set up new large processing sites. This triumph of tactics over strategy directed the systemic response to focus on numbers over priority need and overlooked existing networks of local lab capacity. Even as attempts are made to set up contact tracing at scale to support the easing of lockdown restrictions, the Government seems to have more confidence in a new mobile app than it does existing local public health teams. This is despite the latter’s expertise in tracing the contacts of people who have highly infectious diseases and clear evidence from countries who have successfully managed their lockdown transition.

The formal power exercised at the centre is in direct contrast to the informal role for local authorities, which is having devastating consequences for their very viability. Because councils’ response has no statutory footing in the context of an emergency, they are left exposed to the whims of a few individuals making decisions in Westminster. At the start of the crisis, the Secretary of State for Local Government told local authorities to spend “whatever it takes” to protect their residents. Councils had immediately set about providing relief to shielded groups, protecting wider vulnerable groups and implementing public safety measures, all while ensuring essential services continued as usual. Rather than support these efforts, Government then rescinded this early clear backing, querying councils’ honesty over their cost assessments and leaving many facing a financial black hole.

The double standards central government imposes on its local counterparts is nowhere more apparent than when it comes to local government finance. An emergency on the scale of a global pandemic has required state-led responses on a scale inconceivable only months ago, and with widespread public approval. Central government spending has snowballed to accommodate unprecedented employee furlough schemes, emergency business support measures, not to mention the enormous costs to the NHS. The Chancellor has the leeway to respond to this through a number of different measures – incurring public debt, raising taxes, freezing public sector wages and reducing public spending, a combination of which he is reportedly considering.

Local government has no such room for fiscal manoeuvre. Councils are legally required to balance annual budgets and have only narrow revenue-raising powers through council tax and business rates which are themselves subject to centrally imposed controls. With a shock to their budgets of this scale they are at the mercy of decisions made by a few in Westminster. These have so far resulted in a couple of ad hoc cash injections of £1.6bn each, and a bit extra cobbled together earmarked for social care and rough sleepers – so far massively short of the estimated £10-13 billon shortfall councils collectively face.

It is no way to run a country. It never was, but in the context of the crisis the contradictions of our top-heavy system of governance are laid bare. The rumblings of discontent from Mayors in the north of England at their regions being side-lined, and from councils over plans to fully reopen schools in the absence of clear local test, track and trace infrastructure, suggest the popular tide is beginning to turn against blanket centrally-imposed measures. As local government is increasingly being seen as better placed to protect their residents, particularly in the context of a Government that is increasingly mis-stepping, there may now be an opportunity for a deeper discussion about how our country should be run in the interests of everyone.

Jessica Studdert is deputy director of the New Local Government Network (NLGN), a Londonbased think-tank. She leads NLGN’s thought leadership and research, and contributes strategic oversight of the organisation. Prior to joining NLGN, Jessica was political adviser to the Labour Group at the LGA. She led policy there, working closely on public service reform and devolution. Previously she worked in policy roles in the voluntary sector for a street homelessness and a childcare charity, and she began her career at the Fabian Society.