The Health and Social Care Bill is now the Health and Social Care Act, and yet the debate over the NHS is far from over. At a national level the details of the structure of the NHS Commissioning Board are still being determined and the Board’s Mandate is set to be consulted upon this summer. At a local level the first wave of clinical commissioning group authorisations is about to begin, and local health and wellbeing boards are beginning to take shape.
It is at this local level where the political heat may be felt most. Almost a year ago to the day I wrote about the implications of poor local election results for the Liberal Democrats and their approach to localism. The party has long argued for increased local accountability on health, but that came from a context in which their power was greater at a local level. This year has seen further deterioration of the party’s presence at a local level with a loss of 330 seats. If anything, last Thursday was even more bruising for the Conservatives, losing over 400 seats across England. Localism may well be less appealing when you are not in charge.
A difficult day for the Coalition also saw Labour gain 825 council seats, and take control of an extra 32 councils, as good as wiping out the years of reverses experienced by the party when in power at a national level.
So what implications could this have for the implementation of the health reforms? Recent research carried out by the King’s Fund found that councillors were one of few groups represented on every health and wellbeing board. The research also found that in most cases a councillor will take on the role of chair of the board. With the boards responsible for producing local health and wellbeing strategies they have a significant role in setting the direction of health in their area, and councillors will have the opportunity to be at the centre of that process. In many places, Labour will be in control of a keystone of the new system.
Ahead of voting, Ed Miliband had said: “I think that Labour councils are now the last line of defence against this bill and they have got to use the public health and well-being boards as a way of trying to prevent the worst aspects of this bill. Of course, comply with legislation because the legislation has passed. But I think there is an opportunity for Labour councils to stand up for the right principles not the wrong principles in our NHS.”
What Labour ‘control’ of health and wellbeing boards will actually mean for the direction of health reform is still to be seen (and will only really become clear when they become statutory organisations next April). The boards will have little control over new commissioning structures, they will have to operate within the barriers of legislation and support the introduction of competition in the NHS through any qualified provider, they won’t be involved in decisions about funding allocations and the debate over whether funding should be weighted towards areas with greater deprivation or a higher age profile. These are among the areas that the Labour Party has fought over the last years, and believes that are most likely to damage the NHS.
Yet local health and well being boards also have significant powers, including the ability to refer commissioning plans to the NHS Commissioning Board, an important voice on reconfiguration decisions (a role they may not relish in the coming months) and an opportunity to carve out what integration actually means in practice.
One Labour councillor has made the case that health and wellbeing boards should have oversight of decisions that would move care outside of the NHS and to private providers. Edward Davie, Labour councillor in Lambeth, has recommended that any proposal for care to be moved outside the NHS is referred to the new health and wellbeing board to judge whether changes jeopardise overall provision for residents. This would be a welcome change for many Labour councils, and yet it seems like an unlikely change given the focus of the reforms. Any influence, then, may have to be focused at other areas. This could mean ensuring that local health and wellbeing strategies target areas of particular health inequalities. It could also mean local authorities really embracing their new responsibilities in the area of public health. If this were the case the power of Labour councillors would be extended significantly.
How Labour decides to use its increased local power in respect of health and social care will be critical (both for the party and the reforms). The message that Labour in local government would be the last bastion of resistance to the reforms is probably a better campaigning proposition than it is a philosophy for using power locally (Liverpool in the 1980s might attest to that). Some Labour strategists have argued privately that an ‘unleash the activists’ strategy could be a thorn in the side of the Coalition. This is true, but it could also be uncomfortable for the Labour leadership. Instead, the party should use its expanded local power base to develop and test a distinctive new Labour (yes, that was deliberately a lowercase ‘n’) approach to health, much as some areas did in relation to local government in the nineties.
We have written on this blog in the past about the need for Labour to develop a future-facing alternative to the Coalition’s reforms to health and social care. This could just as easily be inspired by local experience as it could be dreamt up in Westminster.