Following the publication of LGIU’s report, Local Health Systems: Relationships not structures – commissioned by the Local Democracy Research Centre (LDRC) and supported by Browne Jacobson – parliamentarians, council leaders and chief executives gathered to hear about the report’s findings and recommendations for local government moving forward.
Panellists included Chris Clarkson, MP and Chair of APPG on Local Government, Mrs Paulette Hamilton MP, Anja Beriro, Partner, Browne-Jacobson, and Dr Jonathan Carr-West, Local Government Information Unit Chief Executive. Chris Clarkson MP chaired the meeting and gave time for each panellist to provide insights on the report findings before opening the floor for comments from attendees, both explored further in this article.
Comments from Jonathan Carr-West, Chief Executive, LGIU
This report examines what systems thinking is, practical steps that can be taken to implement these systems across local government and how they can work to improve the way we approach complex problems.
One of the key areas that we look at in this report is risk aversion. Local government is very good at assessing the evidence of not doing anything. But the reality is that we probably need to take more risks. We need to create conditions for behaviour change – how many organisations say that we want our people to take risks and fail and then manage that well? We need systems that allow people to change and we can’t build those on a shoestring budget. All of this work in an ongoing conversation with our partners so we’d love to hear what you agree with and also what you’d like to argue with.
Comments from Anja Beriro, Partner, Browne-Jacobson
When you look at local government and its partners, it’s as complex a system as you’ll find. That system is also misunderstood and broken at times. Systems thinking in local government is in its infancy and there’s a big opportunity for further process in this area. This report shows how there is already a lot of understanding in local government around why things need to change and why we need the frictionless movement of money and people through the system.
We can view the needs in the report in 3 areas: mindset, relationships, and resources – relationships and resources being the two that local government has the most capacity. As for mindset, leaders need to have the mindset to make changes across the systems. It’s important to have clear strategic objectives across an ICS area and then understand how they’ll be met and by whom.
As far as risk, it’s important to challenge our colleagues in local government to take more risks and to remember that new ventures always include risks. We have to shift our thinking, especially when it comes to the employees within our organisations. In Manchester, for example, there’s a lot more connectivity between employees and citizens. Local government allows us to see issues through so many different lenses and enables us to communicate with citizens better than anyone else.
In terms of resources, there really is nothing left and the central government needs to recognize that. The expectation is policy makers create radical solutions with no budget. There needs to be an understanding that local governments cannot be doing more with less – or nothing. The way funding is split up is extremely fractured at the moment and that needs to be realigned so that it’s consolidated into bigger pots that allow for more long term investment.
Comments from Paulette Hamilton MP
I was a councillor in Birmingham for 18 years as a cabinet member and covered adult health and social care for 7 years. When this approach was started, it was completely foreign and there was a great deal of mistrust. But I believe that it’s important to go on the journey to grow and change, for everyone from staff to leadership.
We need to change people’s mindsets because this can’t be about structures. It needs to be about services, relationships, and trust. I led on the health and wellbeing board and we were told that we would be an important group in the system. We then set up place boards that allowed us to give input and set the direction and funding. Not many authorities have done that – they’ve tried to work through the original system which means that local authorities don’t have any say in how funding is spent.
My recommendation is to be prepared to give a little bit to gain a lot. But in return, demand the understanding of what you will gain in return for that sacrifice. Local authorities are struggling after 12 years of austerity. There is very little slack left in that system and we need to be prepared to trust each other and understand where we’re trying to get to, knowing that we could fail. But we can brush ourselves off and continue to look at the best way forward, and find incredible success.
Core discussion areas following thoughts from audience members:
Q. Cllr Piers Allen asked, “an editorial yesterday recommended that NHS England should suspend “at place” level until July. Do you feel it’s a risk-averse or pro-risk recommendation?”
It feels like risk aversion leading to greater risk. The dialogue moving forward needs to be about making the system work on a journey. This recommendation feels like a bit of a rush to a destination.
Setting limits on an organisation or structure before they’ve even started will set them up to fail. Many organisations will fail but it’s important to give them the time and space. From my experience, many organisations won’t act out of fear for the repercussions of failure.
It’s very late in the day to be making that suggestion because that’s where so many ICSs are headed already. There has to be a beginning on the journey and it goes back to trust and this may not create good relationships at the beginning.
Q. Cllr. Margaret Thompson noted, “There are two barriers that come to mind which aren’t obvious. Firstly, we use the same words but don’t mean the same thing. We also believe that our assumptions are the same as others’ assumptions. The current systems and structures have been set up by people who like each other and believe the same things. Those systems need to be strong enough to withstand new groups coming in.”
I completely agree that it’s important that we have a consensus when creating these structures for their longevity. I’ve worked in health all my life so I feel like I understand the language used. When I work within a local authority, not everyone will understand that language. This is another reason that it’s so important to bring others like staff with us instead of pushing ahead. This is a massive change and we don’t know the ripples it will have.
This is why it’s so fundamental for everyone to be on the same page before structures start to get built up because if everyone understands the language being spoken, we can begin to break down actual barriers.
Systems and relationships are not enough without systems and systems are not enough without relationships. This also goes back to relationships and how we think about them. We need to shift to a more systemic thinking event with our relationships. And this relates to more dispersed leadership within our systems, mindful relationship building, and more robust relationships.
Q. Thelma Stober of the Local Government Association commented that, “partnerships with the NHS need to be equal. We won’t see total integration until we look at the various legislation that intersects with local government, health, and social care, and the NHS. Forget about the walls between organisations and focus on the purpose of each organisation. People want to integrate but are concerned about their own statutory responsibilities. How do you address the politicians, and different political views when you’re changing things on a system level?”
The legislation isn’t quite there to help us move closer, which is why it is going to be a fluid working relationship between organisations. The NHS is still very target driven, plus local authorities have to end the year with no budget. Certain things need to happen over the next 12 months so that we can reach true integration. What we see in July will not be what we see over the next two years
There are some limitations in the current legislation around ICSs. One of those is that while the ICB can delegate functions of the committees, local governments can’t. There seems to be a lack of consensus when it comes to those functions. We will see the integration white paper, the single accountable person, how an ICS actually works, and other parts coming together over the coming months. The legislation as it stands is not as helpful as it could be.
I love health and wellbeing boards but the issue is that the boards never have a full understanding of their capabilities. A place board will take us further because it has more finances and functionality. If we have crossover with other boards we can have a better understanding and make more progress. We also need ongoing training, development, and direction of travel like the LGA is offering and we need the training for local politicians when it comes to health and social care.
Q. Aileen Murphie of the National Audit Office noted, “Underneath all of this, the problem is money coming together from different organizations. There is something about whose money it is, who gets to control it, etc. Risk aversion. If you don’t tend to people’s needs when they have them, they get worse. People will gravitate to the most expensive areas of the system. Then you have people going out into the community into a broken system.”
Within that system, the most important thing is working toward the same objective.
There are complicated questions like do we have the political will to create such a system. It’s not like we don’t have governments’ challenges and failures to build off of. So let’s do it and work out the kinks. It also reflects on our point about relationships and we shouldn’t rely on chance or serendipity. But it’s about how we move toward brilliant people connecting to a systematic approach
Yes, the budget can be handled by accountants, but if we handed over the budget for Health and Social Care, we still would go over the edge. We can see that with mental health and disabilities services, there is already some integration. But the entire budget is a big budget and I’m not sure if the savings and money would get where it needs to go. We’re nowhere near where we need to be. Local authorities are the junior partners in this and the NHS are the beasts. The government has said that the NHS will get the budget and then the leftovers go to social care.
Q. One policy advisor mentioned, “I’ve spent the last few years fighting for social care reform. Historically we’ve seen a top-down, clinically led, national approach. Systems thinking needs to examine what you put where. No one in the world has done it successfully.”
You make a valuable point. Arguments like this one are easy to ignore. But just because it hasn’t been done doesn’t mean it’s not worth starting the journey.
If an integrated care system or any system works properly, there will be different things going on at different levels. It’s important to find a balance somewhere in the middle when seeing to make progress.
Q. Kedesha Vassell of Cancer Research UK asked, “we focus on preventative health. What is the role of organisations like Cancer Research UK in this integrated approach?”
Organisations like this haven’t had much of a role. But going forward, we hope to introduce more third sector organisations and people at the locality level will be introduced at the place and health and wellbeing board level. Not enough has been done to bring forward organisations like this but we need to do more.
Further opportunities to ask questions
Please feel free to direct any questions to Dr Andrew Walker, head of the Local Democracy Research Centre at firstname.lastname@example.org and he would be happy to discuss the report further. And we look forward to hosting further events on this topic and others. Get in touch at email@example.com to let us know what you’d like us to cover.