Of course, we don’t yet know whether the pause will result in fundamental change or marginal change. If the changes to the core of the bill are not radical, then councils will still need to adjust to working with a more diverse range of health providers, in a more competitive environment. Whether there is an inherent contradiction between more competition (and greater independence and financial freedom for existing bodies, such as foundation trusts), and the thrust for greater integration between health and local government, is debatable, but there must be concerns.
It is likely that the form of the GP consortia will alter – with probably a wider membership from clinicians who are not GPs, and perhaps some patient representation. It still looks like the government would resist local authority, and specifically, elected member representatives. Though the Liberal Democrats may push for this? This leaves open the key issue of accountability. There will, very likely, be concessions about the need for consortia to be more open bodies, subject to Freedom of Information rules and to be held in public. Councils will need to ensure that they do indeed act in ways that give the public access to the critical decisions they will make.
What about health and wellbeing boards (HWBs)? The boards are one of the few reforms in the bill that have received almost universal approval. However, as proposed in the bill, there are questions over how powerful they can be when faced with the new consortia. The pause should give the government time to reflect on how the boards could answer some of the criticisms of the bill – particularly, handing most of the budget to fledging consortia. If the boards powers are strengthened, could they act as a powerful check on them?
There could be more radical solutions to the tricky issues of accountability and integration. Indeed, the Health Select Committee, in its April report, proposes that GP commissioning consortia should become local commissioning bodies, to be called “NHS Commissioning Authorities”, which would contain. a majority of GPs, but would also include local authority representatives, including the Director of Public Health, a social care professional and an elected member, and representatives of other clinical perspectives including secondary care clinicians and nurses.
The committee say that these new bodies would make the need for health and wellbeing boards redundant. The preparation of local strategy for health and social care provision and promotion of integration in health and social care delivery would be “shared” jointly amongst the NHS Commissioning Authorities, local authorities and the new Public Health England…
There are some obvious attractions in this plan – it gets over, for example, the potential confusion of accountabilities between the HWBs and the consortia. But would the local authority representation be enough to prevent the clinical dominance of the new body? It doesn’t look like it. The main objection must be that abandoning the boards misses the point – of recognising the crucial role of councils in tackling the wider determinants of health and wellbeing.
So if the select committee has got it wrong, what should happen instead? At a minimum, the GP consortia need to be much more accountable, through the legislation, to the boards.
What is encouraging over the last few weeks is that these issues have not been drowned out by the more furious debate around competition and private providers. Accountability to local people and how local authorities and health can work in genuine partnership are crucial elements of health reforms, and there is still much to play for.
