Andrew Laird argues that councils should take the lead role set out in the government's intentions for 'place-based' health and social care integration. A version of this article was first published in the MJ on 11th May 2022 here.
Which public sector body has most impact on the wider determinants of population health? Clue: It’s not the local hospital.
The Health and Social Care Integration White Paper, which was published in February, sets out some important parameters for the future of place-based population health. Essentially, it’s all about shared outcomes and accountability with some warm words around pooled budgets.
Some outcomes will be set nationally but there will be space for local areas to agree their own outcomes specific to the challenges faced on their patch. The White Paper states that these outcomes should be designed by partners across the system, which should include councils and other key local players – not just the NHS. So far so good.
The White Paper also makes it clear that hospitals should be incentivised to support public health outcomes, and primary care should be incentivised to support social care outcomes. Even better.
Keeping with the tendency this government has, to want to be able to pick the phone up to a single person (see the push for more mayors), there is also a requirement for a single leader for each ‘place’ who will be accountable for the delivery of the shared outcomes.
My concern is that in most places this person will be someone from the NHS.
I would argue the primary outcome sought by any place should not be the successful treatment and recovery from a condition, but to keep people away from the NHS in the first place. That means a focus on prevention and the wider determinants of population health.
Let’s return to my original question – which public sector body has most impact on the wider determinants of population health? Housing, employment, provision of exercise opportunities, family support, or something else?
It’s not the NHS. It’s councils and their partners in housing and other support services. There are good reasons why the public health portfolio sits with councils.
The big local NHS players may argue that they are the biggest and should lead by right – but that does not mean they are best placed to provide the long-term strategic leadership needed.
The NHS, particularly acute trusts, tend to be focused on day-to-day pressures and as a result can be quite insular in their thinking and protective of their budgets. Generally speaking, the NHS does not have a deep understanding of place in the way that a council does. Hospitals usually cover multiple places, will have conflicting priorities and tend towards a medicalised rather than holistic approach. You could argue that GPs have a good grip on the individuals in their practice area – but their view tends to be individualised, medicalised and generally not across an entire ‘place’.
A key requirement for the single accountable person is the ability to ‘bring their partners together around a common agenda with decisive action in the interest of local people, even when it runs counter to organisational interests’. I think most acute hospital leaders, when faced with the day-to-day pressure of their world, would struggle to achieve that.
Councils are much better placed to lead on shared outcomes for a place. More often than not they will be geographically aligned with the place in question. Councils engage with the local population (especially families and communities rather than just individuals) at a greater number of interfaces and for a wider range of interventions, so are also better positioned to understand the wider determinants of health and to identify local needs.
They are also sufficiently removed from the day-to-day NHS fire-fighting to be able to maintain a holistic focus on prevention and encourage a longer-term goal of self-care.
Councils are the driving force for the levelling up agenda through co-production with local communities. As it stands, the NHS and health and wellbeing more broadly is not properly integrated with the levelling up agenda. Putting councils in charge of health and care ‘places’ would help resolve that.
There are many reasons why council leaders are perfect for this role – and many reasons I can foresee why this will be resisted – but I hope that in at least some areas we see council leaders being given this critical role.
To find out more about Mutual Ventures' work in health and social care integration click here.