As the dust settles after the Spending Review, the coalition government's determination to shift power away from central government is becoming clearer.
Citizens, communities, and independent providers will be given a greater role in shaping services. Funding to local authorities and delivery bodies will be radically simplified, giving them a greater choice over how they spend their money to meet the needs of local people. There is a specific proposal to establish community budgets in 16 areas that will combine separate departmental budgets for families with complex needs, and this will be rolled out to all local areas over the period of the Spending Review. And NHS commissioners will be given £1 billion by 2014/15 specifically for services that support social care and improve health.
These plans all draw heavily on previous thinking around place-based budgeting.
Earlier this year we brought together some of the key NHS and local government players in the original 'Total Place' programmes – a Treasury-led initiative to explore how local public services could achieve better outcomes for neighbourhoods through a single, shared approach to resources. We heard from three of the 13 pilot sites where the local NHS had been substantially involved. The messages were upbeat: participation was described positively (a good thing in itself) and a range of benefits identified, including savings on the cost of care packages, care closer to home, better integration of child health and children's centres, and dramatic reductions in hospital admissions and the number of drug users returning into the system.
But three major caveats emerged about how these gains can be secured in practice.
First are concerns about how to deliver the savings needed from public services in fairly short time frames. Contributors at the conference were candid in recognising that it is one thing to calculate the potential for large savings, but quite another to achieve them when they involve radical system change that could take years to embed.
Second, the proposals in the NHS White Paper herald a period of organisational change. The abolition of primary care trusts potentially threatens the ability of the NHS to contribute to place-based solutions – GP consortia are unlikely to cover the same area as local authorities. If their commissioning budgets are excluded from the place-based budgets it is difficult to see how this will improve the integration of local services.
Third, much will depend on the quality of leadership across the NHS and local government to take forward the controversial decisions about reconfiguration, decommissioning and reinvestment that contributors described as the logical next step. The engagement of clinicians, especially GPs and public health directors, was seen as vital to success, as was winning the confidence of a wide range of professionals in providing care closer to home.
The Spending Review outcome injects new urgency into this debate. As we enter the toughest financial climate most of us can remember, the NHS and local partner agencies are in this together. A place-based approach to achieve better use of resources – including the closer integration of health and social care – is now an absolute necessity not an optional extra. The question is not whether these obstacles can be overcome but how.