Why we need to strengthen local authorities’ accountability for public health outcomes

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After a long delay, local authorities are now certain of their funding for the next two years. However, it came as a surprise to most of us when the Department of Health announced that total public health allocations to local authorities for 2013-14 would be 5.5 per cent higher than baseline figures, with an additional 5 per cent rise the following year. Within that total, each local authority will receive an increase of at least 2.8 per cent each year, and those authorities that the Advisory Council of Resource Allocation’s (ACRA) new formula defines as under-funded will receive more, for some 10 per cent extra in 2013-14 and in 2014-15. This is good news, despite some concerns.

But what are local authorities expected to achieve in the area of public health? Importantly, the public health outcomes framework gives a clear sense of the core resources available and the outcomes the Department of Health expects from those resources. But the accountability for spending money well is, at best, opaque and arguably not strong enough. This issue needs to be addressed given the healthy rise in funding for all and the stratospheric increase for some.

The Communities and Local Government Select Committee has spent a lot of time exploring the complex overlapping array of responsibilities, relationships and balance between national and local leadership in different areas of public health. At the heart of it is a reliance on sector-led improvement, a system based on peer review and support from other local authorities, with very little role for assessment by department’s of state or their appointed agents. Local authorities have won the battle of cultures on this, although the Department of Health will receive a basic report on how their resources have been spent.  Public Health England is also bending over backwards to say it is there to support local authorities, not performance manage them – very un-NHS.

But is this really sufficient when the nation’s public health and billions of national tax-payers pounds are at stake? The focus on outcomes as opposed to specific patterns of services (albeit with some exceptions) is right. In the best cases that will mean innovation in service delivery and undoubtedly there will be much more variation in services as a result. That won’t matter, as long as variations in outcomes do not increase. But what happens if they do? What if some areas actually see a decline in life expectancy or others see outcomes that don’t improve at all as a result of big increases in funding?

The answer seems to be that this will either be spotted and acted upon by hawk-eyed armchair auditor citizens poring over the outcomes framework, or by sector-led improvement. The former seems highly unlikely, at least in the short term. So, will sector-led improvement be able to take the strain? Not if the Draft Local Audit Bill ad-hoc Committee are to be believed. In its report on Pre-Legislative Scrutiny of the Draft Local Audit Bill, the Committee was scathing about sector-led performance as a replacement for the Audit Commission’s role in assessing the effectiveness and value for money of local authorities undertaking their functions. In particular, it was  extremely concerned about ‘...the absence of a formal mechanisms to identify poorly performing local authorities...’ when ‘...witnesses argued that a body representative of the taxpayer rather than the Local Government Association (LGA)...should be responsible for this work, due to the substantial funds that local authorities receive from central Government via taxpayers.

The Local Government Committee has just finished collecting its evidence on the role of local authorities in public health, after a lot of tortuous questioning of the minister for public health on accountability. Will it be as concerned as the Draft Local Audit Bill ad-hoc Committee at an over-reliance on sector-led improvement in delivering public health outcomes and value for money? If so, there may be a stronger role for Public Health England in performance managing the outcomes and value for money of local authorities than we all currently think. Now the funding has been decided, it’s time to move beyond the debate on the reforms and structural issues to what matters: assuring that the resources just announced really do improve the public’s health and reduce health inequalities.

This blog is also featured on the Local Government Chronicle website.

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Comment date
24 June 2015
Why we need to strengthen local authorities’ accountability for public health outcomes | The King's Fund
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Mark Gamsu

Visiting Professor,
Leeds Metropolitan University
Comment date
11 February 2013

I sort of agree with you and sort of don't!

I had a great deal of time for the Audit Commission - abolished by this government - which had a good track record of bringing some grit into the system through bringing some good evidence based challenge to local government as indeed does the National Audit Office. I am concerned with a couple of elements of your argument though.

First, there is already significant variation! - and yes there might be an increase or at least change - things are actually quite tough up here in the North of England at the moment - nothing to do with local government performance - more to do with government policy.

Second, we should be trying to move to more local citizen led accountability - yes it is difficult but local Healthwatch and other groups of active members of the public are required and we (including the Kings Fund) need to bend our efforts to making this happen. We should not default to Government led audit and performance measures. We know they bring their own baggage of political taint, narrow measures that only capture what we can measure etc.

Finally I am not happy encouraging PHE to pick up more of a performance management role. It is a mistake to just focus on public health funding here - it may seem like a lot of money - but it is only really a lever to impact on the much bigger local spend on the social determinants of health. As I said I see much merit in an independent evidence based auditor - but I think this should be generic and system level like the Audit Commission was - and more directly linked to key agencies like Healthwatch. If audit rests with a public health agency like PHE it risk becoming too inward looking and will lack impact and relevance. Remember - who in local government or the voluntary sector cared about SHA Public Health performance management systems!?

Mark Gamsu

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