The Wider Context: Local Government in England (Associate Learning Sessions 'Script')

Welcome to The Wider Context, an opportunity to explore the outside influences on our work in Population Health.

A series of sessions that takes the time to discuss how government policy, research and best practice, influences those who work within Population Health. 

In this session we will explore Local Government in England.

If you thought the NHS was complicated, scratching the surface today will expose you to even more complexity and accountability.

In this session well talk about how Local Government is structured, operates with Healthcare services, and how should we, and our programmes, work with local government to drive improvements in Population Health.

Healthcare services cannot drive improvements in the wider determinants of health themselves. And it’s in this area we need to make the biggest gains if we are to improve a populations overall health.

For working age populations, having a good quality job has a bigger influence over your health and wellbeing than the health care services you receive, so how do we support this to improve the lives of 36 million working age people in England?

Having systematic bin collections, clean water and quality sewage systems, as a short list of local authority interventions, has save more lives than across a population than its healthcare system.  

Preventative health care has its origins in local government, but as a society completes its large-scale primary prevention infrastructure projects, how can government work with health providers to continue to improve the quality of life, morbidity and mortality of the population?

And what does this look like in England in 2020?  

A council needs their partners in the health and care delivery to help address the social problems in people lives that heavily influence ill-health; smoking, obesity, poor screening and immunisation take up, employment, and working towards prosperity to improve outcomes population wide.

And the NHS needs the council to provide the platform in which people can thrive to live happier healthier lives. The two cannot work as silos, and we see this developing as national policy develops integrated care systems (ACO style systems to make a US comparison) to allow the organisations to more formally work jointly to address the wider determinants of health.

For statutory reporting purposes, there are 152 local councils in England. In comparison there are now 130 clinical commissioning groups, CCGs, for the NHS.

I use the word ‘local government’ and ‘council’ inter-changeably, because for most of the real world they are interchangeable. The council is the structure of the local government; that is the local representatives elected to be ‘the voice’ of the local people, supported by their local ‘civil service’ and permeant secretaries and directors.

There are similarities between the national Westminster government and local councils, and we will discuss this.     

Local government touches the lives of everybody, every day. It is responsible for vital services for people and businesses; Among them are known functions such as social care, schools, housing and planning and waste collection, but also lesser known ones such as licensing, business support, registrar services and pest control.

In England more than one million people work in local government, and, on average, each area provides 800 local services.

Local government is split into different tiers segmenting their responsibilities from the macro to the micro; there are currently:

·        25 county councils.

·        188 district and or city councils

·        57 unitary councils

·        33 London councils

·        36 metropolitan boroughs

·        10 combined authorities

·        10 National Park councils; with responsibilities above, and in addition to, a ‘normal’ council; for the conservation of scenic areas.

These are run by 17,700 elected local councillors, and a million local civil servants (they are the council workers).  

There are also 9,000 parish councils; served by 80,000 parish councillors.

All elected on manifesto’s they need to deliver.

The NHS is a very top down organisation; the national government dictates to the department of health and social care, which regulates through NHSE/X/I. They give the money to the CCGs to ‘buy’ health care services from ‘quasi’ independent / private providers; the NHS trusts and GP practices. The NHS, for the most part, dictates regulations.   

Local Government is driven by politics and are completely independent from those who may be seen above or below them in council category ‘top trumps.  

National government can’t dictate to local government, only provide guidance, and guidance doesn’t have to be followed, its only a guide.

National governments must make laws for local government to comply, and this is a more complicated process than issuing annual contracting and strategy as the NHS does. 

Whilst councils have a list of services, they ‘must’ provide there is guidance on how to provide those services, not dictation; this leads to a lot of variation in the quality and quantity of services across the country.

Councils are governed by the people and democracy, not so much national government policies.

Politics and party-political cooperation rule local government.

Everybody has at least 2 tiers of local government, with responsibilities of local services divided between them, but there is huge variety is the size and shapes of councils, we cannot presume they are similar, and not recognising the differences between areas can be the failure of services and their providers.

Cumbria county council is ‘up north’ contains the Lake District national park, covers 2,602 square miles, population of 492,000.

County councils are the upper tier councils and provide more strategic and high budget, high cost, services.

County councils are responsible for: education, highways, transport planning, social care, libraries, waste disposal, public health, and strategic planning.

For some scale of size, Westminster council is a district / city council, covers 8.29 square miles, and takes 20 minutes to drive across, it can take 2 hours to drive across Cumbria.

Westminster has a population density 16,658% higher than Cumbria, 31,483 people per sq mi to Cumbria’s 189. This brings its challenges to Cumbria to deliver the same services to its population as more urban councils.

Adding to the complexity of this services delivery, is the six second tier councils within Cumbria county council, the 270 parish councils, and the two non-terminus integrated care systems that split the county North/South;

North Cumbrian’s are part of Great North Care Record (GNCR) and head east for health services, South Cumbria will be part of Healthier Lancashire and South Cumbria.

Each layer local government, excluding the ICS as these remain non-statutory organisations, has its own leader, manifesto, and elected members, setting out the direction of their area of the county.

I’m sharing this granularity to show the complexity of democracy. Excluding, a few services which are defined in law, services are provided through guidance so each area, and layer, can decide how to deliver the services, or not deliver them, within reason how they like.

The leadership is accountable ‘to the people’ if the people don’t like it, the leaders lose their jobs at the next election.  

And each layer of government is also independent, it isn’t accountable to the one above or below. The leadership of that area has been elected to deliver its own manifesto.   

They are all independent.

Its Political collaboration that defines what’s done across the different layers of local government. Most elected members will be affiliated to a political party and will follow what is put in the national manifestos and are able to follow the leadership of the party; top down, national down to local.

The independence from each other and the separate elections from national to local governments is why there can be a conservative national government, but a Labour council, and the council rejecting the national leadership. This could be seen during Lockdown with local areas refusing to re-open schools in the summer term. The government can’t make them open the schools because the council controls the local education system.

National government has advised schools should re-open, but it is the local government that must be satisfied the situation is safe, because it is those local elected members who are accountable.

But this is where politics and political pressure wields its dark arts. Who will the public blame or praise for the COVID responses? Politicians at all levels want to be re-elected, and there is a balancing act for them to play, to, essentially, keep their jobs at the next election.

We need to introduce another layer of, again, separately accountable governance.

Combined authorities, like those in London and Greater Manchester, may or may not have an elected mayor as the figure head, but these organisations are a group of local authorities that have decided to work to provide region wide government to share responsibility for certain services.

Transport such as TfL, and the tram network across Greater Manchester are examples of where all the local authorities have clubbed together to invest in infrastructure. The Greater Manchester Combined Authority, for example, has been working on direct freight flights from Manchester airport to China, feeding the Northern Powerhouse.

The combined authorities are becoming more relevant to work in Population Health / Integrated health and care as they are developing into integrated care systems. Greater Manchester controls its  ￡6bn health budget. This is important because it transfers the power over the finances from the department for health, to essentially, Manchester’s own local ‘department for health’. They are locally accountable for their own ‘destiny’.

The national scrutiny that applies to everyone else doesn’t apply in GM. This means it can move faster and be bolder in its decisions. For example, GM procured the first step towards population health management in Aug 2019 for the all of the CCGs and the local authorities with its own money.  

Next are the MPs, the members of parliament.

These people are neither members of the local council, or the local civil service, they are separate (again), they are the wider areas representative at the national parliament.

Think of them as the one person the area sends to London to represent the them at the national level.

They are not accountable to any level of local authority council.

We have a lot of representatives; This is why we have so many election days.

If we look at the minister of health and social care, Matt Hancock (in 2020), he represents West Suffolk at a national level, but at a local level west Suffolk is split, and represented by, the 72 local councillors. Who run the council separate to Matt Hancock.

Whilst this may seem complicated, it’s about local power, for local people, local government.

And people take it very seriously.

We know how national government is structured; Ministers, prime ministers, house of commons, select committees to hold ministers and their departments to account, and parliament to hold the government to account.

In West Cheshire, where the Countess of Chester hospital is based, the council has 70 seats at each local election.  

These seats are filled with the elected councillors and are divided into political parties, the same as the commons is. First past the post wins, and the party with the most seats gets to form the local government.

You need at least 3 members of a local cabinet, the leader of the council (local prime minster), someone for finance (local chancellor), and a secretary / deputy leader (local leader of the house). There are then additional members of the local government (the council) who are given portfolios, which would be equal to the ministries at a national level.

The only difference is there is no local ministry of defence, as this is the only function retained by national government.

But why bother with all the faff, just have the national government, and do what they say, in real terms, the council probably will anyway because they will be following the direction of their nationally affiliated political party.

The reasons are partly historic, and I will try and sum up  a concise overview of 550 years of English history in 2 minutes.

In the 15th century, when royalty was divine, there was not a clear line of succession to the English throne, and anyone with family ties to the king could try and claim it upon his death. In 1455 there were 2 main factions who believed they have the right to rule; house of Lancaster, the Red Rose, and the House of York, the white Rose.

In 1450 there were concerns about the King of England’s lack of an heir to the throne, which revived interest in the York's claim to the throne by Richard of York, but we now know how this story ends for him, under a council car park in Leicester.

By 1453 the King had a son, but he had become unable to rule, Richard of York named himself de-facto King; the Lord Protector. Violent fighting in 1459 between Lancaster and York over the crown, forced Richard to flee the country and Henry of Lancaster was named King.

Returning to England from Calais the following year, Richards supporters captured and imprisoned King Henry, putting Richard back in charge, with the actual King now dead, Richard 3rd is crowned.  

The previous Queen, a bit miffed her own son wasn’t King, gathered an army in the North, killed Richard and his Son at the Battle of Wakefield, just there near the pub and the modern-day Land Rover garage, and freed Henry.

A few months later, Henry of Lancaster is captured, again, and put in the tower of London. Yorkist, Edward 4th is made King. But King Edward, a white rose, secretly marries the daughter of an opposition leader, a red rose, driving his original supporters to switch sides.

This new opposition army assemble in Tewkesbury, next to the leisure centre, led by the previous Queen, where they are slaughtered, the old Queen is captured taken to Tower of London, where Henry, the now last surviving Lancastrian, has his head popped off.

Years later, Edward 4th suddenly dies, ending the Yorkist reign, and Henry the 8th‘s dad pops over from France, tells everyone he’s the rightful King, puts everyone else in prison, marries Elizabeth of York combining the two families and ending the war.

The moral of the tale … Northerners hold a grudge? … for 500 years?! about, basically, still not being King, But no its about refusing to pass power to London and establish their own local governments and ‘parliaments’ ‘up north’.  

Now we call them councils.    

And this doesn’t stop at being a bit annoyed for several centuries, and copying the décor of the London Parliament, in York and Lancaster, the local leader of the council also gets a ‘throne’; a fancy chair normally.

At some point, in those intervening 500 years, around the industrial revolution, people start to think, they should have their own parliament councils…

This is a bit more serious through than fancy seats and gothic architecture.

The people elected to these institutions have the position to be able to hold their local services to account. They represent the people, not an organisation or government department.  

And I would ask how often we have this layer of local government governance and accountability incorporated into health policy and development projects?

The NHS is ‘minimally ‘held to account by the people it serves in comparison to the council. This appears to be reserved for top level ministerial questioning in the commons on health policy implementation.

There are attempts to bring health services under the scrutiny committees of local council services; this is the equal of a parliament select committee.

The health and wellbeing board is accountable to a council cabinet member, and the move of public health into the council holds the director of public health account. CCG chairs attend some council scrutiny committees.

As population health projects move outside the acute and into the community, into social care, and into primary prevention services under public health, are they organised robustly to allow projects to be politically scrutinised?

Health does work with council colleagues and leaders. More so, now data is uploaded and onboarded for adult social care services, but these relationships can be difficult to forge and maintain.

If we begin to think about why it may ‘appear’ that improvements in NHS quality and performance health metrics, may not be at the top of a council leaders’ agenda.

As a minimum there are c.800 services which councils must provide, but the list of services can grow to nearly 1,600 depending on the size, geography, and tier of local authority. Councils have minimal statutory services but many guidance documents; imagine working for a team where the short list of a short list is 800 items, of a huge long list.  

How can an organisation target improvement in specific area, even as large as health, whilst it also has to deal with: abandoned bicycles, cave rescues, counter terrorism and controlling the movements of the local pigs!

If a council was a business, it wouldn’t be able to survive with such a diverse portfolio of services.

Consultants would be advising to either concentrate on the implementations of the Care Act 2014, or Horse passports, not both.

And this is without worrying about finances.

Local government expenditure is about ￡96 billion a year and is where austerity really happened.

A council has 2 major income streams, money it makes from council tax, business rates, and car parks etc, and a second as a government grant.

The government grant was cut across the board post-2010, and as the effects of recession leech out across the economy, those councils in more deprived areas saw a reduction in the first stream of money as well as the second, as the people who lived in their areas lost their jobs, had benefits reduced, and those in hardship with no expendable income, that previously may have gone to the council car parks and paid for services, now go to the council to ask for financial help and support.

You have a situation where the income is dropping and expenditure is increasing, and this is effecting the areas already disproportionally ‘underserved’, the effects on real peoples lives just get worse and worse.

And it’s no longer hear-say, as a report was released early this year to very little fanfare, that austerity was a political choice, not a necessity, it hit the most deprived regions the worse, and reduced life expectancy in those areas, it punished the poor for the financial crash; Marmot: 10 years on.  

This is very serious; Life expectancy doesn’t go down in developed countries.

The last time there was a reduction in the UK was because there was a world war going on. For 70 years life expectancy increased year on year, until austerity.

This links to the important financial rule for a council; that a council cannot post an end year deficit, its illegal; the cabinet are accountable. If finances are so bad a full council meeting is called and a section 114 is voted on; this is a dramatic cut of all none essential services: immediately, and a significant increase in council taxes.

This is much more serious than an NHS acute trust posting a year end deficit, where services continue the next day.

You may have seen some councils proposing the solution in response to COVID-19. Their 1st line income reduced to almost zero as a result of lockdown and costs increasing as demand for services, such as social care to clear hospital beds, rises.

Its not all doom and gloom though. Some areas have been in this position and had to think radically to save themselves.

Recently in a series of podcasts and discussions about the changing face of primary care, there are  podcasts about Wigan and the Wigan deal. Faced with unprecedented financial situation where even enacting a section 114, and basically closing the council down, wouldn’t have saved the finances. They had to do something different, and this was to change who and what the council was, they struck a deal with the people of Wigan and both had to make sacrifices.

And these situations bring up the question about what is a local authority and what should it do? Does it provide services to serve the people? Or does it create the platform to which others can provide the services? Is it the market seller or the actual marketplace?

It is difficult to replicate, and maybe its something unique to Wigan, but if want to know how they got themselves out of an impossible hole and improved outcomes along the way, the podcasts are available via the Kings Fund. Not all councils would have been able to turn it around like Wigan did.

Why are the finances so tight for some councils?

One of the biggest areas of expenditure in a council’s finances is social care. There are estimates some councils spend 60% of all income on care.

When we talk about social care, people normally mean adult social care, services for people 18+ .

Adult social care covers a wide range of activities to help people who are older or living with disability, physical, or mental illness live independently. It can include ‘personal care’, such as support for washing, dressing and getting out of bed, as well as wider support to help people stay active and engaged in their communities.

Social care includes support in people’s own homes (‘domiciliary care’); day centres; and care provided by care and nursing homes (‘residential care’); ‘reablement’ help people regain independence; providing aids and adaptations for people’s homes; providing information and advice; and support for family carers.

Adult social care can be short or long term; with support between discharged from hospital and returning home, to intensive nursing care.

Unlike the NHS, social care is means tested; if you have more than ￡23,250 worth of assets, usually a home, you will need to contribute towards the cost of your care.

Local authorities spend ￡22.2 billion a year on adult social care, up year on year, as demand for services increases.

In 2018/19, 841,850 adults received publicly funded long-term social care, primarily in care/nursing homes.

1.5 million people worked with them in adult social care across England.  

In that year, local authorities received 1.9 million requests for support from new clients. 75% received some sort of help from universal services or signposting, though only around 25% were assessed as eligible for formal care.

550,000 requests were from working-age adults, where only 18% received formal care.

Demand for services is set to continue above increases in budget, However, demand for social care is not driven exclusively by an ageing population and the projections by the Kings Fund; the prevalence of disability among working age adults has increased from 15% to 18%, whilst remaining stable at 44% for older people.

There has been a significant crisis building in social care, and a Green paper strategy from the government has been delayed for years. In response to COVID the department for health and social care have announced there will be a strategy, and local leaders are beginning to think about how they can continue to monitor people as they leave the health and enter the care system.  

The 2nd key service which works closely with the health services is Public Health.

The branch of medicine dealing with the population’s health and wellbeing, including hygiene, epidemiology, and disease prevention. That is both communicable, and non-communicable diseases; COVID-19 and cardio-vascular disease.

Every local authority must have a director of Public Health, a senior C-suite executive whose role is to promote health and wellbeing.

It is said there can be no wealth without health, and if a council is to be prosperous it must be healthy, a healthy working age population is needed to drive the local GDP, and keeping people healthy means primary and secondary prevention, working with both the payers and the providers of health and care, to ensure people are healthy as long as possible, and if / when they become ill the receive the best care without variation.

This started in1875 with the worlds first public health act, here in England; it introduced bin collections, sewage systems, and bans on disease spreading practices and poor hygiene, free access to park and green spaces, and the first publicly own park, and inspiration for New York’s central park in Birkenhead.    

And most recently the 2012 health and social care act set out the legal requirements of this function we see today:

·        Responsibility for commissioning Screening and Immunisations; this includes the childhood immunisations but also those for late life cancers.

·        Weighing and measuring children, an important function supported by the health visitors services, the first year of life is very risky, and has a higher mortality rate than any other childhood years, so it keeps babies are safe and well.

·        NHS Health Checks; a much-underrated programme, but the worlds largest CVD prevention programme, to date 15 million adults have been screened for their risk of heart attack, stroke and wider CVD related chronic diseases, and offered behavioural change therapies to address their issues. So significant is this programme there would be a need for primary legislation to change its parameters and delivery, no other programme or workstreams across health and care receives this level of legal protection.

·        Sexual health services cover STD’s and safe sex, HIV and AIDS, and family planning.

·        Fifth; Protecting the health of the population.

I’ve included the sub-text here as this is, I believe, one of the ways to inspire local government to engage with health services development:

“

Each local authority shall provide information and advice to every responsible person and relevant body which exercises functions to the area

”

This relates to the advice given to local authorities and NHS on response to pandemics, which is why we see local authorities leading the COVID responses, but also on inequalities and unwarranted variation.

How can a director of public health properly discharge their duties when their populations are dying early and living longer in ill health? The unwarranted variation is a massive public health issue in the 21st century; between 2016-18, in England, 475,000 people died prematurely.

Population health solutions can help address this variation at a person, micro, and macro level. A director of public health should be very interested in what the health system can offer in advanced analytics and tackling variation across a system.  

Population Health is the health outcomes of a population, including the distribution of the outcomes within that group. Population Health management is further defined as managing the health of a population using data to predict, identify and manage the risks.

This is definitive director of public health territory. The role of the public health consultants are able to position and act upon risk modelling, and the use of combined data, to support tackling the wider determinants health, therefore creating the greater gains in population level improvements.

Population health is an approach which can address primary, secondary and tertiary prevention, supporting improvements in mortality and morbidity.

The population improvement gains come outside the hospital, within the new roles the NHS is investing in; in community pharmacies, social prescribers and with partnership working between health, and care, and the local authority.  

Leadership across the council, which has the influence across policy, the community, via the local councillors, can drive local level structural interventions.

We should think about how we can influence local government organisations, and how we can bring the council leaders into projects; public health, director of adults social services, the local councillor with the health portfolio and the wider council cabinet.  

Looking at our work, we have progressed well, urgent care, GPs, community, and over the past few weeks social care. The system needs to start to move towards the left.

The local authority will already be working with many organisations and the local councillors can be the gateway to connecting improvement projects into wider communities.

Example; the council sets business rates and have a history of promoting good health through retail. The healthy high street programme aims at reducing high fat, high cholesterol fast food.

Public health works with the organisation of vaping retailers to support smoking cessation pathways, of which vaping is a route to reducing tobacco smoking.

Working with faith organisations to interact with vulnerable groups around drug, alcohol, and mental health problems, using temples, and other religious settings, to recruit people to health checks, and support childhood immunisations.

Providing free leisure centres passes as motivation during weight management classes. Conducting screening, immunisations and sexual health sessions in schools.

And local authorities who have large employers, such as factories, or international businesses, can promote and support wellbeing of employers directly, but also promote the platform to which those business can thrive, ensuring they are able to offer high quality work.

How do we influence our councils?

Ensure the council is included in health project governance from the start, director of public health as a minimum, value the public health consultants input as much as acute clinical consultants, and to think differently, more about the population’s lifestyle transformation, as well as medical optimisation. Its win / win. The councillors like the results and buy into more solutions / projects, and begin to move more into the wellness arena, replicate results and success from international research and peer review progress.

…

Thankyou,

Next time I’ll be exploring in some depth the most important public health document of the past 20 years.

The reasons why the life expectancy in England is decreasing, how the crushing effects of poverty make this even worse for people living in the most deprived areas.

And how this applies internationally, health inequalities are not a British pastime; The Marmot review 10 years on

Thank You for listening, if there have been any questions please reach out to me.

Thank you for the time, I look forward to the Next Session of The Wider Context.