Sally Warren - Director of Policy, The King’s Fund

This article forms part of the LGA's Re-thinking local think piece series.

If we’re honest with ourselves, the history of the relationship between the NHS and local government has not been a story of shared endeavour. Too often it’s been a story of when the NHS wants something – efficiency, productivity, better patient experience – it comes to local government. And then it can disappear for a while.

Very rarely has the relationship worked in both directions, with the NHS contributing and partnering with local government to deliver wider local goals about wellbeing. Before the pandemic struck, there were the early signs that this might be shifting with some of the more mature integrated care systems (ICSs) really thinking about health in their places, rather than limiting their horizon to joining up public service delivery.

We know the places where people live, the jobs they have, the homes they live in, the local parks they play in, have a huge impact on a person’s health. So local statutory services need to work together to make sure the circumstances of people’s lives – those wider determinants of health – give them the best opportunities possible to live a healthy and happy life. But within this overall approach of supporting population health, we also know that people want individual services to be better joined up, so a person’s multiple needs are met in a way that makes sense for their lives, and not just what makes sense for statutory bodies.

So what we need is a relationship between the NHS and local government that is an equal partnership, focused on population health and wellbeing. The potential for a new relationship between the NHS and local government can be much more when the vision shifts to population health rather than simply managing sickness.

If we are collectively serious about delivering improvements in health and wellbeing, we need different relationships… 

…between communities and the public agencies that serve them 

…between the various public agencies that play a role 

…between local and national organisations, systems and sectors. 

If those different relationships focus on the outcome they wish to see, we could see communities with more power to drive improvements in the health and care outcomes that matter most to them; better partnership working and alignment between local authorities, the NHS and the voluntary sector; and national policies, regulatory structures and funding flows designed in a way that reinforces effective local leadership.  

We know that people want individual services to be better joined up, so a person’s multiple needs are met in a way that makes sense for their lives, and not just what makes sense for statutory bodies

This means a health and care system which is orientated towards people in places and communities, rather than towards Whitehall or even the town hall. Place- and neighbourhood-based partnerships can better respond to the specific needs and aspirations of a local area and think across the full range of local services and assets to help maximise the health and wellbeing of a community. Leading in this way requires a different frame of mind.

The Wigan Deal demonstrates how a council attempted to create a new relationship with its communities at the heart of its approach to service transformation – an explicit ‘deal’ that was clear about mutual responsibilities and expectations. Healthier Fleetwood is another example of focusing on building health from within the community – where the local primary care team has worked alongside local people across the community to support health and wellbeing to get upstream of emerging health needs. The need to re-orientate services to work within and alongside communities was one also of the main learning points from the response to the tragedy at Grenfell.

These kinds of transformations require energy, consistency over time and determination. They all have at their heart a different relationship between people and services. Often, they include a fundamentally different relationship with staff too. A common feature is the trust given to staff on the front line to do the right thing and know how to support individuals and communities. Trusting staff to understand their communities and respond innovatively to their needs and desires can lead to not only better health and wellbeing outcomes for the local community, but better job satisfaction for staff too.

Some of the more mature ICSs are grasping the potential for new partnerships to improve health. But they recognise this means needing to work differently. A key feature of ICSs is the emergence of ‘systems within systems’ to focus on different aspects of their objectives. This means that within the partnership that makes up an ICS, there are also smaller partnerships centred around more local areas and populations. These are important as ICSs tend to cover large geographical areas (typically a population of more than 1 million) so aren’t well suited to designing or delivering changes in services to meet the distinctive needs and characteristics of local populations. Far from being a traditional hierarchy, these arrangements are more akin to an ecosystem with many connections and interdependencies between the partnerships at different levels. Local systems are taking different approaches to deciding which functions should sit at each level.

So there are positive signs in the early days of ICSs that we may now be in a different, more collaborative phase of shared endeavour between local government and the NHS. But it would be remiss not to add a few notes of caution about future prospects of the relationship, given the often-troubled history to date.

Through the first wave of the pandemic, we saw clear fracture lines continue between the two systems. The Chancellor’s promise of ‘whatever it takes’ felt much more real to the NHS than for local government, who found themselves much further back in the queue for Rishi’s cheques (and the stated priorities for the forthcoming Spending Review risk repeating that mistake). NHS patients and staff got priority access to testing ahead of people using, and working in, social care. Directors of Public Health found themselves needing to battle to get access to accurate local data about positive COVID-19 cases to help direct local test, trace and isolate efforts. So, while we can take a lot of a lot of positives from the joining up of the pandemic response we saw at the local level, we also must recognise that too many fault lines still exist and make the relationship between the NHS and local government hard, creating too many unnecessary barriers to good local working. They are still very much two different systems that are often working together locally despite what is happening nationally, rather than because that join up is being reinforced by national rules and behaviours.      

If we are to believe the widescale briefing in the press, we also have the prospect of some form of NHS reorganisation looming on the horizon. The primary purpose and scale of this is not yet clear – it could range from targeted changes to legislation that the NHS itself has asked for, to wide ranging structural change. We know from past episodes of restructuring that the large-scale NHS re-organisation not only causes distraction away from delivery of services, it also sets back relationships within the NHS and with its key partners such as local government. This could particularly be the case if the focus is on systems at the expense of a focus on places within systems.   

We all agree that COVID-19 is a catalyst for change in our public services. What change it should accelerate is open for debate and presents a clear fork in the road for the relationship between local government and the NHS. Will it be more centralisation and a greater focus on sickness, or a more devolved approach, centred on population health and well-being? Given the scale of the challenge to improve the health of the nation and reduce inequalities, I very much hope it takes the road to health and not sickness.