Written evidence submitted by the Local Government Association (HSC0011)
1.1. The Local Government Association (LGA) is the national voice of local government. We are a politically led, cross-party membership organisation, representing councils from England and Wales.
1.2. Our role is to support, promote and improve local government, and raise national awareness of the work of councils. Our ultimate ambition is to support councils to deliver local solutions to national problems.
1.1. The LGA has a successful track record of supporting councils and their partners in the NHS to develop a shared vision and joint action to improve the health and wellbeing of the communities they serve.
1.2. This White Paper provides a promising base on which to build stronger working relationships between local government and the NHS, as equal partners, to address the wider determinants of health and deliver better and more coordinated health and care services. We will be working with councils, the Government and NHS England to better understand the full implications of these wide-ranging proposals.
1.3. It is also good there is renewed focus and commitment on existing local partnerships and accountability, especially at place level. We support placing Integrated Care Systems (ICSs) on a statutory footing and the creation of an ICS Health and Care Partnership to work alongside statutory NHS bodies. We will continue working with government to ensure clarity on their respective roles and responsibilities.
1.4. We welcome the recognition of place as the level at which most of the planning and delivery of care and support services happens. We also welcome the commitment that, wherever possible, the place should be defined by local authority boundaries. Making decisions as close to the people they affect needs to firmly embedded into the way we work together.
1.5. The LGA supports the government commitment to legislation which enables flexibility and variation in recognition that all areas are different and will require different governance arrangements. Many of the proposals within this White Paper will be achieved through secondary legislation and guidance which will support the NHS and local government to develop arrangements that are appropriate to their own areas.
1.6. It will be important that Government co-produces any guidance that affects local government with the LGA and councils. We would like the Government to make a commitment on the parliamentary record to work with us on this guidance.
1.7. It is also important that any future accountability mechanisms build on and enhance existing local democratic accountability, not bypass or undermine it. Local government needs to remain directly accountable to our residents.
1.8. Some of the proposals, particularly in relation to public health and adult social care, have not been subject to public consultation or engagement. It is important that Government commits to an inclusive consultation and engagement on any proposals that have not previously been in the public domain. These changes will impact some of the core functions of local government, so it is crucial the sector is fully engaged.
1.9. Adult social care has continually demonstrated its value as an essential local public service in its own right over the last year and it is helpful that the White Paper acknowledges the pressures facing social care and the need to address its long-term sustainability and reform. However, such acknowledgement only goes so far and it is disappointing that the Government’s immediate priority for social care is to strengthen national oversight of care and support, rather than bring forward its long-awaited wider funding reforms to support people of all ages to live the life they want to lead.
2.1. It is important to distinguish where ICSs relate to the ICS NHS body - that is primarily concerned with ensuring that NHS organisations work collaboratively to achieve the triple aim of better health and wellbeing outcomes, better quality and safety and better use of resources; and where it relates to the ICS Health and Care Partnership - which is responsible for bringing together a wider partnership to develop a system wide plan for health, adult social care and public health for the whole system.
2.2. Concerning both parts of the ICS, we hope that the new proposals around ICSs will support councils and their partners in the NHS to develop a shared vision and joint action to improve the health and wellbeing of the communities they serve. This White Paper provides a promising base on which to build stronger working relationships between local government and the NHS, as equal partners, to address the wider determinants of health and deliver better and more coordinated health and care services.
2.3. We welcome the recognition that each ICS will need to agree how the ICS NHS Body and the ICS Health and Care Partnership work together and be held to account through the different accountability mechanisms for local government and the NHS. It will be important for any new national accountability mechanism to build on and enhance existing local democratic accountability, not bypass or undermine it.
2.4. Regarding the ICS NHS body, we know that CCG commissioning responsibilities will be transferred to the ICS NHS body. It will be important that ICSs retain or invest in additional capacity and information to commission effectively at place level.
2.5. We welcome the recognition of place as the level at which most of the planning and delivery of care and support services happens. We also welcome the commitment that, wherever possible, the place should be defined by local authority boundaries. Making decisions as close to the people they affect needs to firmly embedded into the way we work together.
2.6. Though the ICS NHS body is primarily focused on collaboration between NHS organisations, they will also need to work closely with social care and public health to ensure that ICSs maintain a focus on joining up health and care and also on improving population health outcomes. Similarly, ICSs will need to focus on rebalancing investment between acute trusts and primary and community health services. ICS NHS bodies will not be effective if NHS acute trusts continue to dominate.
2.7. Regarding the ICS Health and Care Partnership, it is important to note that many such partnerships are already firmly embedded and making strong progress. For example, West Yorkshire and Harrogate Health and Care Partnership takes a place-based approach to commissioning and delivery of care and support. ICSs should be 'light touch' and supportive of place-based commissioning to avoid duplication and adding another layer of management.
2.8. We support local flexibility and we are keen to support health and local government leaders to work as equal partners in setting up the ICS Health and Care Partnership. There is a risk that if this is the sole responsibility of the ICS NHS Body, in areas with no track record of collaborative partnerships between the NHS and local government, this will perpetuate the NHS dominance of the ICS Health and Care Partnership. We have many examples of existing effective partnerships and are keen to work with DHSC and NHSE to promote these as examples of good practice.
2.9. There are questions about additional responsibilities for the Care Quality Commission in assessing ICSs in the White Paper. The CQC continues to have an important role in the drive toward health and care services that provide people with safe, effective, compassionate, high-quality care, as well as playing a part in the improvement of those services through its regulatory activity.
2.10. The question of CQC’s potential role in assessing ICSs needs to be considered in light of the regulator’s strategy for the next five years, which is currently out for consultation. There is much in this to support, such as the strong focus on people and the centrality of the voice of lived experience in the pursuit of services that best reflect what people want and need. It also needs to be considered in terms of the White Paper’s proposal to introduce a new duty on the regulator to assess councils’ delivery of their adult social care duties.
2.11. In thinking about the role of CQC in these different spaces, we would offer the following principles:
2.11.1. We need to build greater parity of esteem between health and care and local government needs to be in a genuinely equal partner in the way in which people are supported to live their best lives.
2.11.2. Any plans must build on existing sector-led improvement work and recognise the crucial role of local democratic accountability.
2.11.3. Any plans must be developed with local government and take a whole-systems perspective based on a shared agreement of what good looks like and the outcomes for people we are committed to achieving.
2.11.4. Improvement is first and foremost a local endeavour. It is local councils, working alongside commissioner partners in health, as well as other partners from the provider sector, the voluntary and community sector, people with lived experience and others, who lead and support an area’s local improvement journey.
3.1. Adult social care has demonstrated its value throughout the pandemic; care and support is now in the public, media and political spotlight like never before.
3.2. The White Paper’s recognition of the pressures facing social care, and a restated commitment to reform, are welcome. But the proposals do not address the urgent need to put social care on a sustainable, long-term financial footing to ensure social care can best support people to live the lives they want to lead. The LGA is committed to working with the Government to ensure that local government is fully engagement in the further development of these proposals.
3.3. It is disappointing that the Government’s immediate priority for social care is to strengthen national oversight of care and support, rather than bring forward its long-awaited wider funding reforms to support people of all ages to live the life they want to lead. We were also disappointed to see no mention of adult social care in the Chancellor’s recent budget. Government should commit to publishing at the earliest opportunity a timetable for producing its proposals on the future of adult social care and support
3.4. It is important to note that the White Paper contains many proposals on adult social care and public health that, prior to its release, had not been in the public domain. It is essential that Government commits to an inclusive consultation and engagement on any proposals that have not previously been in the public domain. These changes will impact some of the core functions of local government, so it is crucial the sector is fully engaged.
3.5. The White Paper also announced the Government’s intention to work with councils and the social care sector to enhance existing assurance frameworks that support the drive to improve the outcomes and experiences of people and their families in accessing high quality care and support. We understand Government’s desire for greater transparency in social care. Councils need to be an equal partner in the design of any national oversight, which must build on existing sector led improvement work (which will necessarily continue to evolve to reflect local/national priorities), recognise local democratic accountability and give a meaningful voice to people who draw on and work in social care.
3.6. Any new processes or structures for assurance and oversight need to be accompanied by a New Burdens assessment to fairly capture the capacity and resource implications for councils in meeting new regulatory approaches. This would also need to consider CQC’s capacity and skillset.
3.7. Any assurance process has the potential to highlight shortfalls in services and delivery of the intentions of the Care Act due to resource constraints. Any assessment of a council’s adult social care services would need to be contextualised in terms of available resources.
3.8. The assurance process must be developed in partnership with local government and the CQC; we would favour a review-driven approach looking at whole systems, based on a shared agreement of: what good looks like – in particular, the importance of person-centred and locally flexible care and support; and the criteria for where greater intervention might happen
3.9. We need to avoid an Ofsted-style system in which a wide range of data is boiled down to a single judgement, leading to ratings and league tables.
4.1. The White Paper also contains several provisions on public health. The Government has said it will bring forward measures to make it easier for the Secretary of State to direct NHS England to take on specific public health functions. It is unclear whether the changes relate only to public health functions exercised by NHS England or equally to public health functions exercised by local government. Any new legislation needs to be clear on which requirements apply to which parts of the public health system. The LGA will be seeking clarity on the Secretary of State’s power of direction.
4.2. The Government also plans to allow ministers to introduce new strengthened food labelling requirements, including changes to front-of-pack nutrition labelling and mandatory alcohol calorie labelling, as well as further restrictions to prohibit advertisements for products high in fat, sugar or salt being shown on TV before 9pm.
4.3. We support proposals to strengthen front-of-pack nutrition labelling and calorie labelling on alcohol. A single, standard and consistent system will help people make informed choices. We also welcome plans further restrict the advertisement of unhealthy food and drink. It is disappointing that the White Paper does not include plans to give councils powers to ban junk food advertising near schools, which is something that councils and the LGA have campaigned for.
4.4. The Government also plans to streamline the process for the introduction, variation and termination of water fluoridation schemes in England by transferring the responsibilities for doing so, including consultation responsibilities, from local authorities to the Secretary of State for Health and Social Care.
4.5. Whilst we welcome the shift to a more streamlined consultation process for water fluoridation schemes, water fluoridation must not be imposed on communities. It has been our long-standing policy that local decision-makers are best placed to take into account locally-expressed views and to balance the perceived benefits of fluoridation with the ethical arguments and any evidence of risks to health. Local authorities have encountered difficulties with the current consultation process, including the fact that local authority boundaries are not coterminous with water flows, which requires the involvement of several authorities in these schemes.
4.6. Additionally, it is extremely disappointing that the Budget did not announce councils’ public health grant for the next financial year, which is only a few weeks away. Funding for public health services have been reduced by £700 million in real terms over the past five years. The public health grant must be published with the utmost urgency. The lack of new funding for public health runs contrary to the aim of addressing the stark health inequalities exposed by COVID-19 and levelling up our communities. It is also out of step from increases in funding for the NHS. Keeping people healthy and well throughout their lives reduces pressure on the NHS and social care.