Partnerships Between Health and Local Government

Stephanie Snape, Pat Taylor

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781135757410
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Politics
• Index: Politics & International Relations

Looks at the partnerships between health services and local government in the UK Examines the misunderstandings and tensions that can occur between agencies Highly relevant to students of contemporary British Politics and New Labour

Health and Local Government Partnerships: The Local Government Policy Context

STEPHANIE SNAPE

LOCAL GOVERNMENT AND HEALTH

‘Short horizons’ is one of the chronic afflictions of the public services and its commentators in the United Kingdom. Such short horizons have contributed to a view that the ‘traditional’ boundary between health services and local government is that of the health-social care divide. However, this ‘boundary’ has only been in existence in its present form for 30 years (and has constantly been subject to change during this period). Before this, local authorities had a greater role in health service provision. Indeed, from the mid-nineteenth century until at least the creation of the National Health Service, local government was the predominant provider of public health services. Local authorities worked to secure sanitary public health, through the development of healthy water supplies, sewerage, council housing and slum clearance, and refuse collection and waste disposal services. They appointed Medical Officers of Health to assess local health needs. And by the 1930s they were managing a wide range of acute and primary care services, including major hospitals. Indeed, Webster writes that local authorities had by 1939 ‘assembled a formidable array of specialist health services’ and that services had expanded ‘to such a degree that this system was already occasionally called a “National Health Service’” (1988:6–8).¹

However, by the mid-1970s this pivotal role for local government in healthcare and health policy had been considerably weakened. In 1974 government transferred a number of key local government health services to newly created area health authorities; services which included home nursing, family planning, health education, ambulance services and school health. Medical Officers of Health were also transferred to the NHS and local authorities no longer reported on the health needs of their local area. There is a widely held view that the transferred Medical Officers of Health (since re-titled directors of public health) rapidly became subsumed within the predominant medical model of health within the NHS (Holland and Stewart, 1998; Hunter, 1999). This is highly significant given that the role of Medical Officers of Health was crucial in both providing a conceptual role for local government in health through the concept of ‘public health’ and a senior officer whose work ensured that health issues remained central to local government.

The 1974 reorganisation is often viewed as a watershed in local government’s relationship with health. The ‘orthodox’ view of the 1974 changes is that it largely transferred local government’s involvement in health ‘en bloc’ to the NHS. And what remained—rather oddly—were local government’s welfare services (now termed social services). Today this equates to a range of care and protection services such as residential care homes and day centres for the elderly, drug or alcohol abuse programmes, child protection and fostering, adoption and children’s homes for children in care. And the health-social care divide became enshrined as the key boundary between the NHS and local government: the arena in which the two leviathans had to co-operate to provide services to client groups such as the elderly. However, local government actually retained control over major public health services such as housing, leisure services, sanitation and so on. In reality, these services have a greater influence over health and well-being than most NHS services, as Campbell argues:

Refuse collectors are not highly paid, glamorous figures like brain and heart surgeons, but they almost certainly do more to keep the population healthy than these stars of the health world. Landlords in the largely unregulated private rented sector are no longer held up as targets for vilification by the media, but they, as well as the length of hospital waiting lists, may sometimes make a contribution to keeping poor people unhealthy. Conversely, research suggests that central heating and insulation improvements to council housing can bring about immediate improvement in respiratory symptoms in children with asthma and a reduction of lost school days… These and many other areas of everyday life that have a huge impact on public health are actually and potentially directly influenced by the work of local authorities. (Campbell, 2000:13)

Indeed, it is one of the greatest ironies of the modern state that while local government has more influence over the health and well-being of its communities than the NHS, for the last 30 years it has had little influence over the shape of local health policy or the operation of local NHS services. This in itself partly reflects the way in which the NHS has captured and monopolised the public’s perception of health; as health and the NHS are often viewed almost interchangeably, with little understanding of the importance of the wider determinants of health and local government’s role in shaping these. And, over the years since 1974, many local authority councilors and senior officers simply ‘forgot’ local government traditions in health and overlooked the council’s key role in shaping the health of its communities. The links between housing and health, for example, which were reviewed frequently in the annual reports of the Medical Officers of Health, became less apparent and less the focus of attention either at the corporate centre or when shaping service delivery. Instead, the prevailing interpretation of local government’s role in health was one almost totally equating to the health-social care divide.

However, more recent policy developments have provided substantive opportunities for local government to ‘revisit’ their role in health:

the new policy context provides opportunities for local authorities to reclaim their original role as champions of the health of local communities… Promoting the health and well being of local people is at the heart of community leadership. While the NHS has a critical role in our local communities, it is only through real partnerships between the NHS and local government that we can effectively tackle the wider causes of ill health. (SOLACE, 2001:2)

From an NHS perspective, the post-1997 emphasis within the NHS on tackling health inequalities and addressing the wider determinants of health can be traced back to the 1980 Black Report and the emergence of the ‘new public health’ movement. Further support for the social model of health was provided by the Acheson report (1998), which clearly demonstrated the highly unequal experiences of ill-health between different socio-economic groups, ethnic groups and gender. The Acheson report also provided the backbone to the new administration’s Green Paper on public health, Our Healthier Nation (1998). This appeared to demonstrate New Labour’s commitment to the values of the new public health movement. However, the publication of The NHS Plan was viewed by many as a return to the more ‘traditional’ focus on the healthcare system and individual lifestyle factors (Hunter, 2000). And certainly there have been examples of contradictions within New Labour health policy; Campbell labels this as ‘schizophrenia’, as the government emphasises both the broader, societal determinants of health while retaining individualized notions of responsibility for ill health and medically focused targets (2000:15).

As in the NHS, there were signs prior to 1997 of some local authorities (and departments within authorities) exploring a broader role in health improvement and tackling health inequalities. The new public health movement had influence over some authorities; indeed, it was local government, rather than the NHS, that drove the Healthy City movement in the UK. Experience in developing area regeneration programmes, anti-poverty strategies and Local Agenda 21 also encouraged the realisation of a broader role. However, as with the NHS, New Labour gaining power in 1997 provided a more propitious national policy environment for authorities determined to reclaim their role in health.

Post-1997 there are three key policy areas which could support change in local government’s involvement in health: innovations in the health-social care boundary; the ‘core’ Local Government Modernisation initiatives; and area-based initiatives. There have been substantive policy changes to the health-social care boundary, with central government encouraging local authorities and NHS organisations to work together more closely through the use of pooled budgets, lead commissioning and integrated management systems. In terms of the ‘core’ Local Government Modernisation initiatives, commentators have in particular stressed the potential of the community leadership role, supported by the new power of well-being, and the health scrutiny role to provide a lever for local authorities wishing to take a broader role in ensuring the good health and wellbeing of their communities (INLOGOV, 2000; SOLACE, 2001; Campbell, 2000). Finally, since 1997 central government has established a wide range of area-based initiatives, such as Action Zones and New Deal for Communities, which have the potential to re-emphasise the relationship between regeneration and health.

And local authorities have received considerable exhortation and encouragement to use the opportunities provided by this changing health and local government context. The period since 1997 has seen an ‘explosion’ of interest and policy guidance on local government’s role in health, produced by such influential organisations as the Health Development Agency (HDA), Democratic Health Network (DHN), Local Government Association (LGA) and the Society of Local Authority Chief Executives (SOLACE) (Campbell, 2000; LGA, 2000; SOLACE, 2000; Health Select Committee, 2000; Hamer and Easton, 2002; Hamer and Smithies, 2002; Cramp, 2002; HDA, 2003; NHS Confederation, 2003). These organisations have been arguing for local authorities to champion the social model of health by promoting health improvement and tackling health inequalities.

Such a changing policy context—and ample encouragement—would appear to be conducive to local authorities re-imagining their involvement in health. However, is there any evidence for such a fundamental change? This article is drawn from the findings of a desk-based review intended to provide answers to this question. Evidence from the review is presented in the following sections: first, the crucial issue of ‘models of health’ is examined; this is followed by presentation of an ‘ideal type’ for a broader role for councils; the next three sections each examine the impact of changes to the health-social care boundary, the ‘core’ Local Government Modernisation initiatives and the emergence of area-based initiatives respectively. The last section presents the conclusions.

The article argues that assessment of developments in the selected key areas finds that in practice the health-social care boundary remains a dominant presence in local government’s vision of health. There has been no paradigm shift in local government’s relationship with health. Although progress has been made in the relationship between regeneration and health, and elements of the Local Government Modernisation Agenda hold the potential for more radical change, the primacy of the social care boundary casts a long shadow. Within social care there is again the potential for change but little radical change has been effected. Certainly, local government practice is far removed from the ‘ideal type’ of a reclaimed pivotal role in local health policy set out in the article. The performance management framework for both sectors is identified as the key obstacle to more radical progress.²

MODELS OF HEALTH

Central to the debate over the relationship between local government and health is the issue of ‘what is health?’ Two interpretations or models of health tend to dominate this debate. The NHS is driven and shaped by the medical model of health. This model sees the NHS focused on the treatment of disease, in which health is defined as the ‘absence of disease’, symptoms or sickness. The predominance of this model within the NHS has been produced by advances in medical science and the power of the medical profession. Such a model emphasises treatment above prevention; indeed, only one per cent of current NHS expenditure is targeted at prevention schemes (SOLACE, 2001:2). Consequently, the NHS is often portrayed as an organisation which focuses on ‘downstream’ issues such as illness and injury.

In contrast, the social model of health recognises the wider determinants of health and seeks to prevent illness and to support well-being and a good quality of life. This model defines health as the outcome of the effects of all the factors shaping the lives of individuals, families and communities. Dahlgren and Whitehead’s (1991) representation of the main determinants of health is widely recognised and used as a faithful representation of the range of factors shaping health. In this model, the main determinants of health are represented as different layers of influence. At the centre are the age, sex and constitutional factors shaping health; the next layer comprises individual lifestyle factors, such as exercise patterns; social and community networks also impact upon health; and, finally, the outermost layer represents general socio-economic, cultural and environmental conditions such as work environment, education, housing. Such a model stresses the need to intervene at a number of points; taking action ‘upstream’ to prevent illness, injury and disability as well as downstream. Commentators tend to perceive local government as the champions of the social model of health (SOLACE, 2001; Campbell, 2000; LGA, 1998).

LOCAL GOVERNMENT AND HEALTH: DEVELOPING A BROADER AGENDA

But what would greater local government involvement in this area actually entail? What would be involved in local authorities developing strategies and initiatives to support well-being? It is relatively easy to determine the general aim of such strategies; they would seek to improve the health and well-being of the population and to address health inequalities. But how? In 2000, academics at INLOGOV devised ‘best practice guidance’ for authorities developing local strategies to tackle the wider determinants of ill health (INLOGOV, 2002). This guidance included advice on mainstreaming health, developing a strategic approach, engaging in public consultation, partnerships with other bodies, operational planning and so on. This article partly draws on this earlier work to set out an ‘ideal type’ of local government engagement in the wider health agenda.

Figure 1 identifies ten components of this ideal type. These ten components cover a variety of issues including information, needs assessment, strategic and operational planning, member and officer roles, and partner and community engagement. They draw on the key benefits that could be produced by broader involvement of local authorities in the health agenda: a commitment to the social model of health, addressing the democratic deficit of the NHS and drawing upon a broader range of skills and competencies. Authorities approaching such an ideal type would truly have reclaimed a more pivotal role in health. However, as will be demonstrated, local government practice in general is far removed from such an ideal type.

THE HEALTH-SOCIAL CARE BOUNDARY

Since the mid-1970s the relationship between local government and the NHS has been dominated by the health-social care boundary. Sullivan and Skelcher have identified three stages in the development of the health-social care relationship (2002:71–7). In the late 1960s and 1970s there was an emphasis on joint planning and co-ordination of policy development. These attempts at coordination have largely been viewed as unsuccessful (Hudson and Henwood, 2002:155). And so have the developments in the second stage of the ‘mixed economy of care’, from the 1980s until 1997, where the emphasis on coordination was also enjoined by exhortation to involve a range of other public, private and third sector providers through quasi markets for health and community care.

Sullivan and Skelcher’s third phase is that of ‘strategic collaboration’. They argue that since 1997 New Labour has ‘overlaid’ the continuing purchaserprovider split with an emphasis on cross-sectoral collaboration and partnership. One of the first documents to set out the government’s agenda of collaboration was Partnerships in Action (DoH, 1998). Its key proposals were enacted as sections 29 to 31 of the 1999 Health Act: section 29 expanded the possibilities for funding transfers from the NHS to local authorities; section 30 created a similar reciprocal relationship for local authority funding of health authorities for certain functions; and section 31 removed legal obstacles to joint working by introducing pooled budgets, lead commissioning and the possibility of creating integrated provider organisations.

There have also been a range of other initiatives which have sought to engender partnership working between health and social care...