We believe that many of the revisions to the bill, recommended by the NHS Future Forum and agreed to in principle by the Government, have the potential to strengthen the role of local authorities and put far greater emphasis on local health and wellbeing needs.
However, the bill as it currently stands does not accurately reflect the Government's initial commitment to a place-based approach and democratic accountability of health planning and provision and we support the below listed amendments which seek to rectify this.
We would like to see a person-centred and place-based `total health and wellbeing' model, and to ensure the bill is fit for purpose. To enable this we believe there should be four key principles at the heart of these reforms:
1. Healthcare decisions accountable to local people and based on local needs
2. Services organised around people's needs – without artificial barriers between social care and the NHS
3. All people looked after as a result of the reforms with ‘whole population' commissioning
4. Local government at the heart of public health.
While some welcome changes have been made to the bill in terms of the alignment of boundaries; emphasis on patient and public involvement, and greater transparency, we remain concerned that not all of the changes that the Government highlighted in its response to the Future Forum have made their way into the bill.
Children's public health
Until 2015, responsibility for children's public health will be split between the NHS Commissioning Board (for children aged 0-5) and local authorities (for children and young people aged five to 19). Thereafter, the responsibility will be transferred to local government. In the meantime we are concerned about the fragmentation of children's health and wellbeing services.
This intention is not stated on the face of the bill but outlined in 'Healthy lives, healthy people: update and way forward' and announced by the Secretary of State on 14 July 2011. We have serious reservations about continuing this split responsibility until 2015. Many local authorities believe that the split responsibility will lead to the fragmentation of children's services and may undermine existing services such as Children's Centres, which are already established in every local authority area.
We would therefore like to see an amendment to the bill that would make local authorities responsible for commissioning children's public health services, from pregnancy throughout childhood.
Integration Clause 20
We are pleased to see a renewed focus on integration in the bill but feel that most of the changes simply reinforce the benefits of integration to the NHS rather than looking at the system from the perspective of service users and using integration to develop person-centred services.
The Ministerial Announcement regarding revisions to the Health and Social Care Bill acknowledged the Future Forum's recommendations regarding the need for greater integration, but this has not been reflected in the bill.
While we are pleased that the Government has confirmed that clinical commissioning groups (CCGs) will be responsible for their whole populations and not just the people on their patient lists, we remain concerned that there is the potential for vulnerable groups to fall through the cracks between services. We are particularly concerned that adults and children's safeguarding concerns are not adequately addressed in commissioning arrangements. CCGs will need to work very closely with their partners in adult social care and with the providers of health and social care services to ensure that safeguarding considerations are embedded throughout the system.
Councils are concerned that CCGs do not have an established track record of commissioning so-called ‘Cinderella services' such as health and wellbeing services for homeless people, people with mental health problems, learning disabilities, AIDS/HIV, dementia and children's health. It is vital that commissioners of these services understand the important contribution of social care and other support services such as housing, leisure and recreation, access to education and other mainstream services make in supporting vulnerable people to remain healthy, independent and productive members of the community.
We would therefore like to see an amendment to the bill which would ensure CCGs are encouraged to delegate the commissioning of such services to councils. Councils have far greater experience in commissioning for people with complex needs.
We also support marshalled amendment 12, 16, 17, 79, 182, 183, 184 and 244.
If not included on the face of the bill we would like to see an explicit commitment from the Government to include in any guidance and/or regulations a far stronger direction to CCGs to consider delegating commissioning responsibility for health and social care services to local authorities.
Health and Wellbeing Boards (HWBs) – Clause 22
We are pleased that the Government has recognised that the powers of HWBs need to be strengthened in order to ensure coordination of commissioning plans with the health and wellbeing needs of the area. However, this proposal needs to go further.
The Future Forum recommended that HWBs ‘agree' CCG plans. The bill requires CCGs to involve HWBs ‘in preparing or revising the plan' and to be able to refer back to the commissioning consortia or upwards to the NHS Commissioning Board.
We believe is not sufficient to ensure that commissioning plans are firmly based on the health and wellbeing needs and priorities of the local community.
We would like to see an amendment to the bill to ensure that the plan receives agreement from the Health and Wellbeing Boards.
In addition we support marshalled amendment 120.
A place-based approach
The LGA has consistently pushed for a greater focus on a place-based approach to commissioning health and wellbeing services. The Future Forum proposed to the Secretary of State that such an approach is vital, through the alignment of boundaries between first-tier councils and CCGs, and the requirement that CCGs will have to plan for the whole population of an area, rather than just their patient list. The Government accepted these recommendations.
However, this is not expressed clearly in the bill and we continue to urge that this is rectified.
As such we would like to see an amendment to the bill which would place a duty on CCGs to ensure their commissioning plans address the priorities of the joint health and wellbeing strategies of the relevant local authorities.
We would also like to see an amendment to the bill which would place a duty on CCGs to cooperate with Health and Wellbeing Boards on the basis of the boundaries of the relevant local authorities.
If not detailed on the face of the bill we would like to hear assurances from the Government that this will be guaranteed in guidance or regulation and in the authorisation process for CCGs to be undertaken by the NHS Commissioning Board.
Death registration – Clause 51
This is a new and entirely unanticipated duty on local authorities brought about by the abolition of primary care trusts (PCT).
There are two stated aims of the duty on local authorities to appoint medical examiners to oversee the death certification process: firstly, to improve the quality of information about causes of death; and secondly, to ensure that there can never be a repeat of the Shipman case, where multiple deaths of older patients went unnoticed and unchallenged.
However, we do not believe this 'death tax' as currently proposed is the best way to achieve these aims. This duty would be an extra burden not only on councils, at a time when their resources are already very stretched, but on bereaved relatives who will be expected to pay an as yet unknown fee for every death registration. We propose improving the current quality assurance processes as a more cost effective and less cumbersome way of improving clinical practice in relation to death certification.
Such fundamental reform must be subject to a detailed impact assessment of the costs to town halls and family members before going out for public consultation.
As such we would like to see this clause removed from the face of the bill.