It has long been true that mayors are more popular than Presidents and Prime Ministers. Of course, local politics can be low grade and parochial, but generally it is more practical, more pragmatic, less ideological.
Local media can be unfair or outspoken but is still more about news than opinion while social media is more focused on information and participation. Compare and contrast the tone of X with Next Door. Ultimately, it is simply easier to act. As one city mayor said: ‘If I need to get something done, I can get nearly everyone that matters into a room with me.'
The contrast between national intractability and local possibility exists in the NHS as well.
I recently attended two sessions on neighbourhood working, the first a workshop on the national implementation programme, the second an event with national leaders in discussion with folk from North Yorkshire and Humber. There were differences of emphasis at the events. The former was more radical in its vision of a new model of care and relationship with communities, while the latter focussed on shifting resources and services within the NHS. But the common theme in both events was the crucial importance of local action and relationships. We know from our members the process of applying for the national programme has not been without its challenges – when it comes to getting every party signed up. Only time will tell whether the signatures on the page signify a real desire to work together around a common cause for the benefit of their communities.
Even in an area like North Yorkshire where much of primary care operates at scale and relationships are generally good, it is unclear who is going to do the heavy lifting of developing multi-neighbourhood providers or enabling Primary Care Networks to evolve into left shifting single neighbourhood teams. In other areas, some local medical committees are telling their members not to get involved in neighbourhood work.
It isn't just about neighbourhood providers and the community-focused ambitions of primary, community or mental health providers. The left shift, on which so much of the Government's 10 -Year Plan rests, cannot be accomplished without commitment and sacrifice by acute trusts. But who will bring them to the local conversation given their own and other trusts' challenges ranging from industrial action and cost reduction to preparing for league tables? The answer for some lies in Integrated Health Organisations but increasingly I hear these will emerge only slowly and only in a small number of places.
One answer is to look to ICBs and their market-making role. It is something they would, in different circumstances, have taken on eagerly. But, exemplifying the difficulties of national policy making, the central reform of systems is chaotic.
ICBs have been given funding limits premised on withdrawing services for which they remain statutorily responsible and on implementing redundancy packages for which they are not funded and approval for which is stuck in the bureaucratic maw of the Treasury. Add to that imposed mergers some of which seem destined to be only temporary, and the idea that ICBs have the capacity for the complex, painstaking, political work of local service brokerage and development in places and neighbourhoods seems fanciful.
When I asked the national leaders visiting Yorkshire who was going to broker local change their answer was based much more on hope than expectation. Given that the development of neighbourhood working relies on volunteers the danger is that the biggest winner is inertia.
Yet without the new ways of working laid out – albeit vaguely - in the 10-Year Plan, the NHS will not turn the corner and may not survive as a universal service. ICBs can and will try to help, and in some places like south east London, they are forging ahead but their chances of success depend hugely on local effort, will and trust.
The Confed is working with local leaders and all parties in local government to convene conversations and explore possibilities. But so much of this comes down to leaders on the ground.
To be fair to the centre it is seeking to be permissive in allowing local arrangements to emerge. But it is taking time for all parts of NHSE, national and regional, to translate what they are hearing into different behaviours. Yet as summer turns to autumn it will take local vision, deep collaboration, organisational generosity, patience and hard practical work to turn this small window of potential into the transformation of care the service and the public so badly need.
