The qualities local public service leaders most crave from their political masters in Whitehall are clarity, consistency and realism. Be clear about what you want, try to ensure the voluminous outputs of the central policy machine broadly align with what you say you want, and take responsibility for designing and adhering to a deliverable plan to get what you want.
Nowhere is this more evident than in the treatment of NHS Integrated Care Boards (ICBs). The NHS 10-year plan makes clear how important ICBs are to the changes ministers want to achieve.
Improvements in population health and reductions in health inequalities will rely heavily on the performance of ICBs. Equally, the major changes in the NHS' delivery model and ideals of neighbourhood health also rely on ICBs to ‘market make', working with local NHS providers to develop models and shift resources from acute to primary settings.
There are many dimensions to this unfolding crisis, but the most shocking is that ICBs are being given neither the permission nor the funding to enable them to make the redundancies essential to meeting their new budget limits.
Yet, rather than ICBs being supported on the journey, they are being asked to massively downsize, restructure, and in most cases, merge with other ICBs without the most basic tools to enable them to do so.
There are many dimensions to this unfolding crisis, but the most shocking is that ICBs are being given neither the permission nor the funding to enable them to make the redundancies essential to meeting their new budget limits.
As one ICB chair put it to me: ‘It's like being told to construct a complex IKEA cupboard, without instructions, tools and with several pieces missing.'
Tragically, it is not bits of hardboard and metal that are at stake, but the jobs and wellbeing of thousands of public servants and the capacity of the NHS to recover and reform.
Despite struggling with the complexity of reorganisation alongside profound financial challenges, local authorities – many of which had been working collaboratively with ICBs – are sympathetic to the plight of their NHS neighbours. But there may also be opportunities.
Mayors like Andy Burnham and Oliver Coppard are leaning into the opportunities of whole-place commissioning for health and wellbeing. The 10-year plan appears to leave open the possibility that, through joint commissioning, local health funding could come at least partially under local democratic control.
Perhaps less appreciated is the opportunity at place and neighbourhood level. One of the implementation challenges of the 10-year plan recognised privately by concerned central officials is an absence of brokering capacity.
Who is going to bring local partners together to explore potential models for the delivery of multi-neighbourhood contracts at place level and single-neighbourhood contracts at primary care network level?
This is a big and complex job about building confidence and collaboration, mediating between the ambitions of different potential providers and ensuring, through integration, that the shift can occur.
The expectation that activity and resources can move into neighbourhoods rests not just on how work at that level reduces demand for emergency services, but how this allows a reduction in acute capacity and thereby enables a benign feedback loop.
Neighbourhood health plans have to be produced by health and wellbeing boards, so there is a mechanism for local authority engagement. But this should be seen as much more than an administrative requirement. As the NHS Confederation is helping local authorities appreciate, a proactive and ambitious stance from local politicians can help partners grasp the transformative potential of new models.
Neighbourhood working should be a lot more than a new way of promoting multi-disciplinary working in the NHS. It requires a commitment to a different model of care, especially for those with long-term and complex conditions and a different relationship with communities, particularly in the most deprived areas. In service of that vision there are many other opportunities to be grasped – from the more imaginative use of the public estate to the neighbourhood commissioning of social care.
The deeply problematic process of ICB reform partly reflects the NHS' long-term inability to see the potential of local accountability, but also creates an opportunity for enterprising local authorities to help the NHS survive and prosper.
Matthew Taylor is chief executive of the NHS Confederation
