devolutionA truism of Local Government is that its enthusiasm for devolving national budgets locally is exactly matched by its reluctance to pool budgets regionally. I worry that frequently the search for increased budget allocation at any cost might overlook that all devolved budgets come with an increase in responsibility. The most recent devolution push poses an interesting challenge to Local Government, the desire to devolve budgets to regions is tantalising but the reluctance of individual Authorities to cede decision making to regional bodies is likely to undermine the benefits that can be achieved.

Periodically there are calls for health spending to be fully devolved to regional structures (or even smaller localities). There is some sense in this as a more local focus increases the opportunity to synchronise Health and Social Care spending. The separation between the two, and more importantly their relative inconsistency in secure funding, sits at the very heart of the current Health funding crisis. Initiatives such as the Better Care Fund were noble in objective but have done little more than tinker with the issue and in many cases drained systems of much needed money in the pursuit of novelty projects.

The most recent push for localisation comes via the Localis report on Local Empowerment. It make some good recommendations, particularly around more pressure on Clinical Commissioning Groups to commission around outcomes and for longer funding allocations. Any move that supports longer contract lengths for service providers will create the conditions for consistency.

Consistency is the underlying consideration that needs to be built into any proposals that might affect the change in current health structures. Although the model of Clinical Commissioning Groups was flawed in conception it’s arguable that the perilous situation that exists in local commissioning is a result of the pace of change. There is nothing inherent in the model of CCGs that was prompted the move away from true commissioning and back to the basic procurement of services. That has come about because the expertise in the system was either stripped through reduced funding or the perception of reduced career opportunity.

For any future model of local health commissioning there are five important factors that need to be put in place before there is any move to devolve budgets:-

1) Geography – Organisations that commission services need to match a geography that the people they serve understand. The application of CCGs across the country has been patchy but in many many cases they do not readily fit an area that is locally identifiable. Designing a commissioning system around current patient flows utterly misunderstands the factors that drive people to use services. Equally this can be applied to new regional authorities. People who live in an area have little time or inclination to conceptualise Local Enterprise Partnerships or Regional Authorities that use nebulous names or cover random tracts of the country.

2) Intelligence – All commissioning should be intelligence led. This is as true of the current structures as it will be of any arrangements around devolved health budgets. In order to make intelligence led commissioning a reality there needs to be real investment in intelligence methodology. This means that there needs to be real access to local data sets, through innovative use of open data, but also recognising the value of the local individual story.

3)  Engagement – Engagement with communities and patients is an activity that was declining before the most recent health reforms but does appear to have ground to a halt since the 2010. Engagement is not an activity that can be subcontracted to another organisation. Engagement is about your organisation being fully integrated into the local networks that exist in your community. That is easier if you can readily explain what your organisation does and people understand the geography you cover.

4) Accountability – Primary Care Trusts were fairly opaque organisations but they did have some mechanisms in place to make them accountable to patients and communities. There was a basic logic in moving the activities of the Patients Advice and Liaison Service, for Primary Care, into Healthwatch but it’s clearly not worked. It doesn’t appear to be an activity that Healthwatch has embraced with any enthusiasm and in many cases has chosen just not to deliver it. This has left a vacuum for accountability and a good source of intelligence.

5) Design – Commissioning isn’t procurement. It’s odd that in 2016 this still has to be said. A commissioning process is not about a member of a Senior Management Team having an interesting idea and then advertising a contract. True commissioning involves identifying a need and then working with communities and providers to design a solution. Commissioning is the point that intelligence, engagement and accountability come together around a geography.

Before we attempt to go through the pain of further reorganisation and the lost years that go with it, please try and put the conditions in place for proper effective commissioning.