Feature

But what role for local government?

The white paper goes some way towards giving local government equal billing with health authorities as the lead local agencies in improving health and narrowing the health gap.

Creating strong local partnerships to tackle the root causes of ill-health is a central theme running through the white paper. A new duty of partnership on NHS bodies and local government is intended to ensure joint action – and 12 ministers, including the Minister for Local Government, have endorsed the strategy. But, in the end, it is HAs which have overall responsibility for improving health locally. They remain primus inter pares.

The monitoring arrangements to ensure compliance with government policy look rather Byzantine. They include health improvement plans, local authority community plans, national service frameworks, the NHS performance assessment framework, ‘Best Value’, and the Audit Commission. With such a complex set of mechanisms there is a danger of monitoring being progressed down vertical silos and not across agencies in recognition of ‘joined up’ government. Streamlining and simplifying such a complex monitoring infrastructure may be necessary.

It appears that the government has heeded some of the criticisms of Health of the Nation, following the assessment it commissioned. This found that local government had not seriously engaged with the strategy and had been largely bypassed by it. There was little understanding of the respective worlds of local government and the NHS.

But has the government gone far enough in recognising the crucial role of local government in public health – one that is sometimes overlooked by local authorities themselves – or is the strategy still dominated by a downstream, disease-based focus? If there is a fault-line running through the health strategy it centres on precisely this issue. The title contains a mixed message. ‘Saving Lives’ is in the tradition of the NHS and its focus on illness reduction. But the new public health, while not neglecting the individual, is more concerned with tackling the social and structural determinants of health.

If, as many believe, local government has more than HAs to contribute to a health agenda, then the new health strategy offers important possibilities for local government to take the lead in a context where the NHS is likely to be judged more on its performance in respect of waiting lists and financial deficits than in narrowing the health gap. But for local government, itself in the midst of a modernisation agenda, rising to the challenge requires the Department of the Environment to give more importance to the health agenda. Unless there is leadership and coherence at national level, combined with appropriate leadership locally to overcome the cultural barriers which still exist, then it is hard to see local government and the NHS getting their act together.