Why are the institutional links between local NHS institutions and local councils so weak?

And do the meetings where the general public can get involved have such a low media profile? Also the prospect of adding healthcare to the above-diagram is something that intimidates me!

This post flows on from my earlier thoughts on doctors’ surgeries and local councils. It also links to my anecdotal evidence on the very low awareness that healthcare staff treating me following my heart attack last month, had of the transport consultations affecting their work places.

In a way it’s surprising I’ve taken so long to turn my focus towards local healthcare systems and structures given my own personal health history. At the same time, it reflects a very fragmented public sector that has essential services sitting in separate silos with isolated reporting lines back to ministers in Whitehall. Successive local government ministers have struggled to break these silos and make good the political rhetoric about local public service providers working together at the grass roots and deciding what’s best for their area.

When I look back at some of the responsibilities of local councils you can see some of the links local councils had with local healthcare, local police, local schools, local magistrates, and more – such as the now privatised utilities. (Water, electricity, gas). Look at councils today – in particular their responsibilities on the climate emergency, and questions arise on their resource capacity and legal competency to meet their obligations.

“Get involved in…! …is the message”

For the delivery of healthcare and education, if you are a single, healthy male in their 20s who seldom needs to go to the doctors, it’s easy to see how the troubles of public service delivery can easily pass people by. I’ve also heard the mindset of “I go private, why should I pay tax for…?” as well. It’s not one I buy. With either mindset, why get involved in things you’re not a service user of? Perhaps that’s one of the weaknesses of our current political system – where many might be unaware of the number of voluntary (with/without expenses) in national public service (see https://publicappointments.cabinetoffice.gov.uk/all/ ) or local/civic society there are. (Something some of you may want to raise in this debate).

Closer to home, I should have taken responsibility of taking care of my own mind & body once I left school to start A-levels. But the 1990s were still an era of young people being disempowered. It’s also hard to get over to those born after what society was like before the internet in terms of the society-wide concepts of simply ‘not knowing’ and ‘not having the curiosity to find out’. Which perhaps is one of the reasons why the film The Truman Show (which pre-dated Big Brother the TV show) is one that has stuck with me. Or the line “If I hadn’t seen such riches, I could live with being poor.” From Sit Down by James – a song I played regularly around the time I started secondary school.

What are the local healthcare institutions for Cambridge?

The multi-tiered structure of local government that Cambridge is tied up amongst is one of the things that makes this complicated – much of Cambridge’s provision is at county level. Or at Combined Authority level. (i.e. including Peterborough). For example every shire-county-level council area has a Patients’ Champion known as a Healthwatch. Because Peterborough is a unitary council they have Healthwatch Peterborough <<– even though this page says the team that runs their organisation is the same one that runs Healthwatch Cambridgeshire. Covering public health functions for Cambridgeshire is Cambridgeshire County Council – in particular the Adults and Health Committee. Over the past decade, public health budgets have been cut drastically by central government – with the grim and predictable results.

“Almost £1 in every £7 cut from public health services has come from England’s ten most deprived communities – compared to just £1 in every £46 in the country’s ten least deprived places. The total, absolute cuts in the poorest places have thus been six times larger than in the least deprived.”

IPPR 05 Nov 2019.
“Don’t you register with a GP/doctor, and dentist, and then they sort you out if you need referring anywhere?”

What public services look like from the service users’ end is rarely the same when you look at the complicated and complex wiring behind the reception desk. Years ago in the civil service I remember when the Official Census made sense – so much public spending is dependent on the number of people recorded as resident in a given area. This was pre-2010 so the amount of money a local council got in their annual grant from Whitehall was dependent on a very complex formula that included the population from the most recent census. Which is why when people cannot be bothered to fill them in, it hits their entire town or district.

Is it only when things go wrong that we start thinking about accountability?

Possibly. Another alternative is that we don’t have politics and democracy embedded in our education system. Given what we know now from past lessons, and given what is now available to us through the internet and big data processing systems (such as those used to run the British Newspaper Archive online – enabling keyword searching of millions of pages in almost an instant), some of those national narratives about things like votes for women, or the building of schools and hospitals locally, can and perhaps should be embedded in local history.

It was people local to me complaining (understandably) about the lack of doctors’ surgeries and NHS dentists in South Cambridge (in the face of lots of house building) that got me thinking.

Because normally I’d point people towards https://www.writetothem.com/ and advise which of their city councillor, county councillor, or MP they should contact. But getting everyone to bombard Daniel Zeichner (MP for Cambridge) seemed a little unfair not just for him and his staff, but for his constituents too, knowing that the convoluted way round via ministers to a local Clinical Commissioning Group (blame former Health Secretary Andrew Lansley – and a previous generation of residents in South Cambridgeshire who voted for him repeatedly) won’t actually solve the problem.

“What’s a Clinical Commissioning Group?”

Formerly Primary Care Trusts, which replaced GP fundholders which replaced…why is healthcare delivery so complicated?!?

In a nutshell, it’s the bit of the NHS that gets funding from Parliament to pay for your primary healthcare. In Cambridge, our one is the Cambridgeshire & Peterborough CCG. More recently, the CCG has become part of an ICS.

“What’s an ICS?”

An Integrated Care System – see here. It looks like this will replace the CCG which itself replaced the PCTs.

“Tell meee…. Why d’ya have to go and make things so complicated?!?!?”

Exactly.

The ICS will incorporate:

  • Two upper tier local authorities:
    • Cambridgeshire County Council and
    • Peterborough City Council
  • Five district councils:
    • Cambridge City Council,
    • East Cambridgeshire District Council,
    • South Cambridgeshire District Council,
    • Fenland District Council, and
    • Huntingdonshire District Council
  • Three hospital providers:
    • North West Anglia NHS Foundation Trust (NWAngliaFT),
    • Addenbrooke’s – Cambridge University Hospitals NHS Foundation Trust (CUH) and
    • Royal Papworth Hospital NHS Foundation Trust (RPH)
  • Two community providers:
    • Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) and
    • Cambridgeshire Community Services NHS Foundation Trust (CCS)
  • East of England Ambulance Service NHS Foundation Trust (EEAST)
  • 85 GP practices  
  • Cambridgeshire Local Medial Committee
  • Healthwatch Cambridgeshire and Peterborough
  • The Cambridgeshire and Peterborough Health and Wellbeing Board
  • Other partners, including parish councils as well as voluntary, community and faith organisations

If you want to get involved, contact them via here.

Scrutinising the various organisations

The main Patients’ Champion is Healthwatch Cambridgeshire.

The main funder for those of us in Cambridge & South Cambridgeshire is the CCG.

Addenbrooke’s Hospital

Our main hospital in Cambridge as many generations of local people know is Addenbrooke’s. It is a giant of an institution that has been around these parts for over two centuries. They are overseen by a Board of Governors – made up of the great and the good over generations. Their public meetings are listed here. Furthermore, the public can join as members that scrutinise the governors – and thus get voting rights to vote on who should become a governor. Furthermore you can also stand for election as one of the public governors.

Royal Papworth Hospital

A similar arrangement is in place for the recently-arrived Royal Papworth Hospital – see their governor pages here.

East of England Ambulance Service

I’m not quite sure how their’s functions as they cover the region, not just the county. Going by their Trust Board page here, it may well be that their appointments are part of the national public appointments system

The Cambridgeshire & Peterborough Foundation Trust

This provides community-level care including but not limited to:

  • Adult mental health
  • Forensic and specialist mental health
  • Older people’s mental health
  • Children’s mental health
  • Children’s community
  • Older people and adult community
  • Specialist learning disability
  • Primary care and liaison psychiatry
  • Substance misuse
  • Social care
  • Research and development

…and with some of these you can see where it crosses over with Cambridgeshire County Council. The public are welcome to become trust members and then stand for election to become a governor, similar to the large hospitals.

“How come we didn’t know about all of this?”

For similar reasons most people don’t know about the constitutional relationship between MPs and constituents, and ministers to MPs in Parliament. I wrote up here what turned out to be a textbook example of how constituents can hold ministers to account through their MPs. This was on my call for a new adult education/lifelong learning college in Cambridge. The problem was I didn’t know who was responsible for funding. So I assumed the Department for Education would know as there was nothing on the local councils’ websites. I emailed my local MP (Mr Zeichner) to forward on an email for the minister with a series of short and to-the-point questions. (i.e. who had the legal power to establish such colleges, and who was responsible for providing the funds to build them?)

You can see the Minister’s response to Mr Zeichner here.

(It makes it so much easier for the staff working for MPs if at the start you keep your letter/email short, and simply ask them to ‘top and tail’ your letter with questions for the Minister. That way, the MP’s covering letter to the minister on your behalf is:

“Dear minister, please see the enclosed letter from my constituent A who has asked me to forward onto you a series of questions on issue B. I’d be grateful if you could respond to the questions enclosed which I can then forward onto my constituent. Yours. MP.”

The more diligent ministers take this sort of day-to-day correspondence seriously (I used to have to research and draft the responses for ministers in my policy areas during my civil service days) because responding to MPs writing on behalf of their constituents is one of their central responsibilities as a Minister of the Crown.

“The route via MPs is still convoluted, and the elections to hospital boards…we don’t really see the campaigns…do we?”

Perhaps it’s similar to being elected to stand as a governor of a school. For all of these to function and to have that diversity of candidates and even contested elections between high calibre candidates who really want to serve their communities, you’ve got to have a properly-functioning system of public administration within a locality. And we don’t have that.

The old adage is that the public want Scandinavian-style public services with US-rhetoric low tax rates. You can’t have both.

The Simpsons – School funding vs tax rises.

And that was just for a local school board in the US! Many moons ago the old Cambridge Borough Council had a local Board of Education which – prior to the days of universal suffrage, were one of the few areas of public service that women could be co-opted onto. Mary Allan of Homerton College and Eglantyne Jebb, later of Save the Children both served on it – though the latter missed many meetings (due to a mix of illness and her mother taking her abroad for long periods at a time as a chaperone due to her own illnesses and age).

Yes but…

“Yes but?”

Yes but not under the existing systems or structures for either. Which is why any reform carried out by a future government needs to ensure health, education, local government, and even future town and transport planning (i.e. where you build new facilities and train new staff) must be co-ordinated. That means coming to agreements on:

  • What level of taxation funding for services comes from (something that is at the heart of social care service problems)
  • Where the administrative boundaries should be – making them consistent across different public services
  • What the lines of local and national accountability should be? – In particular at what point should ministers say: “That is not a question for national government – please contact your local council…”
  • Which oversight functions require ‘ex-officio’ posts for elected councillors – i.e posts reserved for elected councillors on health boards *by virtue of them being elected by their constituents* and then nominated by their full councils.
  • What role any governors and full time senior executives and healthcare practitioners should play in working with/advising local councils. Whether on resource allocation to a GP telling a local housing office that a patient of theirs in a council house needs re-housing due to the impact of poor housing conditions in their council house. Or to take enforcement action against a landlord for permitting slum conditions.
  • What role healthcare professionals can do to warn councils of public health issues – in particular but not limited to air pollution – even to the extent where they issue a formal notice to a local council to take action.

I could write more but I’ll save it for later. Chances are there are some things I’ve missed out, and also some inaccuracies. (Please point them out so I can correct them!)

If you are interested in the longer term future of Cambridge, and on what happens at the local democracy meetings where decisions are made, feel free to:

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