Mechanics of localism: thinking anew

13 November 2017

“One of the Government’s most fundamental roles is

to protect the most vulnerable people in our society.”

In difficult times, I felt a tinge of hope to see this refreshingly definitive statement make it as the opening line of a Government document. But there is always a competing perspective.

Localism is no longer new. So it was no surprise to hear the Minister with responsibility for drugs and alcohol remind us at a recent event on implementing the Government’s 2017 Drug Strategy that local authorities are best placed to understand local needs.  After all, another Government document is equally clear-cut: “The Government is committed to continuing to give local authorities greater control over the money they raise locally.” So with many local authorities out to public consultation on their spending priorities for 2018/19, what do the convoluted mechanisms of translating central government policy into local decision-making tell us about which philosophy will win out in the case of drug and alcohol services?  Will protecting vulnerable people outweigh localism?

Let’s look at some of mechanisms shaping drug and alcohol provision. For example, PHE’s guidance on commissioning alcohol services runs to eighteen pages. It “outlines key principles that local areas might consider” when developing their plans. These principles are supported by a series of prompts to help local authorities put them into practice. Together with the equivalent (and overlapping) guidance on commissioning drug treatment which runs to a further twenty-three pages, these prompts comprise over 170 questions relating to planning and commissioning. The guidance locates responsibility for all of this with local Health and Well-Being Boards (HWBs). Indeed, it was said at the Drug Strategy event that we should be “ensuring health and well-being boards recognise the benefits of drug and alcohol services”. So how does this guidance operate in practice?

Firstly, HWB agenda items tend to be of larger scale, for example, a review of local mental health services. Improving hospital discharges. The local provision of care homes.  A review of primary care.  Certainly, drug and alcohol services will be embedded somewhere in strategies and commissioning plans, but struggle to get on the agenda in their own right.

Secondly, how do we know this abundance of guidance results in better lives for people with addictions and their families and communities? For one, the Care Quality Commission (CQC) judges the services: that is its job. Undoubtedly, being faced with CQC enforcement action is best avoided. But no self-respecting local authority will wittingly allow itself to slip that low.  If money is running out they might, however, grudgingly take the hit of a “Requires Improvement” rating, not least because this won’t register in the public consciousness like a failing care home or closing a library.  In times of austerity, inspection is maybe more useful in ensuring compliance with minimum standards than taking us to new heights.

My previous blogpost spelled out how the Public Health Dashboard judges too, but not in real time or in a way that will drive change.  We also have the more detailed Public Health Outcomes Framework which we are told we must “collectively use to better capture the joint ownership” of services that is required to help people recover. But here too, nothing can bite harder than the Government barks and using the Outcomes Framework to drive implementation of the Drug Strategy is only rhetoric unless the Strategy is resourced.

So, thirdly, how does the Government require local authorities to spend the grant that covers drug and alcohol services?  The conditions on local authorities in spending Public Health Grant do not legally require the provision of drug and alcohol services, only that councils must, in using the grant, “have regard to the need to improve the take up of and outcomes from” its drug and alcohol services. What they don’t say is how much improving – or money – is required, leaving this deliberately wide open to local interpretation. This together with the planned removal of the ring-fence on the Grant from 2019 is what has already given local areas the green light to disinvest over the past few years and to go on doing so.

So here we have our answer: localism apparently trumps the Government’s desire to protect vulnerable people.  I say “apparently” because the next few weeks will see an appointment to the new role of the Recovery Champion who will be responsible for driving vital collaboration at local level and for advising Government on where improvements can be made to the drug treatment system. She or he will be accountable to the new Drug Strategy Board chaired by the Home Secretary, which will meet for the first time before Christmas.

Working in local government, I used to joke that one of the best policy tools available is to live in hope. And in the words of Lincoln in his Second Annual Address to Congress, the will of the Home Secretary in chairing this Board is probably our “last best hope”. We can live in hope that she acts on Lincoln’s words:

“The dogmas of the quiet past, are inadequate to the stormy present.

The occasion is piled high with difficulty, and we must rise with the occasion.

As our case is new, so we must think anew and act anew.”

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