This week’s White Paper, whilst containing lots of familiar words around person centred care, also contains within it some clear statements about the role of place, which start to get to the heart of some of the genuine opportunity and complexity in mobilising the revolution in health and care that the White Paper and its siblings the Health and Care Bill and the Adult Social Care Reform White Paper Bill envisage.
There is much to celebrate. Firstly, the definition of ‘place’ as being something that is ‘meaningful to people’ is key. Successful place-based working will ultimately require co-creation of health and care outcomes within a local community – that will only work if people recognise themselves as part of that community and feel a sense of connection and community with the others contained within it. Big tick for this!
Secondly, the recognition of the complexity of pooling budgets (so quick to say; so tortuous to achieve) is also welcome, as is the acknowledgement of, and a degree of pragmatism and support around, the challenges around data sharing and workforce integration.
And the attempt to describe a meaningful governance at place and scale, already widely shared and attracting debate, is a great attempt to kick-start a national debate which might otherwise consume hours of time within local places as they individually attempt to resolve some of the contradictions and challenges it presents.
However, as with any radical agenda with big ambitions, some of the most eye-catching parts of the White Paper are those where what is said provokes some big and interesting questions.
To start with the most obvious – the creation of a local leader at Place ‘accountable’ for the delivery of outcomes. We are familiar with the idea that with great power comes great responsibility. It might equally be argued that with great accountability needs to come great empowerment. These leaders will need to be empowered in a way that will be, by definition, a challenge to the statutory bodies that make up the Place partnership, and to the central bodies who are used to managing that accountability.
If this is to work, a lot of people are going to feel uncomfortable but, if they don’t, it will be evidence that not much is really changing. In that instance, the really big question is why would anyone want to step into a role where they are accountable for the actions of others, over whom they have no influence? Big question number 1.
And number 2 is the ongoing question about what that accountability looks like in a sector where there are currently (at least) two forms of accountability operating in tandem – national regulatory accountability and local political accountability (we will leave national political accountability to one side for the moment but it is, of course, the elephant in the room).
How to ensure that local people’s political voices form part of local accountability, and are seen as ‘equal’ to national regulation is a live challenge across so many local places. It is not yet clear how the Place Board will link to local political accountability. Resolving this will be key to understanding whether local political engagement is able to operate as a keystone in this new approach.
And the final two questions are really two parts of the same whole – the question of how local priorities will be set, and what this means in practice for things that are not identified as local priorities.
Firstly, prioritising is really hard work. By definition, it means that some things that people really care about are defined as less important. Everyone struggles with priority setting in real life, let alone in an abstract setting where they are representing a particular organisation or badge.
Trust is the magic ingredient that unlocks effective priority-setting, so there will need to be hard work and time spent within local places to allow people to believe that, just because something they care about is not on the initial priority list, it doesn’t mean it will never happen. And the flip side is the seemingly benign idea that ‘people's wishes and wellbeing’ will shape the setting of those local priorities and outcomes.
People are notoriously complex and it is entirely possibly that their wishes do not form a helpfully consistent agenda, or even that they may not align with the ambitions and outcomes of the organisations within the partnership. One reason that the health and care system has become increasingly centralised is that setting national priorities and following them creates a parent-child dynamic that is probably the ‘easiest’ of the models available to organise services. We may now feel that it has significant drawbacks but there is usually a reason why something that people may not like remains embedded for so long.
The White Paper is an exciting step towards a new way of envisaging health and care and a step closer to a vision of co-creation of health outcomes rather than a model of wellness vs illness.
It is also a hopeful statement that builds on what we learnt about the power of local communities throughout the pandemic; and the power that comes from local connection.
But, in taking that radical step deep into Place, we will have to learn to understand and celebrate the diversity of perspective that may produce, and to empower local place leaders with the time, trust, support and agency to lead differently.