healthcare update - issue 12
Total Place – the final report
Following on from our update in the last edition of our healthcare
bulletin, the Government has now published the final report from
the Total Place pilots.
The Total Place approach was developed over 12 months through
the work of 63 local authorities, 34 primary care trusts, 12 fire
authorities, 13 police authorities and a wide range of third sector
and service delivery bodies. The report, released shortly after the
Budget in March 2010, summarises the outcomes of the pilots and
sets out how it intends to build on the findings.
As Communities Secretary John Denham commented on the day the
report was published, it is clear that “the pilots have made a
compelling case for a radical re-think in the way local services
are provided.” As the impending General Election comes closer, it
is also apparent that the Total Place concept is here to stay. All
three main political parties have publicly committed, at differing
levels, to support the development of further integration between
public sector organisations.
The main proposals
1. The ‘single offer’
The single offer will give places a range of freedoms where they
work in partnership with the Government to co-design services and
arrangements which have the effect of delivering greater
transparency, efficiency and value.
These freedoms will include freedom from central performance and
financial control as well as other incentives linked to local
collaboration. These may include further reduction of ring fences
for local authorities, PCTs and other partners; agreement as to the
outcome targets and indicators which reporting will focus on and/or
a lighter approach to assessment and reporting. This is a refresh
of the “earned autonomy” principles with which many PCTs will be
familiar!
The first high performing place will be able to participate in
the single offer initiative from 1 April 2011.
2. The ‘innovative policy offer’
The innovative policy offer will be available to places where
they can demonstrate real strengths in a particular policy
area.
This offer allows the Government to devolve responsibility for
functions falling within an agreed delivery theme. The freedoms
will be similar to those under the single offer but linked only to
that theme.
3. Total capital and asset pathfinders
Several pilots noted that the efficiency and effectiveness of
the local public sector estate could be improved through a more
joined up approach to asset management.
The Homes and Communities Agency worked with a number of the
pilots in relation to new capital investment and this identified
the potential to create a collaborative commissioning approach to
both new capital investment and existing property assets. The work
has built on the Government’s commitment to develop regional
strategies for the Government’s estate in ‘Putting the frontline
first: smarter Government’.
Going forward, the Government will be working with 11
pathfinders to co-design and deliver capital and asset strategies
to deliver improved services and better outcomes. It is envisaged
that these pathfinders will develop specific models which support
strategic decision making, investment planning, governance,
accountability, collaboration, procurement and programme
information.
With the emphasis on better and more effective utilisation of
their estate, which may in part be driven by CQC and other
regulations in relation to the quality of that estate which is used
for patients, it is inevitable that the NHS will look to develop
new asset management models and related procurements to support
‘fleet of foot’ but cost-effective development.
Challenges for the NHS
The final report and the subsequent political support for its
findings indicate that a step change from organisational working to
a system wide approach is imminent.
This change will result not only in a new way of thinking about
how health services can be effectively delivered, but also a
fundamental change to the way that health organisations, both
providers and commissioners, are structured.
Although the exact formats are unclear, it is likely that health
bodies will increasingly be expected to assess whether services
could be delivered more effectively through innovative new
approaches before formally initiating them. These new approaches
could foreseeably include:
Multi-agency partnerships which share responsibility for
delivering certain services
It is arguable that the
statutory duty on local authorities and the NHS to work together
has already introduced the concept of partnerships to a certain
extent, for example in establishing Sure Start children’s
centres.
However, the partnerships envisaged in the final report are
potentially much wider, creating amongst other possibilities,
permanent collaborations and involving private and voluntary
organisations outside of the public sector.
The potential rewards are numerous but they will be resource
heavy at the outset, particularly in agreeing and determining the
governance and accountability frameworks that will apply. If
successful, they are likely to reduce overheads and transaction
costs by reducing duplication and encouraging efficiency. The
partnering of activities and funding in this manner will also
enable better targeted spending towards the needs and priorities of
each place.
Collaborative procurements
The pilots made
clear that substantial savings could be made by combining projects
to fit into a larger project rather than commissioning on a project
by project basis. However, this may lead to the emphasis on
competitive dialogue as the vehicle for procurement which, again,
will be resource heavy.
Joint ventures and local property
vehicles
Joint ventures and local property vehicles
could play a key role in the provision of services and effective
use of assets, particularly in relation to the effective management
of NHS estates.
Kent has already taken the lead, announcing that it intends to
establish a countywide management board and appoint private
consultants to help run its separate property portfolios. It
estimates that it can sell £278m of property assets in the next
five years, as well as finding revenue savings of £40m a year.
Pooling and aligning budgets
The pilots
called for an increase in the use of pooled and aligned budgets and
to support this, the final report refers to the development of
template documents which will be designed to enable local
partnerships to collaborate. The recent audit commission paper
‘Means To An End: joint financing across health and social care’
advises on the pitfalls and benefits of such processes – the lack
of legal agreements being such a pitfall!
What next?
The next stage of the Total Place initiative has been dubbed
'Total Place 2'. Although the number of places taking part has not
yet been announced, the idea is that these places will consolidate
and build on the recommendations of this report to develop, by
April 2011, a clear understanding of what it is like to be a
'customer' of all the public services in their place.
The impending General Election means that it is impossible to
predict exactly how the initiative will progress. However, in light
of significant anticipated public sector cuts the findings should
be of interest to all NHS organisations looking to make savings and
increase efficiency.
We will keep you updated with any developments. If you would
like to discuss any ideas or initiatives based on the Total Place
approach, please do not hesitate to contact us.
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The content of this update is provided for the purposes of
general interest and information. It contains only brief summaries
of aspects of the subject matter and does not provide comprehensive
statements of the law. It does not constitute legal advice and does
not provide a substitute for it.