The Place-Based Challenge

Introduction

Governance issues and conflicts in terms of how to deal with health issues are evident if we look at the local dimension of healthcare delivery. The United Kingdom has a very specific situation in that local government and local authorities, who are in part responsible for healthcare delivery, do not have any codified rules or any constitutional guarantees. National parliament is sovereign and therefore NHS institutions, while they collaborate with local authorities and social services in the delivery of healthcare, are actually accountable to central government. The absence of constitutional checks and balances in the British system of government means that new legislation may be implemented and both local government and NHS institutions need to adapt service delivery to such regulations. A lack of information and ability to follow such evolving legislation is a major issue for National Health Service (NHS) providers in the localities (European Observatory on Health Systems and Policies, 2015).

The situation has become even more complex since the move towards devolving responsibility for the delivery of healthcare. From 1997 onwards and the process of devolution, which transferred powers to manage health to separate bodies in Scotland, Wales, Northern Ireland and England, the nations of the UK began to manage healthcare quite differently. Health services are funded via block grants for Scotland, Wales and Northern Ireland and a budget is allocated to England from the UK government. Each health department then funds health organisations in the regions and sub-regions of the separate nations who arrange services on behalf of their patients (European Observatory on Health Systems and Policies, 2015). Further transfer of power to the local level was also encouraged by New Labour and set out in the publication Shifting the Balance of Power: The Next Steps (Department of Health, 2001). Whereas healthcare delivery used to be divided quite distinctly between on the one hand, strategy, policy and management, and on the other hand, medical and clinical care, the move to a more decentralised system of healthcare has resulted in a blurring of the two divisions (Grosios, Gahan, & Burbidge, 2010).

When considering the provision of healthcare services in a country, it is necessary to examine action at a local level and problems that local health service providers must face. This is essentially because it is within individual communities and neighbourhoods that most public health interventions take place. Local intervention is also important in order to co-ordinate a more even pattern of healthcare provision across the regions. Where regions or localities are seen to be failing in their provision of good quality services, action is needed at both the local and national level. This is because the NHS is a national institution and should therefore provide for the needs of all its citizens in an equitable way. The role of healthcare services in the region goes beyond the sole domain of health. Quality healthcare can contribute to attracting new industries and skilled people, and is important for the social and economic prosperity of the region. Health service providers also contribute to the overall economy of a region, raising both GDP and employment levels, with clear linkages and multiplier effects. Issues such as coping with an ageing population, poor health and higher expectations for healthcare delivery are ever more evident at the local level and raise even more governance challenges since health performance is so uneven in the United Kingdom.

It has become clear over recent decades that there are significant disparities between regions and inter-regions. When looking at a wide set of indicators in the regions¹, there is a definite north-south divide in terms of health. Sub-regional disparities are often even greater than those between regions, but this does not diminish the weight of data that shows that the majority of southern regions fare much better than their northern² counterparts for health outcomes. In England in particular, recent cuts to public services, welfare benefits and public jobs have severely affected those regions. Overall, health inequalities have risen. Life expectancy has increased steadily in the United Kingdom, but some areas are experiencing declining life expectancy once again. This chapter will thus explore local governance policy. It will then review uneven health performance across the regions and policies to address such health inequalities. It will consider how England and each of the devolved administration is performing and to what extent the current public health service governance framework, and especially NHS health service provision, at the local level can mitigate disparities in health outcomes.