Monday, 20 July 2020

Is it always best to think local?

I’m quite a fan of the New Local Government Network (NLGN).  Their starting point is that government in the UK could be more efficient and effective if more power lay in the hands of local authorities and local communities.

In the past few weeks, their director, Adam Lent, and today deputy director, Jessica Studdert, have made points that have got me thinking about where localism might not quite work as a policy solution.

As in so many areas of politics and policy, debates can end up framed as adversarial – in this case, a choice between ‘localism’ and ‘centralism’.  Given that any conclusion will involve some level of both central and local control, the argument needs to be framed as finding the right balance.  I know that advocates of localism would acknowledge this this, and their fundamental argument is simply that we’ve got the balance wrong, but I want to suggest that too often this leads to suggestions that a local solution will be better when experience tells us something different.  I think more than this, though, I want to be pragmatic about the politics.

First, I want to consider Adam’s critique of Michael Gove’s speech on the future of government.  I think this sets the scene well for the sorts of issues both localists and centralists (if that’s not perpetuating the false binary) are grappling with – and offers an insight into why localism is a powerful idea.

Gove* suggests that there are two key problems with government today: (i) there is rising inequality; (ii) people have lost trust in the ability of (central) government to improve their lives – and these two issues are linked.  Paraphrased by Adam Lent, Gove’s argument is: ‘government is not very good at understanding what makes people’s lives better. As a result, government rarely does make people’s lives better – hence inequality – and the people no longer trust government to actually make their lives better – hence mistrust.’

Gove’s solution is for more expertise in government, to be achieved by two key changes.  First, different people should be recruited to the civil service: more mathematical and scientific experts, rather than ‘those with social science qualifications’.  Second, these staff should be given more stability in their posts, allowing them to develop deeper experience.  These experts will then be brought closer to the people literally: more government should be based in places like Newcastle (in contrast to Sheffield and Bristol, apparently).

The critiques of this that I have seen are twofold.  First, as Abby Innes has argued, the solution to genuine complexity and unpredictability is not simply more ‘expertise’ and ever more complex statistical models; it’s accepting that there will always be issues and situations where decisions have to be made with imperfect information and uncertain consequences.  This approach, she suggests, has more in common with the post-Stalinist Soviet Union than English conservatism.

(I have to say that I find this apparently renewed emphasis on the tenets of New Public Management disappointing almost to the point of feeling exhausted, given that it seemed this might be receding - a development celebrated in the work of people like Toby Lowe and Simon Parker.  In practical, personal terms, my job commissioning substance misuse treatment services has been changed by the fact that the central control and emphasis on ‘performance data’ from the National Treatment Agency has been replaced by advice and support from Public Health England, but more of that later.)

The second critique is that locating ‘experts’ in Newcastle won’t bring government closer to people in any real sense.  As Adam Lent concludes (unsurprisingly for the Director of a think tank that champions the value of localism), what is really needed is ‘a major programme of decentralisation of power and resources; a more participatory and deliberative approach to democratic decision-making; and a fundamental shift away from the paternalism of councils and public sector towards a community-led model.’

I agree with the core of this – that for people to feel trust and a sense of connection to politics, we need ‘a more participatory and deliberative approach to democratic decision-making’ – but I worry that the idea of ‘a major programme of decentralisation of power and resources’ sets up an adversarial debate between ‘centralism’ and ‘localism’, where we have to pick sides.  And it is itself a major programme of bureaucratic reorganisation.

I think this is particularly clear in Adam’s recent comment on the idea that a national social care service could be established to raise the profile of social care and improve its quality and efficiency.  He states: ‘The NHS is an overly hierarchical, bureaucratic, unstrategic institution with a poor organisational culture. Plus it is far too subject to the whims of politicians. Why anyone would want to emulate that in social care is beyond me.’

Again, the solution instead is ‘to localise the NHS under the control of councils and their communities not centralise social care under the control of Westminster.’  Jessica Studdert has expanded on this in today’s piece in the Guardian.

I am not an unequivocal supporter of the NHS.  I have written before about how it is often unfairly used as a way to criticise local commissioners of services, who are seen as ‘privatising’ provision and preferring private or third sector providers.  It can be disappointing.

However, my experience of commissioning substance misuse treatment services since 2011 suggests there are two key advantages to the NHS – or, rather, a national care organisation.

The first point is about funding and politics.  As Jessica notes, “At one level, the issue for social care begins and ends with money”.

Crucially, almost all public sector funding comes from national sources.  We can imagine a world in which regional or local government had more control over revenue-raising, but it seems a long way off at the moment.  And many sources are likely to remain national: VAT, income tax, duty on imports and products such as alcohol and tobacco, to mention a few.

The trouble with local government is that the operation of the service is separated from the source of the revenue.  Central government raises and distributes revenue, then local areas make decisions.  This is why local government has been targeted as part of austerity: it allows central government to effectively outsource the cuts.  The blame for what has been cut and how can be placed onto the local decision-makers, not Whitehall.

A national politician is held to account for a national service.  This is why the health services in the NHS have seen their budgets largely protected (in cash terms, at least), in contrast with those in local authorities (like sexual health, school nursing, health visiting and substance misuse treatment), which have seen theirs cut by 20%.

Civil servants supportive of substance misuse treatment effectively made a gamble when deciding where to put it as a result of the 2013 health reforms: should it go into local authorities or the NHS?  Prior to this it had straddled both, with PCTs commissioning some services and local partnerships generally led by councils commissioning the rest.

It ended up in local authorities, the theory being that substance misuse funding in the NHS had never effectively been ringfenced; it was often used to cross-subsidise other (under-funded) areas like mental health.  As critiques like those of the NLGN suggest, money is too easily lost in such a large, unaccountable organisation.  (Or rather such large organisations, as the NHS is not one entity with a single culture.)

In local authorities, it was thought, the funding could be more easily insulated.  This is probably true,  But it wasn’t foreseen that budgets (including the public health grant) could be more easily cut in local authorities than in the NHS.  Yes, the budget has been relatively well insulated when compared to the NHS, but it’s still got smaller and smaller.

So having social care as a national service might mean that national politicians would be more likely to protect the funding.

Of course it could be argued that we need to revolutionise local government finances, allowing councils to raise more money themselves, but I still struggle to see how there could be genuinely local taxes to generate sufficient income to support all their services, or how this could be equitable across the country.  Is there enough business to support the care needs of the ageing population through local taxation in a rural council area like Dorset?  Or to support the complex needs of a town like Blackpool?  There would surely have to be national funding agreements, and with them the reality of national politics.

Even if we could fund social care locally, I’d suggest there’s another benefit to a national arrangement.  Let’s think again of substance misuse treatment.  The CQC regulates some (though not all) services, but you can’t rely on their occasional inspections to ensure quality provision.  That needs other forms of management and quality assurance.  And the design of services is left up to local areas too, as well as the prioritisation of different issues.

In the eyes of advocates for localism, this is a boon: it means that services can be adapted to local need and preferences.  These days, not every local authority has to have a ‘crack strategy’ to deal with crack cocaine if they feel this isn’t an issue.  And if pharmacies aren’t the best way to deliver needle exchange in their area, they can use other sites instead.

But at the same time, this approach can be inefficient.  Every local authority writes its own audit plans.  Every local authority writes its own specifications.  And so on.

Yes, there can be collaboration, and we’re hopefully seeing this with the creation of a national substance misuse commissioners forum.

But think of what this variation means in practice.  We know that the NHS isn’t truly a national service.  Different medications are available in different areas.  This is also true in local substance misuse services.  In the past, for example, you were more likely to be prescribed buprenorphine in Dorset than in Bournemouth.

But the variation in local services is about more than this: the actual dosages varied dramatically, despite national guidance suggesting that the therapeutic range was typically between 60mls and 120mls of methadone.

This was down to local organisational culture, and part of a pattern (of almost random variation) that could be seen across England.  I’m not suggesting that these kind of variations don’t happen in the NHS; simply that the broader oversight, with national data collection and comparison, means they are less likely. (A positive development on this front is that the National Drug Treatment Monitoring System as of this financial year now collects prescribing data.)

Moreover, although Adam worries about the NHS being dependent on the ‘whim’ of national politicians, the variation in these doses and drug choice is partly dependent on local politicians.

Decisions that shaped these patterns were based on NHS or local authority commissioners and managers interpreting national guidance, with their interpretations inevitably shaped to some degree by both local and national political rhetoric.

Low medication dosages and falling numbers of people in treatment are the result of a ‘recovery’ agenda, most prominently expressed by Iain Duncan Smith, but also embraced by many local council officers and politicians.  Politics and rhetoric affected the quality of the treatment available.

If ‘success’ was defined locally as reducing the number of people in treatment, so it looked like fewer people had a ‘drug problem’, that could be engineered (albeit not always consciously).

What this means is that every local authority has to win the argument to provide treatment in line with the evidence base.  National guidance is not enough.

It might seem that this is less risky than centralisation: if political issues mean that Bournemouth struggles with this, for example, at least we haven’t necessarily lost Dorset into the bargain; whereas a national decision covers everywhere.  But the apparent weakness of the NHS is also a key strength: it may be hard to manoeuvre, but that means it’s also harder to universally manipulate.  If this sounds like a distrust of politicians, it’s not my distrust, but Adam’s.  We’re back to those dangerous 'whims' of politicians again.

The issue comes down to where one sees the greatest risks, and I’m not clear about the answer.  I certainly can’t say the solution is obviously either centralism or localism.  Do we have the level of resource and expertise to invent the wheel in almost 150 local authorities in England?  Or are we better off getting something more nationally controlled and mandated?

In my experience, looking at the history of substance misuse treatment, we were better off with the inefficiencies of the centrally-controlled regime, rather than attempting to create independent solutions in every area.  People who seemed to hate the National Treatment Agency at the time now seem to long for it.

And as Jessica points out, “care is essentially about people and relationships, not buildings and services”.  I’d absolutely echo that point.  But I’d therefore emphasise that the key is not to think too much about the structures, given that what makes a difference is people.

And let’s not imagine that this wouldn’t constitute a form of bureaucratic reorganisation.  We’re all agreed that the current arrangements are unsustainable.  Jessica suggests that “There is no question that the care system is in urgent need of funding reform, but nationalising social care wouldn’t solve its problems”.  I would argue that without changing the political arrangements, there can be no funding solution.  Of course, I don’t want to position myself into the same adversarial central/local argument that I started this piece by describing, and there are other options for organising services that we should be considering.  But I worry that the dream of localism could lead to a reality of poorly funded services with inadequate quality assurance.

 

*I’m never quite sure how to refer to people in these kind of pieces.  In an academic article, you’d just say ‘Gove’, ‘Lent’ and ‘Studdert’ and not worry about it.  But this seems oddly formal and stilted for a blog.  Here, I’ve decided that I’m saying ‘Gove’ because I’ve never met him, and this seems appropriate for a national politician, whereas I’m referring to ‘Adam’ and ‘Jessica’ because I have once met them – and they’re not national politicians who are often referred to only by their surnames.  I hope that seems reasonable and sufficiently human!

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