Governance and accountability: ICSs and LGR
In this guest blog, Mark Sandford, a senior research analyst at the House of Commons Library, delves into the implications for local accountability through reorganisation and the Health and Care Bill.
When institutional reforms take effect in the UK, governance, accountability and scrutiny are accustomed to being the afterthought. Often, accountability is thought of in narrowly financial terms, or at best as an ill-defined additional benefit of ‘reform’. It is often used to denote different things in different contexts: it can relate to transparency, audit, reporting requirements, targets and sanctions, or political oversight.
An additional challenge for accountability is how it can function within systems of ‘place-based leadership’. The idea of joining up policy-making across public sector organisations within defined ‘places’ has resurfaced during 2021 during proposals for restructuring within local government and the NHS. This is an intuitive idea: organisations working together towards a common goal. But when this happens, who is to be held accountable for decision-making or for failures? Neither commentators nor government have really got to grips with this question.
Local government restructuring
In October 2020, Robert Jenrick, the Secretary of State for Communities and Local Government, invited councils in Cumbria, North Yorkshire and Somerset to submit proposals to create unitary authorities in those areas. In each area, separate proposals were submitted by the county council and by a coalition of district councils.
On 22 July 2021, the Government announced its decision to create a single unitary authority in North Yorkshire, a single unitary authority in Somerset, and two unitary councils in Cumbria (on an ‘east / west’ basis). Cumbria County Council has announced plans to seek a judicial review of the decision.
The Government published statutory guidance on reorganisation proposals in 2019. The guidance mentions the purpose of reorganisation as being “more sustainable local government and local service delivery, enhanced local accountability, and empowered local communities”. Ministers have rarely elaborated on what ‘enhanced local accountability’ comprises, and it is rarely raised in Parliamentary debates.
Integrated Care Systems (ICSs)
In parallel, the NHS appears to be reviewing how it manages relationships with other parts of the public sector at the local level. NHS England published a consultation on Integrated Care Systems in March 2021, which discusses ‘place-based partnerships’ at some length. It proposes a future in which “each place has appropriate resources, autonomy and decision-making capabilities” and “a clear but flexible accountability framework that enables collaboration around funding and financial accountability, commissioning and risk management” (p12-13). It also states that “collaboration between partners in a place across health, care services, public health, and voluntary sector can overcome competing objectives and separate funding flows to help address health inequalities” (p5). To this end, the consultation suggests allocating funding on a population basis at regional level in future years. Also, Integrated Care Boards are to be permitted to establish committees – including place-based committees – and delegate functions to them if they see fit.
The Health and Care Bill 2021-22, which will establish statutory Integrated Care Boards and Integrated Care Partnerships across England, began its committee stage in the House of Commons in September 2021. The Bill itself, however, does not make any provision for place-level operations at geographical levels below that of the ICS itself.
Place-based policy-making appears to enjoy some popularity within Government at present, as evidenced by the announcement of the pilot “Partnerships for People and Place” in July 2021. Indeed, the NHS England paper Designing integrated care systems in England, published in 2019, defined a ‘place’ as somewhere “served by a set of healthcare providers… connecting primary care networks to broader services”, with a population of 250,000-500,000. And the King’s Fund paper The health and social care White Paper explained, published in March 2021, says that “experience suggests that much of the heavy lifting of integration and improving population health is driven by organisations collaborating at this level”.
However, where executive decisions are made by a partnership body with multiple members, who is accountable for policy, and who should be scrutinised and held responsible locally? Guidance published in September 2021 states that, within ICSs, accountability for any delegated functions will remain with the delegating body. But it will be up to ICSs themselves to decide how this accountability is discharged.
In parallel to the question of accountability, a place-based system of service delivery must address the question of whether the geographies of different bodies within the system should – or must – be aligned. This is as key a question for accountability as it is for decision-making. Where boundaries are not aligned, a health body (for instance) might claim that its decisions were framed by the priorities of a neighbouring local authority – and thus it could not be held entirely accountable for its actions. Ostensibly, such a scenario would erode the degree to which local representatives could hold decision-makers to account.
In the event, the Government announced in July 2021 that a number of planned ICSs that would cut across local government boundaries would be allowed to remain unchanged. This represented a step away from a report from the Health Services Journal in February 2021, which suggested a number of established ICS areas that could be required to change in order to align with local government geographies (such as Cumbria; Bassetlaw; Glossop (Derbyshire); Waveney (Norfolk); Frimley (Surrey / Hampshire / Berkshire); West Birmingham; Essex; and North Yorkshire.
This goes against a prevailing wisdom of administrative geography, that coterminosity – the alignment of different organisations’ geographical coverage – is beneficial. The Health Devolution Commission’s response to the consultation proposed aligning ICS geographies with combined authorities, or with “one or more county councils”. However, writing in 1998, Mark Exworthy and Stephen Peckham found that the benefits of coterminosity were “assumed, rather than proven”. Some groups of organisations might benefit less than others from aligning boundaries, and it was not possible to say that service delivery improved more where more boundaries aligned with one another.
Governance, accountability and place
But the caution expressed by Exworthy and Peckham may help to explain why few links are apparent between the geographies of local government restructuring and recent discourse on place within the NHS. It seems likely that some local partnerships will continue to be formed of public bodies that share boundaries, and some will be formed of public bodies that do not. In either case, holding partnerships accountable for decision-making is a complex undertaking, with much scope for experimentation.