Few things get me excited about local political (small “p”) possibilities. Total Place is one of them. It points the way out of the morass of unjoinedupness in which local public services and their users are mired up to our necks. HM Treasury surveyed the TP pilots in March and concluded their potential should be expanded. Any new government after the 6th of May should focus on this – lots of savings and efficiencies to be had for those prepared to be bold and take a whole area approach to commissioning (planning) and paying for integrated services in England.
Tantalising possibilities of Total Place
There are a growing number of Eeyores moaning that commissioning has failed in England, including the gloomy souls who wrote the recent Commons Health Committee report. I think they are wrong. Commissioners – especially NHS ones – are not being smart enough and bold enough. Too many are still stuck with purchasing the same old, same old.
Karen Cherrett of PA Consulting agrees about commissioning in an excellent, inspiring even, piece is in the current Guardian Public. She identifies Total Place as the way forward for strategic commissioning but is stern in what must happen first for it to succeed: the painful effort needed to get even this far also illustrates that encouraging, even forcing, agencies to join up in operational delivery is not enough. The most senior levels of policy making need to address the more fundamental issues of how delivery is incentivised and prioritised before they focus on the structure of delivery through Total Place. The old lesson that “culture eats strategy” certainly applies here, but it can be prevented.
Piecemeal, timid, little customer insight
Commissioning hasn’t failed. On the contrary, we haven’t applied it properly – yet. We are only just learning in the NHS what strategic commissioning means. What we have done so far is too piecemeal and timid and largely in isolation from customer insight – the vital ingredient for success. Without customer insight we will never understand demand and never have the business foresight to make changes.
Total Place demands engagement with users and the public – the Treasury evaluation of the TP pilots is quite blunt about the characteristics of a successful system: services have to be built around citizens and their needs. That means Local services have a clear picture of the needs of users, the appropriate services to meet those needs and the outcomes that they are looking for services to achieve, developed through user-engagement. (p 45) Third Sector bodies – closely in touch with users – have an essential role to play in this.
Surviving the resources famine
Total Place shows a way forward for those Councils and PCTs that are bold enough to abandon their insular cultures and do things jointly with their residents that make a difference. In the coming resources famine that will overtake us after the 6th of May glow recedes, people will discover this. It is quite different from just handing community health commissioning to the Councils as some naively argue because that would perpetuate inbuilt cultural and structural problems.
We need new-style integrated agencies which are democratically accountable to take a strategic commissioning approach to “total place” issues – including not just health and social services, but policing, housing, transport, education and leisure. And these bodies must have the power to stop doing things that are duplicated or of dubious effectiveness.
Let’s start now with local government
From the perspective of a London PCT PEC member for eight years, I see no alternative but to invent Total Place approaches for each borough and pool our resources – people and money – with local government to do things that make a positive difference to health, well being and inequalities. Strategic commissioning must do what it says on the tin.
Are there any local politicians in London bold enough to take up the Total Place challenge and do what needs to be done?