Place and policy making: how can local decision-making achieve greater change?

1 March 2021


Reported by Samuel Ward, CSaP Policy Intern

In the penultimate seminar of the Christ’s College Climate Series, Dr Jeanelle de Gruchy, Professor Michael Kenny and Sir Chris Ham examined the merits of placed-based health systems designed around the needs of local communities.

You can listen to a recording of the event here:

Throughout the discussion, the challenges facing local healthcare systems in the UK were encapsulated in four words by Dr. de Gruchy. She called for respect of the systems that we already have in places, and the knowledge they currently hold; emphasised that the local is the level where the largest impact is experienced; and noted that we need to recognize the importance of local communities. She then asked, based on these points, how can we strengthen local systems?

Reflecting upon the state of these systems, Sir Chris noted that throughout the early 2010s, the NHS system became increasingly complex and fragmented. This was the result of years of market-oriented reform by successive governments, which had left a system that he believed was not fit for purpose. However, more recently, the structure of organisations has become more varied, sparking the hope of creating a more capable infrastructure. Integrated care systems now operate at the regional level, whilst GP practices working together form a primary care network that administers the local level. An additional layer of partnerships also exists between the NHS and local authorities, and within the NHS family itself, to link hospitals, mental health communities and commissioners. The aim of these place-based systems of care is to improve health, wellbeing and care.

However, understanding place-based health systems has often remained difficult and complex. Places sit at the intersection of geography, sociology, epidemiology and economics, explained Sir Chris. Places contain communities of different people with many assets and relationships, and they have different patterns of health and wellbeing that reflect the underlying local determinants of health. These systems function based on a different logic from the the top-down methodology currently embedded within the NHS, where the centralisation of control allows Parliament to hold the money and accountability, whilst the central NHS is the ultimate judge of performance. This isn’t to say that a more horizontal approach is impossible, as Elinor Ostrom’s empirical work on fisheries and forest trees has demonstrated that governance of common resources can succeed through shared ownership and responsibilities. Discussion participants noted that we have also observed a more recent confirmation of this 'horizontal approach' philosophy as the health system works with mutual aid to respond more successfully to the global pandemic. On the other hand, the pandemic has also shown there are real weaknesses in the capacity of a centralised government to draw on a diverse range of expertise to learn from its actions.

So will interest in the value of the local continue, as the pandemic subsides? While the vocal demand for recognition from regional mayors and first ministers in the devolved administrations has been powerful, Dr. de Gruchy cautioned that the strengthening of local powers is ultimately tied to their funding, and that a question remains as to whether the government is prepared to share responsibility, without the inclusion of costly private sector entities. Regardless, central governance will remain valuable when tackling large-scale challenges such as the rolling out a national vaccine programme, for example. As such, the challenge moving forwards will be to strike a balance. Discussion participants were left with the question: Can we have a system of government, with more collective and distributed leadership, that is capable of flexing in response to strong shocks, rather than a culture of heroic leadership around the few?

The 2021 Christ’s College Climate Seminar Series focuses on achieving change for population and planetary health post pandemic. This year's series is hosted in partnership with Christ's College and the Lancet-Chatham House Commission on Improving Population Health Post COVID-19. Throughout the series, we will be exploring how three major threats to population and planetary health— infectious diseases, non-communicable disease, and climate and environmental emergencies are intimately intertwined, and how synergistic actions across these areas have the potential to promote transformative change. You can learn more and register to attend upcoming seminars in this series here.

Dr Jeanelle de Gruchy

The Association of Directors of Public Health (UK)

Sir Chris Ham

The King's Fund

Professor Michael Kenny

Bennett Institute for Public Policy, University of Cambridge

Samuel Ward

University of York