Commissioning and social determinants: evidence and opportunities

This chapter argues that local authorities can and should use their purchasing power strategically to address the social determinants of health that affect their local area. It examines commissioning and procurement as local authority functions, defining these concepts and exploring the conceptual confusion between the two. The chapter then looks at the evidence of current practice of local authorities (with a particular focus on local authorities in the UK) in strategic use of their purchasing power. Core to the argument is the role of local voluntary organisations and small and medium-sized enterprises (SMEs), so there is a particular focus on the commissioning experience of these types of organisations. Finally, the chapter makes the case for the role that voluntary sector organisations can play in addressing social determinants of health, before drawing some broad conclusions about the way forward.

Conclusion

This concluding chapter explains that in order to develop interrelationships and interdependencies across the various domains within a social determinants of health rainbow model, there needs to be a good understanding and respect for each of these contributions to the health and wellbeing of people and their communities. In the ten-year period of austerity preceding the COVID-19 crisis, many local authorities have radically reduced their social and health services for children and families and young people, concentrating solely on those with the most acute need, those whom they have a legal obligation to support. Indeed, local government has 'retreated from its historical position as the front-line of defence against social evils'. There remain major concerns about local authorities' ability to support their communities in the post-COVID-19 period. Ultimately, although there are large numbers of reports and reviews aimed at local commissioning policies and practices, there is very little evidence to support the interrelated and interdependent approaches utilising a social determinants of health model that specifically addresses 'wicked issues'.

A place-based approach to healthy, happy lives

This chapter outlines innovative approaches to maintain a healthy, happy, and safe community. The wider determinants of health — housing, environment, leisure, income, and education — are well recognised and are just as important as access to good health care. If we want to develop long-term strategies to enable social and cultural change with new models of care, more community-based responsibility for our neighbours and more freedoms and flexibilities to help us make better choices, then the role of place is key. place-based approaches, involving health and social care integration and outcome commissioning, have been developed with a view to a consideration of 'health' in all council planning. This reflects the place-based approach that is being promoted by the London Borough of Sutton as it delegates its statutory duties across the range of services it manages, collaborating with other statutory and third sector organisations within and beyond the two parliamentary constituencies of Sutton and Cheam, and Carshalton and Wallington. A place-based approach to health and wellbeing, in its widest sense, can bring together all parts of the public sector to focus on positive outcomes.

The role of the third sector working with the hard and soft structures of public–private partnerships to promote individual health and reinvigorated, healthier communities

This chapter discusses the role of the third sector working with the hard and soft structures of public–private partnerships to promote healthier individuals and communities. It considers how a recommitment to the 'local authority' of citizens and beneficiaries offers the possibility of revitalised and healthier individuals and reinvigorated and healthier communities, which are unachievable through the hard and soft structures of the commissioner/provider statutory approach. The chapter then identifies the pivotal dynamic of one-to-one relationships in these processes and their association with health outcomes (emotional, physical, and spiritual) alongside the opportunities and challenges in agencies engaging/re-engaging with the agency of citizens and beneficiaries. It explores the tension between the 'agency' of citizens and beneficiaries that constitutes bottom-up power and 'agencies' with top-down power. The chapter also looks at the benefits of embracing the expertise and investment of individuals and their communities in their personal and shared lives, how this can be supported and how it can be undermined.

From front-line defence to back‑foot retreat: the diminishment of local government’s role in social health outcomes

This chapter investigates the diminishment of local government's role in social health outcomes. The 20th century led to radical improvements in public health across England and the United Kingdom (UK). Modern local government in the UK was born out of a growing concern about the links between social conditions and the state of public health. Yet while 'social determinants of health' has become a global discipline, local government has ceded its role over the last decade as its capacity has withered during the time of austerity. The COVID-19 crisis of 2020 has shown the capacity of local government to mobilise anew around public health issues, but its fundamental fiscal and constitutional weaknesses show that a new settlement is needed more than ever.

The changing landscape of local authority commissioning

This chapter assesses the history of the relationship between public and private sectors and the extent to which the political and regulatory environment of governments and institutions such as the European Union (EU) can help or hinder the efforts of public bodies in seeking to deliver services that determine the health and quality of life for communities. The relationship of public and private sectors in the United Kingdom (UK) and the commissioning, procurement, and development of public–private partnerships is driven by the prevailing political and economic environment. However, rigorous academic research on the benefits of partnering to organisations, societies and between countries is limited. Evidence is needed to fill the policy vacuum. A bolder approach is necessary to work with public and private sectors to develop and implement successful partnering alternatives to the outsourcing of public services. The growing catalogue of outsourcing failures in construction, probation, rail franchising, health, and social care is creating an appetite for change, and the exit of the UK from the EU provides the opportunity.

Introduction: Key sociopolitical changes affecting the health and wellbeing of people

This introductory chapter provides an overview of the relationship between health and housing, regional disparities and responses across England, Wales, and Scotland in the provision of health and social care and local authority commissioning. It considers how the Municipal Corporations Act (1835) led to the establishment of elected town councils. In the mid- to late 20th century, municipalisation gave way to centralised government, which subverted the autonomy of local authorities. Currently, social care is provided and funded by local authorities and private funders. The main objective of social care is to help people to live well and happily, and live as long as they can. This person-centred approach is in contrast to the systems that have been developed to support the health care needs of people. In 2020, poverty still remains a key driver of poor health and wellbeing.

Future generations: the role of community-based organisations in supporting young people

This chapter presents two non-statutory approaches aimed at engaging young people in the community. The Youth United Foundation (YUF) supports the development of well-established community-based organisations including the Scouts, Guides, and Boys' Brigade, joined recently by the creation of new uniformed youth organisations, including Fire and Police Cadets, to help significantly increase opportunities for young people from the most disadvantaged communities. Building on the place-based policies of the London Borough of Sutton, Sutton Community Dance (SCD) is an example of reimagining the local high street and prioritising shared places as an important context for building intergenerational bridges. Such a model of reimagination and creative agility will be critical in helping already challenged town centres to develop new possibilities for reform post the COVID-19 pandemic. This all-age inclusive development makes a significant contribution to the social determinants of health in this South London borough, through improvements in health and wellbeing and the promotion of self-actualisation.

Strictly come partnering: are health and wellbeing boards the answer?

This chapter highlights the need for partnership working, which has been a long-standing objective of health and social policy. For many years, the National Health Service (NHS) and local authorities have been attempting to deal with 'wicked issues'. Issues such as homelessness, disaffection of young people, and the ageing society that have complex multiple causes require joined-up approaches by the statutory and third sectors at national and local levels. In 2012, at the time when Public Health responsibilities were transferred from the NHS to local authorities, health and wellbeing boards (HWBs) were established in England. With few exceptions, HWBs punch below their weight and are not the powerful system leaders that were hoped for. Evidence of their value and impact is negligible, with poor-performance indicators, and the difficulties in overcoming deep-seated departmentalism and a silo approach prevalent in government and public services, leaving 'wicked issues' as deep-seated as ever.

Steadying the swinging pendulum – how might we accommodate competing approaches to public service delivery?

This chapter reflects on the challenge of accommodating competing approaches to public service delivery. Discourse around the social determinants of health is skewed towards the parts of the population whose adverse social circumstances harm their health the most. Local authorities are much closer to the complexities of service delivery than central government departments, and thus have an instrumental role to play in efforts to support these groups. They do not play this role alone — it is shared with other local delivery agencies, such as Sustainability and Transformation Partnerships in the National Health Service (NHS), as well as private providers and local community groups. There has always been much debate around what role each of these actors should play, and how they might interact with one another so as to create masterful theatre rather than a depressing farce. This question continues to be the focus of much policymaking, experimentation, and debate. The chapter then considers the West London Zone for Children and Young People, a cross-sector delivery partnership. It also explores some of the intersecting themes across other efforts, drawing on research from the Government Outcomes Lab.