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Who really makes decisions about local health funding for the Voluntary and Community Sector?

June 9, 2014

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A summary of the governments policy on health and social care is a bit like this:

  • focus more on prevention
  • support people to live longer in their homes through better integration

…..and the solution is to take money out of acute care and invest it in communities

This should represent a real opportunity for organisations with expertise in working in communities and on the social determinants of health – in particular the local voluntary and community sector – to contribute and get access to funding. It does not feel that this is the case!

In part this is because we are locked into an analysis of how commissioning works that does not reflect reality.

The official commissioning model.

  • Assess need at local authority level using the JSNA
  • Debate and agree local priorities through the Health and Wellbeing Board
  • Put these priorities into the Joint Health and Wellbeing Strategy
  • The JHWS drives commissioning plans of CCGs who then rationally commission local services

…….and so we achieve the shift from acute to community.

The problem is this is not how the system works.

The Real World

Most funding is tied up in the acute hospitals and care trusts and although in theory this can be released and reshaped as contracts are tendered and renewed there is huge inertia in the system. Not least because even if the provider changes – local commissioners do not usually build in voluntary sector provision into these contracts at a sufficient scale.

This is often because they are searching for evidence of impact (savings, better outcomes) that does not exist and probably never will – at the level they require.

At the same time we see an increasing number of examples of clinicians who are convinced of the role of the VCS – this is because they are on the front line and see and feel the impact of the VCS. So, the expertise in making decisions about service design and development rests primarily with providers rather than with CCGs or NHS England.

The governments creation of the Better Care Fund (ring fencing existing funding) is a recognition that the local commissioning model described above is not sufficient to achieve change.

At the moment the organisations with the power are the NHS Trusts and GPs – they receive most of the funding and have some freedom to design services to deliver outcomes. They are more important and relevant because they have a better analysis of the challenges and opportunities in providing relevant services to improve wellbeing.

Government led marketisation means that these organisations know that they are in a competitive environment where their services may be up for tender or at the least market testing. They have a huge self interest in retaining control of this funding and of course ensuring their survival at a personal and organisational level. They also have a great deal of influence with the CCG and with NHSE.

What can the voluntary and community sector do?

I think there are two key actions.

Operational/Service Level

VCS organisations need to focus on co-producing with NHS providers service models that build VCS provision into clinical pathways. There are a growing number of examples of these – these are some that I know about:

I think that these co-produced relationships often work to a more realistic view of what evidence is. Clinicians on the front line can have a more sophisticated view of impact than a commissioner who will only feel able to fund a service if it can demonstrate measurable savings or direct health outcomes.

System Level

This is more challenging, the better care fund despite justifiable cynicism about it does offer hope here. Arguably this is where CCGs can play a role – leading a co-produced approach across sectors through Health and Wellbeing Boards. Nicola Kingston has drawn my attention to the Whole Systems Integrated Care approach being taken in North West London which does look like a genuine attempt to co-produce a solution.

It is important to note though that the VCS does not appear on the list of partners – it does feel very statutory. Nonetheless if voluntary organisations have been able to play in on the coat tails of some of the partners mentioned here in the way I describe above then there may be some traction.

What do you think?

Working with the local voluntary sector to tackle Inequality and Exclusion – a better JSNA

May 6, 2014

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This is a story about some work I have been doing for the last year or so to improve the way the expertise of grass roots organisations is heard by local commissioners.

The problem

There’s nothing inherently wrong with the Joint Strategic Needs Assessment (JSNA) and the Joint Health and Wellbeing Strategy (JHWS) but the way they have been developed means that they are:

  • read by few,
  • provide a very high level view of need that is largely based on a set of standard national measures
  • struggle to bend system priorities to complex, small and pressing issues that too often slip below the radar.

It is often the case that it is these small, complex ‘wicked’ issues that grass roots organisations are tackling on a day to day basis – and they feel frustrated that the problems they are addressing do not seem to be understood at a JSNA or JHWS level. This of course is one of the reasons why commissioning continues to favour big statutory and private organisations.

I think that one of the reasons this happens is because we fall into the trap of thinking that the JSNA process is primarily a linear one – gather up all the data, put it all in one place – a web site or a report and then analyse it.

I am not arguing against this process – its good to have a population level view - but it is not sufficient if we want a genuinely responsive, inclusive and integrated approach to local commissioning, specifically one that is able to bring issues forward that:

  • Affect small populations
  • Are complex – multi-causal
  • Have poor incomplete data sets
  • Are about power, exclusion and inequality

Many of the organisations that work in this area are voluntary and community sector ones. If you work in areas that are easily ignored with people who are unpopular with policy makers then you are likely to struggle to be heard too. Witness the Trussell Trusts exclusion by Ian Duncan Smith.

So, we need a more asset based approach. One that gives voice to these organisations, playing to their strengths and allowing them to share their analysis of the issues they are tackling. This means providing opportunities for the expertise of these organisations to play in and for the voice of the people they serve to be heard.

It also means making it worthwhile for these very pressured organisations to contribute to the process.

Rapid Intelligence Review

About a year ago I started a project to try to come up with a rapid way of trying to address this problem – this is not rocket science. Working in partnership with Involve Yorkshire and Humber and funded by what was then the Yorkshire and Humber Public Health Observatory (now Public Health England Knowledge and Intelligence Team) we devised a model based on the following principles:

  • It had to make little demand on the voluntary and community sector in terms of time or resource
  • It needed to be led by a VCS view of what issues we should focus on
  • It had to capture a more complete story – so a mixture of qualitative and quantitative data
  • It had to be cheap
  • It needed to make some recommendations

The VCS in two areas (NOVA in Wakefield and Voluntary Action Sheffield) with their respective local authorities worked through the process with us. In Sheffield they identified food banks and specifically the people who use them as the priority area and in Wakefield they identified Pressured Parents.

The Wakefield Report is available here
The Sheffield Report (which I referred to in an earlier blog) is available here

Jake Abbas (Interim Director, PHE Northern, Knowledge and Intelligence Team) and I have written an overview report on the process which has now been published by Public Health England. This is titled:

Using rapid intelligence reviews to strengthen the voice of the voluntary and community sector in local commissioning.

Implications

The experience of doing the two reviews has led me to the following conclusions:

  1. the JSNA process cannot just be about putting all the data into one place – it must also include a continuous process of small reviews that focus on “wicked issues” and the process for determining these should be jointly agreed with local civil society organisations.
  2. it is important to have actions and recommendations – but for a number of these issues just using the review to create a debate at a place level is a step forward.
  3. we need a more inclusive view of evidence – lack of population level data or RCT evidence is not a good reason for failing to investigate a topic – its actually an abrogation of responsibility.

What do you think?

Footnote

Jake and I will be sharing this work at the Local Area Research and Intelligence Association Conference this year – and hopefully at other national events – if I can get the abstracts done!

Public rate NHS England higher than GPs and Hospitals!

April 7, 2014

BLOG Insight dashboard NHSE

The latest data from the NHS England Insights dashboard shows that the public are making more positive comments about NHS England on social media than negative ones this compares far more favourably than comments the public are making about General Practice and Hospital Services.

 

Data for March 2014

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What is the NHS England Insights Dashboard?

The NHSE Insights Dashboard is meant to be a triangulated insight tool that provides a set of measures reflecting feedback to the NHS from patients using services and conversations being had about the NHS. It was due to be launched in April 2013 as an iPAd application – I don’t think this has happened yet. I have no idea how much it costs. However it is part of an ambition that NHS England has to:

“Use online social listening tools to monitor conversations (online comments about the NHS) in detail”

The intention was that from April 2013 NHS England would be able to:

“monitor real time and historically…. a wide range of metrics including volume: force (aggregate influence of conversations); sentiment (whether conversations are positive or negative); demographics (who is having the conversations); and trends (identify trending topics and themes)”

Both of the above quotes come from a paper by Tim Kelsey for the NHS Commissioning Board (now NHSE England Board) produced in February 2013

What does the March Insights Dashboard tell us?

There are a number of possible conclusions here.

  • The first is that NHS England is simply so good that the public holds it in very high regard and this is reflected fairly in the scoring.
  • Second, it could be that as a national agency it may be that NHS England staff and their associates use social media more in the course of their work and are more likely to say positive things about NHS England. Furthermore most members of the public have no idea about NHS England at all so are unlikely to comment or complain about it. The March dashboard includes the period of the NHS Expo.
  • Third, it might be that most of the negative comments about hospitals and GPs could be about the cuts.

Other Insights

If we compare this “insight” data to others we get a different picture. IPSOS MORI in their latest report for the Department of Health note that when people were asked to rate how satisfied they were the last time they visited an NHS hospital or GP their satisfaction ratings were as follows:

  • Inpatient – 85%
  • Outpatient – 84%
  • GP – 83%
  • A&E 80%
  • NHS overall – 66%

Since publishing this blog Steven McDermott at the University of Leeds has sent me a link to a social network analysis he has done of tweets about the NHS – 400,000 tweets by 21,000 over a month. You can see it here.

Comment

Tim Kelsey is clearly keen to drive innovative approaches to insight and voice in NHSE. As he notes in the February report I mention above:

“each month there are approximately 500,000 unique online comments made about the NHS” 

So on the surface it might appear to be a real opportunity to attempt to analyse these. However, so far the insight tool reach seems very limited for example for GPs (using the data above) it only captured comments that equate to about 16 comments per CCG (N = 211).

Tim Kelsey’s Black Box

In addition to the points above the biggest problem is that we cannot see the “workings out” for example:

  • What is the demographic profile of the social media comments being captured – employed/unemployed, old/young, ethnicy, employed/unemployed, professional/non professional
  • What is meant by hospitals – Acute, Community etc?

Of course it could just be that the Insights Dashboard is just not very good… and that this is an example of an ambition to innovate distracting us from focussing on current priorities.

Postscript

A month or so after writing the piece above I heard that NHSE will not be updating the Insight Dashboard – they have “had a tough budgeting round and will not be doing any updating or further development.”

So thats that then.

 

BMA survey of public health workforce – transition and division?

March 31, 2014

BLOG BMA PUBLIC HEALTH

The recent BMA survey of the public health profession provides a useful insight into the current concerns of public health professionals and into the general condition of public health as a profession.

The survey is worth reading. However, I think its message is quite different to the headline statements from the Faculty of Public Health and the BMA. They have chosen to focus on two areas of loss.

Loss of Independence and Loss of Medical Professionals.

“We are particularly concerned that over half of the people surveyed say they don’t have the freedom to speak out. That freedom has saved countless lives in the past when public heath leaders have spoken out, often going against the grain of popular opinion to do so.”

“This survey confirms what our members have been telling us for several years: public health specialists are very concerned that the new public health structures in England are a risk to people’s health. We know the system is working well in some places, but the number of professionals who are considering leaving the public health profession is one of many reasons for concern.”

John Ashton President of the Faculty of Public Health

John is supported here by Penelope Toff the BMA Public Health Committee Co-Chair

“Two thirds of doctors who responded are considering leaving the specialty and more than half of medical trainees are planning to move on.”

Lets have a look at these two questions in turn.

Q – “I have the professional independence I need to speak out on public health issues”

  • Agree – 49.90%
  • Neutral – 23.7%
  • Disagree – 26.4%

Ok, it is possible from the above data to truthfully claim that less than 50% of public health professionals believe they have the professional independence to speak out, after all the figure is .1% below 50%.

But it is equally possible to say:

“Hooray! Twice as many public health professionals feel that they have the professional independence to speak out, compared to those who do not feel they can speak out”

Indeed if we were to put aside those who were neutral we could even claim  that almost 2/3 of public health professionals who have an opinion about this feel that they do have the independence to speak out.

Q – Medics – have you considered leaving the profession in the past two years?

  • Yes – frequently and or seriously – 25.7%
  • Yes – it has crossed my mind – 34.7%
  • No – 36.3%

So from these figures Melanie says 2/3 of medics have considered leaving the profession – presumably she has added together “frequently/seriously” and “its crossed my mind”.

Of course we don’t know how many people who said ‘yes’ have actually left the service and the single largest group are those who have never thought about leaving the service.

In the last 3 years it has ‘crossed my mind’ on a number of occasions that I might go and live on a canal boat, in a remote cottage, travel round the UK in a trawler etc – I have no intention of doing any of these things. (Yes, I know that some people reading this wish very sincerely that I had taken up one of these options.)

I think it is perfectly reasonable for people to indicate that leaving the profession has ‘crossed their mind’ and for them still to be generally happy and committed to their job.

More Survey Problems

Of course the survey has no base line either – so it is hard to know what public health professionals might have said when they were based in the NHS. I can still just about remember those happy days and there were plenty of public health professionals then who felt constrained by the bureaucratic and apolitical straightjacket of the NHS.

So we do not know what the variation is between present perceptions of independence and past perceptions when public health was in the NHS. That is of course what matters.

My favourite question has to be:

Q “In my local authority, the public health grant is not seen as a resource to be raided”

This is beauty! What a loaded question! This implies that some local authorities are being run by Highwaymen or Vikings – excellent! For those of us long in tooth I remember a constant complaint in the NHS was that there was no specific public health budget allocation at all – with any funds having to be fought for and protected every year.

For a good objective account of the current state of play in public health funding read the article by Gareth Iacobucci in the BMJ.  In this there is a thoughtful response by John Middleton (Vice President of the Faculty of Public Health) who notes that:

“My (council) is no different (transferring money from the public health budget), although we are taking the opportunity to remould services in a more evidence based and public health focused approach … Its not wrong to apply public health funding to other areas, but some councils have just done it very crudely”

In the same article Duncan Selbie Chief Executive of Public Health England notes that:

“I welcome local government reviewing where the money has been spent. Local government is pretty advanced in looking at outcome based commissioning and of course they will be looking for more value….. the duty is to improve the public’s health, not to provide a public health service”

 What is the real issue?

I think focusing on loss of independence and funding distracts from addressing a much more important and serious issue which I would suggest is something like this:

“How to develop a strong fit for purpose public health profession that is seen as relevant and useful to local government.” Importantly it also distracts from building on some of the strengths and positives that also come through this survey.

What the survey tells us

This is a profession in transition and as the introduction to the report on the survey notes – a divided one. It seems to me that non medical public health professionals and trainees in particular are generally more positive about how they view the future.

It also seem to me that there are quite large numbers often around 30% who are undecided about the present and future prospects for public health. In some ways this is fair enough – we are only one year into this transition.

There do seem to be as many concerns about Public Health England as there are about working with Local Government.

Some thoughts

  • This is a profession in transition, the Faculty in particular has to come to terms with a changing membership that is increasingly non-medical and recognise and represent their interests more.
  • Public Health is still bedding into the new structures.
  • Its not just about local government – if anything there are more fundamental concerns about Public Health England
  • Trainees are generally positive about their future.
  • Non Medics are positive about the future
  • The independence of Directors of Public Health (whatever that means) is not under threat
  • It is tough in public health – but that is no different to the experience of the rest of local government and the voluntary sector – there are common causes to be made.

Conclusion

It is really important to be working closely with local authorities to design a profession that works for them and not to try to impose the existing model onto them. It is particularly important build on and support those in the profession who are successfully establishing credible relationship within local authorities.

What do you think?

I am really tired of ‘conversations’ about health

March 4, 2014

Conversation Blog

I was pleased to see the recent blog by David Buck at the Kings Fund “Health Inequalities we need a national conversation” calling for more collaboration and clarity between Public Health England, NHS England and the Department of Health. I share his frustration at the continued lack of co-ordination and leadership shown by these big (and comparatively well funded – compared to local authorities) national institutions.

I do however, take a different line. 

First, I am really tired of the way national agencies and government launch into these  national ‘conversations’. So was concerned to see (thanks to David drawing attention to it) that Public Health England have started one of these.

Remember the “NHS Listening Exercise”? What about Tony Blair’s “Big Conversation”? Or David Nicholson’s Call to Action? None grabbed me, maybe some of you reading this thought they were tremendous and made a real difference – if so please leave a comment!

Thus far I have been unimpressed by these attempts to establish a national dialogue with  citizens and local players. They too often feel like a half hearted attempt to engage with the public and front line who already have quite enough to do with getting on with local challenges.

Having said that Public Health England do seem to have a  more considered process which involves focussed interviews with Directors of Public Health, Councillors and local voluntary organisations.

Of course it is important to bring local voice and experience powerfully to national agencies. I just think that dialogue should be built around substantial long term relationships which recognise independence of view rather than fixed term conversations.

As a trustee of Citizens Advice I am impressed by the model that this organisation uses – but they are not unique – There is a long list of NGOs who provide evidence based challenge to policy – they include MIND, CPAG, Barnado’s, Disability Rights UK etc. Some of those get funding from government and its agencies to the irritation of right wing think tanks like the Institute of Economic Affairs who pejoratively  brand these organisations “Sock Puppets” in their recent publication “The Sock Doctrine”.

One of the important services provided by Citizens Advice is to capture the evidence of need that emerges through front line delivery by its 350 or so member Citizens Advice Bureau across the country and interpret this, using it to bring suggestions for policy improvement and sometimes direct policy challenge. Through doing this they directly contribute to making policy better, society fairer and democracy stronger.

I think DH, PHE and NHSE in particular should look across the communities and people they serve and check that they are providing sufficient resource to advocacy organisations ranging from local government to the voluntary sector to ensure that they are exposed to continuous evidence based policy challenge. If they were to do this consistently and in a co-ordinated way they would not need one off ‘Big Conversations” instead they would be continuously exposed to powerful debate and dialogue from organisations who are directly connected to citizens and front line services.

Second, a little comment on David Bucks three national agencies and his suggested actions.

  • NHSE – fully support his call for a greater focus on what primary care can do to tackle health inequalities – as I pointed out in an earlier blog the NHSE inequalities strategy is to put it politely – weak. I do think it is unfortunate though that the two areas that David focusses on are both to do with physical health – the role of  of primary care in addressing poor mental health is crucial here.
  • Public Health England – I am not convinced that David is right in calling for PHE to do more on health impact assessments of other government departments – for the reasons I outline above I think it would be better that PHE funds local government and NGOs to do this work – this will give much more independence and transparency to the challenge.
  • Department of Health – I struggle to have expectations of the Department of Health. While I take David’s point on the Social Value Act I think that local commissioners just need to get on with it and guidance would probably better come from the sectors concerned.

We need to push government not rely on government departments giving us permission.

What do you think?

What on earth are voluntary sector trustees for?

February 19, 2014

trustee blog 2

I have been involved as a trustee or committee member of various voluntary organisations for a long time. Well actually – for a very time.

I have become increasingly concerned that it is us in the voluntary sector who are too often unclear about the role and contribution of trustees. This is ironic because the voluntary contributions of trustees is one key element that makes the voluntary sector different and brings so much added value.

The dead hand of governance

I know that as the conversation turns to governance its time to switch off…. don’t stop reading just yet! I am going to try to avoid getting sucked into a piece on the bone dry world of corporate governance here.

I know they are not elected but being a trustee of a voluntary organisation – local or national – is just as political (with a small ‘p’) as being a councillor, MP or non exec on an NHS trust board but I don’t think this similarity is sufficiently understood or utilised within the sector.

It is too often the case that executive teams see trustees on voluntary bodies as a necessary evil – who will go through and check their work at board meetings – provide some useful support to key internal processes such as HR and Finance and sometimes bring a bit of internal testing on user experience and that – more or less – is it.

This is frankly not good enough. If we are to play to the strengths of the voluntary sector we need to expect that trustees will bring with them much more than this -  here are three examples:

Specialist Technical Knowledge – When I was a trustee of a specialist CAB working in the mental health sector we always had at least one specialist NHS mental health worker on the board and often a current or ex service user of mental health services.

Environmental Analysis – another voluntary organisation that I am currently a trustee of has clearly worked hard to ensure that they have a wide range of trustees who have powerful connections and current experience of the wider social policy environment in which the organisation operates. The board spends little time on long discussions on finance, HR and programme implementation – the CE clearly understands that they have to do the bulk of this work and report on it to the board. Instead the CE uses the board to understand the environment, test ideas and develop strategies for action.

External Relationships – Trustees can bring real added value to developing relationships at the top of organisations. In many cases voluntary sector managers – even at Chief Executive level are compromised. I think that some of the challenges they face can include:

  • Status – executives in a voluntary organisation may be at the top of their organisation but large funders – for example a local authority funding a local voluntary organisation – will see them as effectively a middle manager at best. They will often allocate a fairly junior manager – usually responsible for contracts to manage the relationship. This immediately reduces what should be a strategic relationship to a contractual service provider one.
  • Conflict of interest – discussions about funding – particularly at a time of cuts – can be particularly difficult when these are led by managers whose staff (and indeed the manager) may be materially affected by the outcome of negotiations. This is particularly true when local funders will know that the final decision about financial viability and strategies to address deficits rests legally with the trustees not the manager.

Trustees are actually the custodians of an organisations values and vision – they should be in the best position to articulate these to leaders of other organisations – elected members, MPs, trust governors. They bring with them an experiential authority that comes from their willingness to take on unpaid positions of leadership on voluntary organisations boards. In my experience politicians and non executives understand, respect and value this role and welcome the opportunity to have this sort of dialogue and relationship.

It is through building these strategic relationships that foundations are laid for long term practical joint action and sometimes even funding!
What do you think?

Primary Care, Neighbourhoods and Health Inequalities

February 3, 2014

NHSE in their recent report “Promoting Equality and Tackling Health Inequalities” note that “inequalities in both health outcome and service experience have endured over time despite substantial investment in healthcare” I Neighboorhood blogthink that the reasons are fairly well established – the root causes of health inequalities are fundamentally to do with the social determinants of health – and as the NHSE report says only…

“15 to 20% of the life expectancy gap can be directly influenced by healthcare interventions”

As a CCG non exec I know that there are front line GPs who have a long history of working hard to improve the health and wellbeing of the communities they serve. They are frustrated by the limited range of interventions they can offer – many of which assume that people are in good housing, have stable incomes and have had access to a good education.

We know that there is no magic wand here, many of the people experiencing the greatest health inequalities are under the cosh, even more so at the moment as they are hit from all sides by government policies.

Yet there is more that we can do. There are tremendous long standing examples of good practice which are built around peoples own relationships and communities, they build on their strengths as well as addressing their needs.

One of the best examples in my view are neighbourhood organisations (sometimes referred to as community anchors) that:

  • Provide a range of services and therefore respond holistically to peoples needs
  • Have a history and experience of working with people as assets – as volunteers, employees, trustees
  • Are independent and accountable to local communities

The relationship that these organisations have with some of the most excluded communities is so much more coherent than the transactional one that health service providers find themselves forced to adopt.

The example that is often cited is Bromley by Bow Healthy Living Centre, but there are plenty of other longstanding neighbourhood based community organisations. Many of these are members of Locality – which is the umbrella body for these. Locality was formed through a merger of the British Association of Settlements and Local Action Centres (BASSAC) and the Development Trust Assocation.

…and yet these organisations rarely appear on the radar of health and wellbeing boards and Clinical Commissioning Groups as agencies that are a key part of the solution to addressing health inequalities.

At Leeds Metropolitan University Health Together we did a piece of work with a small number of Locality Members. working with them to capture their views about how local commissioning can better support them in their work. The full report “Strengthening the Voice of neighbourhoods” is available here – its not very long!

Some of the issues that emerged from this work and subsequent discussions at the 2013 Locality Convention included:

The tyranny of public health evidence – There is very narrow view of the evidence which ignores peoples experience as a whole and focusses too much on measurement of clinical conditions and the evidence for clinical solutions. We at Leeds Metropolitan University recently organised a national conference on this topic – and there is more information including speakers videos here.

The commissioning delusion – there is an assumption that most health services need to be commissioned at ‘place level’ (local authority or CCG) rather than at neighbourhood level. I know that many Local Authorities have ambitions to push budgets out to neighbourhoods through Area Committees, Area Panels etc but in my experience they have struggled to gain interest and the amount of funding they have available is usually trivial.

There are a number of options here, some of these are spelled out in ideas from the project we did with Locality members which include:

  • A greater focus on the contribution of neighbourhood structures – not just area committees and panels – but the role of Parish and Town Councils
  • A need for more work at a national level to support good practice guidance on neighbourhood led commissioning
  • A great emphasis on joint/integrated commissioning across CCGs and Local Government
  • More visits to and presentations from grass roots community organisations by health and wellbeing boards and other governance structures.

There are real possibilities to be generated through formal alliances between General Practitioners and their local community neighbourhood organisation – usually a Locality Member or a neighbourhood based health living centre. As well as providing the opportunity to tailor services directly to particular communities it also starts to develop a service model which may help the sustainability of not just small community based organisations but also of independent primary care.

All of these ideas have a fit with continued government interest in Whole Place and Community Budgets. The always excellent House of Commons Library has a useful summary report on these here.

 What do you think?

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