As is quite evident from this blog, due to various commitments and lack of time, I rarely blog. However, David Cameron has just ordered health and social care services to be brought together in order to benefit patients in a move which government advisers are calling the NHS‘s most urgent overhaul. This integration of services seems to be motivated by cost cutting and to save money says prime minister, while NHS warns that changes will lead to hospital closures.
Therefore, given the importance of this announcement and both the vast opportunities and threats that it presents, here are my immediate thoughts in a nutshell.
On the surface, the proposal for integration of health and social care services is most welcomed, and indeed there are many examples of more or less integrated services in other European countries and has also been proposed by NHS and Local Councils in Scottish Highlands as well as Torbay system, Lincolnshire and Herefordshire.
Therefore, I would like to think of this as a huge step in the right direction and believe that it offers a rare opportunity for us all to take leadership in this process in order to ensure that the focus extends beyond financial metrics and remains on services and users of services.
Health (both physical and mental), care, connectedness, and inclusion are fundamental to individual well-being and foundational for greater social justice in civilised and progressive society. Therefore, although research indicates that healthy competition will serve to improve systems and services, this should not result in myopic fixation on immediate returns driven by purely financial metrics.
Unfortunately, however, too often econometrics and financial considerations are and have been the main driver of change and realignment of services, and this has resulted in repeated and sadly wasteful reforms. Suffice it to say that it was Tory government who pushed for separation of Health and Social Services in 1988, and are still pushing for further fragmentation of services through Health and Social Care Bill.
Therefore, it is important to see the intent and extent of Cameron’s proposal. Indeed, for this proposal to work effectively, there are many questions that need to be clarified and challenges that should be addressed. For brevity I include 5 of such questions and challenges below:
- Integration of services has been notoriously complicated and frustratingly difficult. Therefore, there is need for vigilance to ensure that integration of services do not result in a greater and more rigid bureaucratic behemoth that will further distance policy, commissioning, decision making, and other related processes from users of services.
- Pending Health and Social Care Bill in spite of its provision for greater coordination through Health & Wellbeing Boards, in practice will lead to competitive positioning between different GP Consortia based on cost, and a “pass-the-buck” attitude between GP Consortia and other services; as GP Consortia will focus on protecting their own profitability and financial viability. Hence, there will be little regard for shared objectives between service providers. This runs counter to Cameron’s intended integration of services. So I wonder if Cameron’s declaration means that the government has now changed its mind and will back-track on its Health and Social Care Bill?
- If Cameron decides to proceed with Health and Social Care Bill while calling for an integration of services then I think the results will only relegate NHS health care responsibility and workload onto social services and local authorities and as such, will shift the blame from national government to local government and local services. This will also enable the government to cut costs by: firstly, transferring workload and responsibility from a high-cost-base centres (NHS and hospital care) to a lower-cost-base/cheaper centres (community, local authority, and social care); and secondly, in all likelihood, such transfer of national cost to local authorities will not be accompanied by an equivalent relocation of resources and/or increase in funding for local governments. In the end, this will be catastrophic for already overstretched social care and local authority services, and will only exacerbate the difficulties and desperation of patients and users of service.
- Such integration of services will inevitably extend the current social service coverage for adults (at least for those with long-term or recurring health care needs). This is a welcomed development, but, at the same time will lead to increased workload for social services. The question is whether this will be accompanied by increased resources and workers? or will it mean increased caseload for existing workers who are already overstretched?
- Social services need their own reform for a better and a more integrated service. Will Cameron’s merger consider/include such integration and realignment within social services as well? Ignoring the need for a holistic approach and comprehensive integration of services, including those within social services, will only lead to continued overlaps and gaps in services.
Hence, I do welcome Cameron’s proposal for integrated services, but, given the precedents, I will take this with the proverbial “grano salis”. Nonetheless, I remain hopeful that through national and local leadership we can use this opportunity to make a real change for a more meaningful and efficient service and a more effective and sustainable system.