Prevention, innovation and integration have been broadly accepted as the route to relieving social care pressures, but an overhaul of leadership and governance is also vital. Mark Rogers outlines his proposals for transforming the health and care system
Fond as we appear to be of the ‘what’s out, what’s in’ lists which abound at this time of year, in one respect 2017 will pick up exactly where 2016 left off – in returning to the wicked issue of how to provide those who need it with timely, accessible, high quality, integrated and sustainable health and social care services against a backdrop of escalating demand and continuing resource constraint.
In the weeks before, during and after Christmas and the New Year we have been inundated with facts, figures and human interest stories, all of which broadly reach the same conclusion: there are wonderfully talented and committed people working in the NHS and adult social care (and beyond), but they are increasingly struggling to keep up with the pressures placed upon them by indecision and a fragmented, under-reformed and demand-intensifying system.
There is much talk of this system being under such stress that it is fast approaching breaking point. In a number of areas it is being reported that the collapse is already starting.
It must be alarming to acute providers and local authorities alike that the pressures on A&E clinicians and social work assessment and enablement professionals, while well recognised, appear almost beyond amelioration because human resources are so stretched by the immediacy of the expectations being placed on them that ‘firefighting’ is inhibiting more strategic service reform.
The degree of acuity is variable due to the pressures and their impact is not uniform across the country. Nonetheless, there is something approaching a broad consensus that the regular suspects of more prevention and early help, more integration, more innovation and, inevitably, more money should all be given significant investment, time and attention – now.
I do not disagree with any of this, not least because a good deal of what is being reported accords with the local experience here in Birmingham and other parts of the West Midlands.
What is to be done? Addressing the aforementioned issues would help, especially investment in more prevention. But there is another factor which needs to be tackled.
For many – maybe even all places – it is the prerequisite to long-term reform and sustainable success, namely, a new approach to the leadership and governance of the health and care system at both the national and local levels.
The timing for such a revamp is perfect because the new(ish) Government is still thinking through its particular approach to devolution and could do worse than use health and social care as a worked example for how to strike a new balance between what is decided and taken responsibility for at Westminster and what should be ceded to local determination.
Here is an initial proposal. At national level why not immediately establish a ‘grand committee’ to bring together the key movers and shakers from the NHS, its arm’s-length bodies and crucially, the Department of Health and the Department for Communities and Local Government to formulate new policy and law on the long-term funding and integration of health and care.
By coming together in this way, the committee would have the opportunity to ensure truly compatible approaches to delivering an inclusive ‘triple aim’ to underpin a long-term health and social care sustainability and transformation initiative.
Such a committee could, nay should, also be constituted in such a way that it draws on ex officio membership from the relevant local government sector bodies – the Local Government Association, the Society of Local Authority Chief Executives and the Association of Directors of Adult Social Services – utilising their invaluable advice, guidance and extensive experience of implementation.
Locally, working initially with the existing 44 Sustainability and Transformation Plans’ (STPs) footprints – which, in due course, could be incentivised to rationalise themselves – equivalent local grand committees should be formed.
Fortunately, there is a pre-existing legal partnership framework to work with in the shape of democratically-led health and wellbeing boards. These should be beefed up through rapidly prototyped devolution deals empowering them with the authority and responsibility for agreeing and providing the home for consolidated or even unitarised local leadership and governance of the NHS and social care.
In this way, local areas could truly be said to be taking responsibility for prioritisation, strategy and crucially, resource decisions in the interests of the communities served by a single or consolidated STP footprint.
Inevitably, eyebrows and questions will be raised, not least because there is legislation, regulation and above all, culture, custom and practice that will get in the way.
This is why it is the perfect time for a new government to reimagine the leadership and governance of health and social care because what we presently have is clearly not working well enough for anyone – especially the vulnerable. We cannot wait a moment longer to reform the system.
Mark Rogers is chief executive of Birmingham City Council
