The Independent View: This is the right time to drive forward integrated health and care

nhs sign lrgThe NHS is becoming too big to fail. Like a more benign version of the banks, it has become such a vital part of our national life, with such a slick lobbying machine and such a powerful public profile that it has become hard to challenge. So when the system starts to creak, everyone from MPs to doctors immediately shouts for more money. The problem is that more money may not solve the problem, but simply allow the NHS to subsist in a state of perma-crisis.

The only way out is a transformed NHS working much more closely with local authorities. Ministers must put their tin hats on and allow councils to force change.

The challenge for the NHS is simple. New demand pressures – principally due to an ageing population – are expected to create a funding gap of something like £40bn by the early 2020s. Traditionally, the NHS has got by with large funding increases. The service has had an average of 4% more a year since its inception. With money now increasing in line with inflation, NHS managers are issuing doom-laden predictions about their ability to balance the books in 2015/16.

The idea that any government will find the £40bn is fanciful. The problem with dribbling smaller amounts into the system is that it will simply sustain the perma-crisis. Adding a few more beds and nurses every year against a backdrop of rising demand is just a way to stagger on with full wards and constant red alerts.

There is a clear answer on offer: redesign the health service so that much less work is done in expensive hospital wards and far more in community settings by GPs and nurses, allied with much more assertive approaches to preventing illness and promoting healthy, independent living. This model is not cost-free. Indeed, in the short term it may cost more. But getting it right may help the NHS move beyond crisis and onto a more sustainable path.

Early attempts to move towards this model have not proven propitious. The government’s Better Care Fund transfers £3.8bn of what was previously NHS money to local authorities, the idea being to support reforms to social care which reduce hospital admissions and support prompt discharge.

Rather than working collaboratively with councils to deliver these improvements, the response from many NHS organisations has been to protest against the whole idea, followed by an attempt to shift as much risk as possible on to councils. This despite the early evidence from councils like Greenwich which demonstrates that integration really can reduce A&E and hospital admissions, eliminate delayed discharge and save cash for social care budgets.

Can the NHS reform itself, or is the sheer pressure of rising demand forcing it into a short term focus on survival? A recent expert discussion organised by Public Policy Projects offered some stark messages – there is currently no transformational plan for the future of health and the service believes that it will be bailed out by the next government.

It is hard to imagine that the NHS can really make it into the 2020s without some substantial new money but, as organisations like the Kings Fund have argued, that money needs to be ring-fenced for transformation. The best people to spend it are not hospital trust managers struggling to contain permanent red alerts, but councils working through their health and wellbeing boards. Local government’s responsibilities for social care and public health mean that it has a huge stake in getting community services right.

The moment is right: with local government being sucked into a bigger role in supporting CCGs, and even merging with them in some areas, we have an opportunity to drive real integrated health and care, build new preventative services and finally stop the NHS acute tail wagging the primary care dog. NHS England’s chief executive, Simon Stevens, last week said that the ‘N’ in the service’s title must stand for both ‘national’ and ‘neighbourhood’. Time to deliver on that aspiration.

The Independent View‘ is a slot on Lib Dem Voice which allows those from beyond the party to contribute to debates we believe are of interest to LDV’s readers. Please email [email protected] if you are interested in contributing.

* Simon Parker si the Director of the New Local Government Network

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13 Comments

  • “The only way out is a transformed NHS working much more closely with local authorities..” Yes, but also with the voluntary and community sector. – which is already doing some pretty impressive stuff!

  • Richard Dean 21st Jul '14 - 5:34pm

    If a service is asked to do more, then the straightforward answer is to increase its resources. “Far more [work done] in community settings by GPs and nurses ” means we will need far more community settings, GPs, and nurses. Where will they all come from, who will pay, and how will this change achieve cost savings?

  • Of course we could reevaluate the idea that we should live forever regardless of cost, oh that’s right the politicians are against assisted death

  • Richard Dean 21st Jul '14 - 6:10pm

    Is it right for a government to rely on the voluntary sector? If public services are required, they should surely be paid for properly, and from taxation.

  • A Social Liberal 21st Jul '14 - 6:53pm

    David
    the voluntary sector should not replace services which is carried out by the NHS, it should be added value to our health service. Nor should it be carrying out work that ought to done by the NHS.

    The problem with Camerons Big Society is that it is all about replacing and not complementing!

  • John Broggio 21st Jul '14 - 8:30pm

    If the OP works for a private healthcare firm (CIGNA Healthcare?), should he/you not disclose such a conflict of interest to allow people to weigh up his arguments in light of that knowledge?

  • Stephen Donnelly 21st Jul '14 - 10:54pm

    The current level of NHS funding is not sufficient to support the services as currently structured. The Lansley bill was supposed to address this problem by enabling change, but It has failed miserably and expensively (£billions) to do that. Either, we must pay higher taxes, or there must be structural reform. The latter will mean service reconfiguration i.e. the closure of some hospitals, and the withdrawal of services from other hospitals. In some form or other both will probably be required.

    No doubt local government and the voluntary sector have a role to play, but I simply do not buy the argument put forward in this piece that “the best people to spend it (new money) are not hospital trust managers struggling to contain permanent red alerts, but councils working through their health and wellbeing boards”. The best way is to allow doctors and nurses to make the clinical decisions, and give patients more control over their own healthcare. Admittedly much easier said than done.

    The Liberal Democrat contribution to this debate has so far been very disappointing.

  • Why should social care be provided by Councils? For the mental ill it is provided by the NHS. Why can’t GP’s be given the Social Care budget and then let them be held to account for the spending of the funds by Councils? Wouldn’t this be the best way to integrate health and care?

  • Jenny Barnes 22nd Jul '14 - 8:39am

    I seem to remember a major reorganisation of the NHS, not foreshadowed in either LD or Tory manifestos, quite recently. How’s that working out for you?

  • the voluntary sector should not replace services which is carried out by the NHS, it should be added value to our health service. Nor should it be carrying out work that ought to done by the NHS

    Not sure I know what this means.

    What are a couple of examples of services which ought not to be provided by the NHS but would be added value, so should be done by the voluntary sector?

  • David Ellams 22nd Jul '14 - 12:35pm

    I do think the government needs to accept that to transform you need a good deal of upfront, ring-fenced cash. The community services need to be up to speed before you can seriously consider reducing the acute sector. Without this upfront spending, there are only two possible outcomes: long term snowballing of health spending or the destruction of the NHS. In fact, the former can only go on so long before the latter happens.

    Whether or not it should be local councils making spending decisions or someone else, there is no doubt that the broad thrust is correct – more needs to be done in a community setting, and less in acute hospitals. However, let’s face it, that will mean some hospitals shrinking, being downgraded or even closed in the long run. And that is a politically very toxic message. I think this political challenge is the biggest hurdle, and I wish there was an answer to it.

  • matt (Bristol) 22nd Jul '14 - 1:03pm

    Michael BG – I have direct experience of GP’s abilities to assess risk and proportionality of service in community situations and attempts to dictate to local authority staff how the social care budget (access to which is governed by eligibility criteria and towards which contributions from services users are means-tested, in a completely different financial framework to the NHS) should be spent.

    I am fully confident that the result of what you propose becoming the norm would be a masive overspend, and high risk of a restrictive insertion of care and surveillance into the lives of elderly people in a way that would be easily describable a breach of human rights.

    Local authority staff in adult social care do a more complex and nuanced job than is understood by many outside the profession, and the efficiency and discretion with which they work, balance conflicting opinions and advise vulnerable people, is not appreciated, not least by the NHS, which has long regarded social work as an undesirable insertion by an alien specialism into its own area of dominance and control.

  • matt (Bristol) 22nd Jul '14 - 1:05pm

    Oh, and Michael BG – Social work for the mentally ill is not carried routinely out by NHS trusts in many areas; it is only done so if there is an agreement between the authority and the trust in quesiton – otherwise the legal responsibility and duty remains with the authority (who can ‘fire’ the trust, if it so wishes).

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