In a sequence of events, that could only be dreamt of (up) by election pundits, Simon Stevens announced the day before NHS Change day that his Vanguard programme will support “radical care redesign….for patients across England”. But did he really ‘fire the starting gun' or is this simply another shot in the dark?
Let us be in no doubt. The health and social care system has never faced such critically challenging times. The usual way of delivering efficiency isn’t going to work anymore. So what are we going to do now the 'salami has gone?’
A crisis brewing?
Looking ahead at the financial position facing health and social care and the results in the latest Nuffield Trust Health and Social Care Leaders’ survey, it would be difficult to argue that a crisis is not looming, if it hasn’t already started. But in solving this crisis we cannot look to short-term drastic interventions. We need to keep our eyes on a long-term vision for designing an effective and sustainable health and care system.
The survey makes compelling reading. By far the biggest issues are access: to urgent and emergency health care; adult social care services for the elderly and to a GP. A pattern is emerging.
Which issue concerns you most regarding access to health and social care services in your local area?
And if that isn’t stark enough, the Health and Social Care Leaders' panel forecast the greatest staff shortages over the next five years will be for A&E doctors, general practice and community nursing. These are the staff at the front door. There is a vicious circle in our access problems.
Paying for services in the future
Inevitably much of the focus in the lead up to May’s election will be on NHS funding. The majority of the panel is confident that the NHS will remain free at the point of delivery over the next parliament, but most are unconvinced that the NHS can meet its £22 billion efficiency challenge.
Local government have seen much of the same story over the past five years. Recent analysis from the IFS has shown that net spending per capita on social care was cut by 16.7 per cent in real terms between 2009–10 and 2014–15. 85 per cent of respondents to the survey think the quality of social care services has worsened over the last year. Is this a surprise?
When major efficiencies need to be made during budget cycles, the quickest and most reliable method is to change eligibility criteria to social care and keep pay low. By March 2013 85 per cent of local authorities had set eligibility criteria at the highest two thresholds. As a result we have a social care system which is difficult to access, has unacceptable variation in quality and is operated by an underpaid workforce.
Any new government should remember that protection of health and continued paring down of social care is a false economy. Perhaps the Better Care Fund sought to address this, but double counting and mixed messages from government departments to local areas have militated the levels of protection required in social care to make a sustainable difference. Social care, often ignored and overlooked in the wider health system, must be protected but sits in the system in which it is often the easy target for the scythe of budget reductions.
The Five Year Forward View into action
The 5YFV sets an ambitious vision for a new health and care system. But has society yet had the breathing space to ask what kind of health and care system we want?
There is often a disconnect between positive intentions at a leadership level and those cogs that drive the machine: rationing, performance targets, quality standards and regulation. Real strengths of the 5YFV are its focus on local cross organisational leadership, permission to do things differently at scale, drive for innovation technology and a move toward coherence in the management of all the various national change initiatives.
Our experience in Leeds
As one of the original integration pioneers, our gun started firing some years ago. Our financial challenge is £650M over the next 4.5 years, and we have built several platforms (none of them burning), upon which we are creating a sustainable health and social care system to improve lives for the people of Leeds.
We have embedded cross-organisational leadership so that it becomes the norm. This includes: a common Chief Executive letter setting out how we are working together as if we were a single organisation using the Leeds £ to make the best use of our collective resources; creating integrated neighbourhood teams for adults and children; and a thriving third sector including 37 neighbourhood networks supporting people to stay at out of hospital and lead independent lives.
City wide approaches to workforce, estates and finance put Leeds in a great position to achieve its ambition to be the best city in the UK for health and wellbeing and global leaders for health innovation. Together with innovations such as a truly integrated Leeds Care Record, a coherent informatics strategy, which is being used as a template for Pioneer sites across the county, and embedding these with related innovations such as the Leeds Data Mill, Leeds Innovation Health Hub and health app developments we believe we have the ingredients required to address many of the issues highlighted in the Trust’s survey results.
But we also need long term financial settlements, upfront investment, greater flexibilities within the professional workforce and a regulatory system that oversees an integrated system rather than focuses on a single cog. Without these, the latest starting gun will just be another shot in the dark.
Rob Kenyon is the Chief Officer, Health Partnerships for Leeds Council. Please note that views expressed in guest blogs on the Nuffield Trust website are the author's own.
Kenyon (2015) ‘A starting gun or shot in the dark?’. Nuffield Trust comment, 19 March 2015. https://www.nuffieldtrust.org.uk/news-item/a-starting-gun-or-shot-in-the-dark