There is an argument to be made for Labour simply sitting back and allowing the government’s misguided health reforms to unwind. But it is to Andy Burnham’s credit that he has chosen to start a debate about the health and care system we want in the twenty-first century. There is no denying this carries political risk. ‘Who do you want making decisions about your NHS – doctors or the council?’ will be a question the Conservatives are likely to pose to the electorate. They are also likely to misrepresent any Labour approach to funding long term care, although Burnham’s reference to a ‘dementia tax’ neatly encapsulates the unfairness of the current set up.
The speech was rightly positioned as the beginning of a conversation rather than a detailed prescription for health and social care. The effort that has already gone into consulting key people in health and social care suggests he has learnt from the Lansley car crash that listening exercises are best conducted before final proposals are set out. So some changes may be made and there are areas of detail that will need to be ironed out over the next few months. But the central vision is clear, compelling and undoubtedly radical. In short, Burnham envisages a health and social care system that is built around the needs of individuals rather than organisations and which can cater for people’s physical, mental and social needs. The failure to get close to this after decades of talking about it has led him to the conclusion that combining health and social care is the only way to make this work. One budget, one system.
Whether such radical change is possible without a big reorganisation is open to question, but it is right to emphasise what can be done within existing structures. In reality, much of the frustration with reorganisations in the past has been when they were seen as pointless, such as Labour’s constant tinkering with health authorities or positively damaging such as those driven by the Health and Social Care Act. If NHS and social care professionals can buy into the vision, they may well accept that some structural changes are needed to make it work.
A more important challenge will be the cultural change needed in both the NHS and local government – Alan Milburn’s previous attempt at integration failed when local government saw it as a power grab by health. What is clear is that there will be a big change in the role of GPs. The reference to GPs coordinating interdisciplinary teams is encouraging but needs more work to be brought to life. Just as important will be clarity over the role of GPs in commissioning. Through clinical commissioning groups, GPs have acquired unprecedented influence and it’s hard to see them remaining engaged if they are only given an advisory role in future.
Setting out a major role for local government in the NHS is probably the riskiest aspect of his vision. One of Labour’s most effective lines of attack has been to talk about the government taking the ‘N’ out of the NHS and there is a risk these proposals could be presented as doing the same. We need to emphasise that our vision allows the flexibility to respond to local needs whilst setting out clear national entitlements across health and social care for the first time.
The imminent return of public health to local government has shown that many NHS professionals take a fairly dim view of the ability of local government to discharge health responsibilities effectively. Whilst local government would see this as unfair, we have a responsibility to build confidence in the ability of councils to take on new roles by ensuring the public health transition works and by demonstrating the real difference health and wellbeing boards can make in their area. Some of the concerns around local government’s role going forward could be effectively addressed by positioning the health and wellbeing board rather than councils in isolation as the body overseeing health and social care locally. This makes it even more important that the boards can quickly demonstrate their impact and effectiveness.
Many party members are likely to be delighted by the proposal to make local hospitals the preferred providers of health and social care although concerns have already been raised about whether the procurement rules that cover local authorities would allow this. The Labour argument that when money is scarce we need to co-operate rather than compete is likely to resonate with the public and it seems hard to make the case that a patchwork of different providers is best placed to provide integrated care. A tension that will have to be addressed is that between single preferred providers and the moves towards greater personalisation in adult social care in recent years. Emphasising a single point of contact for people and a single organisation coordinating the various aspects of health and social care rather than providing everything may emerge as the way to deliver both personalisation and integration.
Ensuring that public health approaches are at the heart of a new health and social care system is rightly seen as crucial to containing future demand. The parallel public health policy review should be looking at how we can engage the widest range of health professionals and get the NHS to use what Gabriel Scally has called its ‘societal authority’ to drive the changes needed to reduce health inequalities. Whilst there may be anxiety that local government might raid NHS budgets to make up for reductions in its own resources, it may be a different proposition if doctors and nurses were to make the case for investment in some of the wider determinants of health.
When looking at why this might work where other attempts at integration have failed, it seems that with this approach different parts of the system have to give away some power but they get some back in return. So local government commissions health and social care but the NHS decides how social care is delivered. Acute trusts may lose income from beds but be set on a sounder financial footing by being allowed to evolve into a provider of care from the home to the hospital. There are still unresolved issues and details to be worked through, but we have put forward a coherent response to the challenges in health and social care that the government chooses to ignore and identified a vision worth fighting for.
——————————————————————————————————————————————
Cllr Jonathan McShane is the cabinet member for health and social care in Hackney and a member of the LGA’s community wellbeing board.
——————————————————————————————————————————————-