The Ask of the Pause

Drawing the Health and Social Care Bill back into its committee stage is fairly good news Delay isnt politically or administratively neutral of course: different lengths of delay can affect different parts of the social care and health system differently But only as this Pause and Think period of reflection has gradually drawn to an end has it begun to dawn on people outside the health and social care `family that the debate over the Bill - which was deliberately drawn up to talk about health and social care - has been totally dominated by the health side of the equation.
Will GP consortia work? Well, roll out the RCGP, former RCGP chairs, PCT spokespeople, learned physicians and health management gurus Will its current wording let loose the engines of competition both European and transatlantic red in tooth and claw? Bring in the same consultants, representatives of the pharmaceutical industry, experts on European competition law, former Secretaries of State for Health

Can the Bills objectives be achieved without any legislation at all even? Out come the BMA. Yes, there has been no end to a fulsome debate on the health side of the equation about 95 per cent of media comment and political analysis devoted to 50 per cent of the Bill...  What about the composition and powers of local Health and Wellbeing Boards? Too complicated for the average viewer/reader. Next

But only until recently. The Prime Minister himself has now begun to make the vital connection. And so has the Times - in a seminal leader on May 24. Noting that the increasing demand for health care is structural; that two thirds of the of the total health budget is spent on patients with chronic conditions, and that longevity has thankfully increased, the Thunderer at last wakes up to the fact that the health service is composed of a series of incentives to send people to hospital rather than empower them with their own budgets not to.

Or, as ADASS has recently put it elsewhere, the `care part of the Bill has been woefully neglected, yet the key to caring for a rapidly increasing elderly and/or vulnerable population is the same key that will unlock the door to a more efficient and effective health service. The Association has now, formally and publicly, urged the Coalition Government, as we have done privately, to extend the period of the Pause in deliberating the Health and Social Care Bill so that the Dilnot recommendations can be part of the reconsideration currently underway. Delaying the Bill is an important concession to that stated aim.

One of Andrew Dilnots stated purposes has been to attend to the other half - redressing a position where the founding patrons of the welfare state, all of 65 years ago and understandably perhaps, left social care alone to look after itself. What we are managing today has grown like topsy out of the neglect of the past; it has been admitted by all parties  to be an unsustainable settlement and yet still, it seems, politicians, broadcasters and some professionals cannot grasp the complexities involved in bringing these issues together.

Dilnot should remind them, as well as the population at large, that there can be no sustainable, long-term solution to the problems facing the NHS without a simultaneous, sustainable, long-term settlement for social care, including grasping many a painful nettle concerning its funding. That might be the biggest `ask that the pause has to offer: wait for Dilnot, digest his recommendations and ensure a Government commitment not just a Department of Health one to implementing the best of his findings. But there are more. We fully support, for example:

  • A developed role for robust health and wellbeing boards (HWBs) bringing together politicians, clinicians and others in a meaningful strategic partnership. We have already made great strides towards realising this opportunity through the establishment of over 130 HWB pilots. They should hold a strategic overview  and scrutiny function across the locality holding commissioners to account and lever in improved outcomes for individuals and local populations. And they should be empowered to sign off commissioning plans aligned to local health and wellbeing strategies, underpinned by local Joint Strategic Needs Analysis, creating synergy, integration and  focus upon improved shared outcomes

And yes, there are issues concerning their alignment with the National Commissioning Board. And particular care must be taken to sort the relationship with Childrens Trusts Boards. Childrens safeguarding arrangements, too, might need a second look if the split in responsibilities for 0 5 and 5 19 year olds is going to be maintained.

  • An NHS that has a greater focus on place and personalisation, as indeed the Times demanded. Shouldnt these and individual outcomes championed by local government be extended into the NHS?
  • The transfer of public health responsibilities to local government, who are well placed to deliver localised integrated early intervention and prevention approaches. We want public health leadership coming from councils to achieve better outcomes for all. And we want especially to see a new focus upon those conditions, like strokes, that have poor outcomes, with an adverse impact on people's independence. But the line management relationship and financial arrangements have to be transparent. 

Maybe there will be a split in the DPH role between national `risk activity and local `healthy living activity (although some colleagues wonder if there should be any accountability to Public Health England at all). But however that split is made, it must be clear and concise, and the transfer should include the DPH and his/her team. Should s/he have a strictly advisory role? That might be something left to localities, but Ministers should have sight of its wider implications.

  • The development of the NHS in a way that makes it ready to improve the outcomes for older people with long term conditions, like dementia. We want to work with clinical leaders  providers and citizens  to bring about a greater focus on these outcomes. Indeed, as the seminar we are holding this/next month with the British Geriatrics Society demonstrates, we are already in productive discussion with key players in the hospital medical community. Currently, as one of our members put it so succinctly recently, the discussion about care, and the discussion about the rest of the Bill, are being held in two totally different places.
  • The wishes of the increasing number of people who wish to live and die at home to be recognised and met. We want to see proposals for more integration around provision for older people and opportunities to enhance the valuable part played by the independent sector in support at home.
  • Is it true, again, as a colleague complained recently, that the NHS has never understood carers,? Perish the thought! But we have to develop improved support for carers, and we welcome local forums that will create accountability for addressing needs together, including people who previously have been the most isolated and overlooked, and we are fully committed to placing citizens voices at the centre of our work.
  • We also welcome the Care Ministers determination to ensure that money voted by Parliament for the support of carers should be properly transferred and accounted for. Building community capacity is one of the bedrocks to an integrated and sustained solution and we welcome further explicit commitment by the Government to support this.
  • And last but not least, the role of Healthwatch is welcomed so far as it goes. There are continuing issues concerning its composition and its structural position next to scrutiny committees, Monitor and the Care Quality Commission. This is the sort of detail in which the Devil thrives, and clarifying those important lines of communication and function is an urgent task still waiting in the in-tray.

So, yes. Lets pause, think and touch Lets go back to committee stage (but for six months..? Really..?) and let's re-engage with the politics of the Bill. But lets make sure that everything is thought about and touched, and that social care a pillar no less important to underpinning social welfare and wellbeing than is the NHS gets its proper place in the sun.