It's not all it seems.
Richard Bourne is the former Chair of the Socialist Health Association.
The care system was in a poor state before the pandemic, after years of austerity. Staffing remains a huge problem. The social care system is a disgrace after years of neglect and cuts to Local Authorities. Cuts to Public Health made the pandemic worse. The system is performing heroically to deal with Covid-19 and will take literally years to recover to whatever the new normal becomes.
The idea that we now need a reorganisation of the NHS with a hat tip to local government is baffling. Yet the government is saying it is vital that it legislates for major changes as set out in its White Paper – Integration and Innovation. There is time to spend on moving the deck chairs but not for an enquiry into the real causes of the Government’s dismal record during the pandemic.
The new White Paper dilutes the requirement for competitive tendering for NHS services; removes powers the Competition and Markets Authority has in the NHS; allows more non market methods for payment for services; lessens the autonomy of some organisations within the NHS and removes the independence of others and moves powers to Ministers.
It allows Ministers to more directly determine how local services are configured. Just over 40 Integrated Care Systems that will be in place across England by April based on defined geographies. These are put on a stronger legal basis with new Partnership Boards (which include local government and others) which oversee but cannot actually direct how local NHS and related services are planned and delivered based on the needs of local “place”. It also ends current informal arrangements bringing the various management bodies at the centre of the NHS together so oversight of planning and deliver are in one body – not several.
When the previous NHS White Paper – Liberating the NHS came out a decade ago many bought into the then coalition Government’s vision of an NHS that promised to “put patients and the public first”, and where “no decision about me, without me” is the norm. Many welcomed proposals to “give everyone more say over their care and treatment; with more opportunity to make informed choices, as a means of securing better care and better outcomes”. It was a hoax.
There was a strong campaign against the Bill derived from the White Paper, but it still became the Health and Social Care Act 2012. And so, what is generally acknowledged to be the worst piece of policy in years, passed into law – only to be largely ignored. Whilst the worst fears about the Act have not come to fruition the many criticisms of it turned out to be all too accurate.
Now the government presents a new White Paper to “reduce bureaucracy and to build on the lessons from Covid-19”. And just incidentally to rip the heart out of their own mess, the wholly discredited Act.
Don’t be too optimistic again. Last time the NHS was in a better place to ward off ideological onslaughts. And now there is little money.
To get back to the performance and satisfaction levels achieved in 2010, let alone bring in some much needed improvements in patient care in areas like Mental Health and Community Care, needs a lot of money. Without the money this organisational stuff is not worth discussing. There are simply not enough staff – there has to be a credible workforce plan funded by the money. Without a solution for social care and some idea about what we want from Public Health then using words like integration are meaningless.
A passing read through of the new White Paper is enough anyway to flag up the problems; just as a proper read by anyone in government in 2010 would have shown the flaws in Liberating the NHS. The new White Paper lacks depth of support since it ought to have been co-owned and co-developed with local government and the staff; not just subject to a tick box consultation.
The new offer is apparently all about “integration” (nothing at all is said about the innovation bit!); about removing the obstacles that have led to disintegration and to care that is not joined up. The major obstacle being the ideology that required us to pretend our care is a commodity in a market. Market think is to go – collaboration between everyone is to replace the competition between bits of the NHS brought in by the Act and complicated new organisations will somehow repair the open hostility between the NHS and the rest of the public services.
Privatisation and outsourcing in the NHS will be more limited but not abolished; the damage done will not be reversed; NHS capacity will not be rebuilt; local authorities will not have their role as care providers restored – attention to the already privatised social care sector may or may not be dealt with later.
The impossible to define “integrated care” (you know what it is when you experience it) is obviously desirable and the current fragmented mess does not deliver it. Fair enough. But integration is a major problem within NHS as much as between the NHS and the Local Authorities who deliver social care. Integrated Care Systems like they have in Wales and Scotland sound attractive but do not appear to automatically lead to integrated care.
The English care system does not deserve another structural mess. Think again. To integrate maybe you don’t reorganise – you do not break up organisations, change everyone’s job title and you do not make redundant or TUPE transfer thousands of staff. If instead you appoint the right people and if the right relationships are nurtured and not distorted by the ludicrous ideas of competition – then that is the way to go.
But such analysis takes the proposals too seriously. Here is the simple alternative requiring a minimum of legislation.
- Put the money in. Use an independent organisation like the OBR to vet the funding against the ambition.
- Value the staff and give all care staff proper, decent terms and conditions. Do not just clap.
- Make all personal care free, as with the NHS (removing huge barriers and bureaucracy).
- Repeal Part 3 of the Act and permit competitive tendering for NHS funded services only where necessary. Only allow contracts with organisations that meet proper criteria like paying tax and having decent terms and conditions for staff.
- Progressively improve quality of social care (by investing in the care staff) and remove obstacles to accessing care so far more qualify.
- Prohibit NHS bodies from outsourcing their core care responsibilities and outlaw any two-tier workforce options.
- Reverse the outsourcing that has been done and rebuild public service capacity.
All possible with a short and simple Act that would have wide support. But only possible with the increased funding and the change in attitude away from the favouring of markets, competition and privatisation.
If that was done and the workforce was nurtured and developed then the rest would take care of itself in an integrated way.
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