Burnham should get second opinion on care prescription

by Craig Dearden-Phillips MBE 27/10/2014

Labour's Andy Burnham has probably articulated more clearly than any other politician how the NHS is going to have to change from a hospital-based service to one which also supports people to stay healthy. 

He has also been very clear that this will involve hospitals, or parts of them, closing, as care is moved into the community.  

He rightly cites Torbay Care Trust as an example of integrated health and social care, where wards have been closed in order to free resource for better community-based care.

So far, so good.  Where Burnham has not got it right, is his vision for a new National Health and Care Service (NHCS) which, in his own words, would be a 'refounding' of the NHS for our times.  

While still sketchy, the vision is, it sounds, for hospitals to be recast as the organising force for combined health and social care services to form a seamless service for the citizen. The role for councils in all this isn't clear but appears to be through participation in beefed up Health and Well-Being Boards. Council social care budgets, appear, in the world of the NHCS, to disappear into a redrawn local Clinical Commissioning Group (CCG).

While many a Council CEO will sigh with relief at losing their single largest budget pressure to health, others will be rightly concerned about what this means for local people because Burnham's plans to hand over the social care budget to health may not, as Burnham intends, rebalance the health and social care system but actually make the current imbalance worse. 

Think about it. At the moment, the NHS is gripped by a crisis of resources which even Jeremy Hunt accepts is genuine. Hospitals are being crushed in a slowly tightening vice of demand as the population ages. There are infinite and insatiable demands on hospitals and, as the most powerful elements within the NHS, hospitals also have a huge gravitational pull on resources. 

Therefore, it is almost inevitable that money released from councils into the NHS would not, as Burnham hopes, fund a benign new patterning of services, but be sucked straight into the carburettor of  NHS Trusts which, without any other way of funding their activities (e.g through charging for hotel services), are faced with no other choice, at least in the short-term, than to grab every penny they can, whatever Ministers say about the importance of social care.

The consequences of this could be a disaster for local councils. Today, councils, as holders of social care budgets, act as a bulwark against the natural tendency of the NHS to divert all available resources to core medical services.  

Without council commitment to social care, we could see this eroded beyond current levels, causing even more vulnerable and older people to be tipped, unnecessarily, into the nation's hospitals than do so today.  Except this time the council would be powerless to act, except through health and well-being boards. Burnham would see his plans overwhelmed by the public support for hospitals which would, in many areas, be encouraged  by beleaguered NHS acute trusts.

There are two other big problems with Burnham's ideas. One, the biggest, is fiscal. 

Social care, unlike the NHS, is relatively cheap. It is provided by thousands of providers, large and small, local and national with both the private and voluntary sector playing huge roles. 

While the net effect of this diversity has been a lowering of terms and conditions, and union power, in the care industry, Burnham's desire to bring social care into some kind of harmony with the NHS calls, implicitly, for the direct costs of social care (mainly wages) to rise significantly. 

This, will create a guaranteed impact both on individual payers (higher charges) and on taxpayers (more taxes) - or reductions in social care based what can be funded with available resources.    Whatever the moral case may be for greater pay in social care - and I believe there is one - this has to be made in the context of the full consequences and alternatives.  One of these is even more stringent rationing of social care than is the case today.

The other problem concerns the social care market and its place in the new NHCS.  Quite how a market-based system, which local authorities have become skilled at managing, becomes managed by the CCGs and hospitals, which specialise in the organisation of medical care is a big unanswered question. 

It will make for poorer commissioning decisions and, possibly, models of care that rely on an over-medicalised approach to care which is inherently costlier and, arguably, less empowering to users. Providers of social care everywhere will find their long-term business relationships with councils handed over to what is, in effect, the largest super-provider of hospitals in the developed world - an organisation that has no real experience of working with a market, least of all a make in social care services and with a baked-in preference for funding hospitals not care.

So what might Burnham do to square the circle?   One potential approach is to give local councils the leading role in the management of single health and social care budgets. 

Burnham could do this by placing CCGs inside councils, as the Coalition has done with Public Health. This locates the drive for integration not in the needs of NHS hospitals but in a rival power-centre, the local authority which, in turn, is accountable at the ballot box.  

On a practical level, councils would then be deciding the right balance of social and health care, not unaccountable and often very weak CCGs, who tend to be dominated by the acute sector locally.   Council-led commissioning sees their skills in local care market-management and in citizen engagement used to the full in a social care system based on overall local priorities, not just those of the NHS.   

While hard decisions for councils will fall out of this, these can be tested and judged in the appropriate way. Yes, this means some restructuring – a move of CCGs into councils -  but a lot less than under the Lansley reforms – and a lot more accountable to local communities.

If Burnham wants integrated health and social care, he needs to look to councils, not the NHS for his answers.

As published in The MJ:

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