Rachel Joyce: Localise the NHS and integrate health and social care

Rachel Joyce is a doctor and a director in a Primary Care Trust.

> Policy summary

There is significant duplication of resources between health and social care, and at the same time there are major gaps in care, particularly for the elderly population. Localising the NHS would improve accountability and enable integration with social care services, which would not only dramatically improve efficiency, but would also improve outcomes and the care experience for patients.

> Policy Explanation

The recent significant rise in expenditure on the NHS has not resulted in significant improvements in health outcomes as compared to other OECD countries. Moreover, there has been a measurable reduction in NHS productivity. The NHS is a centrally driven monolithic organisation with an artificial divide between it and local government-run social care services.
There is significant duplication of resources by the NHS and social care services, at the same time as major gaps in meeting local needs. For instance, an elderly person living at home may be visited by a district nurse as well as a care worker on the same day. Either one may be able to meet the patient’s whole needs on that day, freeing up the other member of staff to meet other people’s needs, but artificial divisions in regard to what is a “health need” and a what is a “social need” lead to the inefficient use of both.

Furthermore, poor communication between the NHS and social care, as well as perverse incentives can see vulnerable patients “slipping through the net”, often leading to poorer outcomes for patients at higher long term cost to the tax payer. An example is the hospital admission that could have been avoided or shortened if the GP or hospital could have easily accessed social care that met the patient’s needs in a timely fashion. Hospital admission is usually more expensive than care at home, is less popular with patients, and can lead to undesirable consequences such as hospital acquired infection, or confusion in the elderly. The problem is that although better social care for this type of patient is an efficient and effective use of resources, it benefits the NHS, but is funded by social services (creating perverse incentives). There are also many other examples of perverse incentives that work the other way (such as better and more rapid stroke care and prevention paid for by the NHS can lead to a significant reduction in the need for social care services for these patients). 

In an attempt to overcome these problems, significant management resource is expended by both NHS and social services managers in “partnership working”, attempting to find ways around these gaps and duplications. However the perverse incentives are difficult to deal with in organisations facing budget deficits and no amount of management resource can deal with the root cause of this problem, and this management resource could be better employed elsewhere in the system.

By localising the NHS, there would be improved local planning that is based on LOCAL need, greatly improved efficiency, better health and social care outcomes, and increased patient satisfaction. Moreover, the services would be more accountable to local people, which will result in better engagement and ownership of people in regard to their own health. Improved efficiency of services could make the Wanless Social Care recommendations (extending social care) an affordable option.

Other advantages to localising the NHS include closer links with education and housing (which are run by local government), leading to further improvements in outcomes and efficiency (housing solutions such as “extra-care housing” can reduce the need for health and social care as well as the need for admission to nursing homes, and education is a major wider determinant of health).

Options for the method of localisation would include either:

• The Local NHS run or commissioned by local government (as social care is currently) with some central running of highly specialised services. An advantage is that it would also facilitate good links with education and housing. Accountability would be to the local electorate.
• A choice of More than one health and social care maintenance organisation available at a local level, funded by local or central government on the basis of their patient demography. This would provide the patient with a choice of health and social care organisation, and introduce an element of competition. Accountability would be direct to the patient, who can move their funding to another organisation if not satisfied.

> Political Risks and Opportunities

Risk: The NHS is thought of as a national treasure, and changing the way it works may lead to some concerns. However, improved efficiency and outcomes as well as accountability should reap early benefits.

Opportunity 1: The Government has so far failed to act on the recommendations by the Wanless Social Care Review. Localising the NHS and integration with social care could make these recommendations an affordable option.

Opportunity 2: The different local options (local government run/ commissioned or choice of organisation) will improve accountability, and the latter would lead to better choice.

> Questions for ConservativeHome Readers

• Should the policy include adopting the Wanless Social Care recommendations?
• Should the system be run/ commissioned by local government, or should patients have a choice of organisation?

> Policy Costs

There would be some minimal administrative costs in the short term, but probably no more than is spent on the constant minor reorganisations the NHS is subject to.  In the medium and long term, there would be improved efficiency and therefore improved cost-effectiveness compared to the current arrangements.

Comments

[clive elliot]

This is one of the most intelligent analyses put up on this site so far. Whether the proposal is absolutely right may be open to question, but the basic thinking, namely that we must prevent the needless duplication and thus target limited resopurces better, is spot-on.

[Ian Mullins]

This would certainly work and be popular at both PCT level and undoubtedly with local authorities.
If we are going deliver quality person-centred services, we have to make sure that there is genuine partnership working between the 2 different organisations. Moreso there needs to be more of an ethos of accountability within health, and less of a driver to simply 'cost shunt' to the poor cousins at LAs. The only way of making this happen is a systemic change in the monolithic commissioning bodies of the NHS.
Strategic partnerships with the generally better managed and streamlined, not to mention politically accountable Adult Services depts of councils is the way forward......ultimately I passionately believe that Joe Public doesn't care who delivers services, or who they work for; all they care about is that they get those much needed services delivered.

[voreas06]

I think local accountability is an excellent idea. The possibilty then comes of saving your local hospital. I would also prefer that the financing was raised locally, and I might even go further and annualy elect the chairman of the local trust. My only concern would be an increase in postcode lottery, but at least people would have a say.

[Prentiz]

I think this is an excellent idea - I've seen Govenrment get off the hook by blaming PCTs and PCTs by blaming the Government recently - we need local accountability and to remove the expensive distinction b/w health and adult care.

Slightly off topic: Voreas06 - you cannot welcome local accountability and still be concerned about a post code lottery! They are two sides of the same coin. I wish that Conservatives would stop using the latter phrase - local accountability might mean differences based on postcode - but they are based on democratic choices not a random lottery!

[Penultimate Guy]

Dr Joyce's proposal is welcome although not novel. It's already Lib Dem party policy, for one thing (on the local authority model). And Prentiz is quite right about the postcode-lottery/postcode-democracy distinction.

[Denis Cooper]

I think county councils might cover the right size of area and population, rather than local councils which for some purposes could be too small.

[Simon Chapman]

I whole-heartedly approve & had been considering a similar proposal myself. I am baffled that the party has not embraced health localism. The outline NHS Bill that we announced a few weeks ago had nothing on this at all - a real missed opportunity.

A main focus of local outrage here in SW Lincs, as in other parts of the country, when faced with a threat to our local A&E Service at Granthm Hospital, is the lack of any locally-elected politician who is accountable.

Health is political - but it should be done locally.

An unequivocal Yes.

[matt wright]

I think improved working between adult social care and NHS is important and like this aim but I worry about the bureaucracy in having all the seperate bodies and we cannot dodge the "postcode lottery" issues. When Mrs Smith can't get what she wants in Exampleshire when its available in Blogshire she will blame the Govt (us if we were the Govt who instituted this). As someone said above, people just want good services but don't really want to know how its done. In summary like many I am drawn to localism in theory but I think it needs an awful lot of working out and health is an area where any problems would become very emotive,

Matt

[Mark Wadsworth]

YES.

[Paul Charlson]

I dont think local Government should run the NHS. The service is already beginning to fragment and local Government would increase this. I would not have confidence in local politicians making decisions as I am doubtful they have sufficient understanding of how healthcare works.

An independent national body is required to ensure standards and direction and clinicians in the driving seat locally This is not the same as the current sham with PECs