Over the past few months we have seen tensions between local government and the NHS spilling out nationally and locally – about who is doing what, where and how with the extra £2bn for social care.
But why? Health providers and local government are facing some extreme and shared challenges. Much more unites than divides us – demographic changes, increased demand, citizens with more complex needs, and lower funding increases, to name but a few.
Councils have faced punitive funding cuts and a phasing out of the revenue support grant. The NHS has faced real terms cuts with the provider sector alone running a deficit of £800m last year and funding increases dropping even further this year.
These pressures were well publicised last winter when we saw the worst winter health and care performance in a generation. All services were reporting increases in demand, a reduction in response times and overall system resilience weakened. An important manifestation of this was the extreme pressure facing some A&E departments, with trolley waits of 12 hours, soaring ambulance handover delays, and the linked and inexorable rise in the rate of delayed transfers of care (DTOC), deriving from both NHS and social care sources. And, yes, DTOCs come from inside the NHS as well as from social care.
Local government has long been warning that social care services are on the brink due to a lack of investment, a fragile care provider market and rapidly rising demand. That’s why all of us in the NHS joined local government last year to call for more money for social care as a priority over health investment.
The extra investment is welcome and needed – to meet growing adult social care demand, to stabilise local social care provider markets and to help the NHS by reducing NHS social care related delayed transfers of care. We support the principle that local authorities are best placed to decide how this extra money is spent between these priorities. The problem is that the Government is seeking too great a double benefit for health and care from the same pot of money when that’s simply not possible.
For the NHS, the Government has said that this money being spent on reducing NHS DTOCs is the way to create the increased capacity it needs to manage the coming winter safely. So the NHS, including our organisation, has put significant pressure on local authorities to maximise spend on reducing NHS DTOCs. But, unsurprisingly, as we knew all along, and as the original Better Care Fund proved, you can’t spend the same £1 twice.
There are also some big underlying issues here, centred around trying to pretend that local government and the NHS have become a single, integrated, system when they aren’t. A lot of good things are happening up and down the country to integrate health and care but some big problems remain.
The first is inherent structural issues. The architecture of Government mitigates against the necessary integration, with its separate departments of state for health and local government. The 2015 General Election, the change in political leadership last year and this year's General Election were all opportunities to make the required changes to the machinery of government. They were not taken.
The second problem is a fundamental lack of capacity, in terms of staff, beds and services. Over the years the capacity to maintain current performance in health and social care, let alone bring about the innovation needed to tackle the current challenges, has been seriously eroded. With underinvestment and rising demand, this is inevitable.
Third is input imbalance. Giving the money to social care to support challenges emerging in the NHS might seemingly work on paper. If we chart the flow of patients through the healthcare system, we know that social care is critical to avoid delays and bottlenecks. However, the theory is undermined in practice because of the lack of capacity outlined above. There is a resource gap to fill before we get to tackling the problem in hand.
Finally, there are competing priorities. Both local government and healthcare have a host of priorities that compete for input and resources. Forming new partnerships, tackling a major deficit, balancing the books, focusing on prevention, and boosting productivity all sit alongside managing delayed transfers of care and preventing another challenging winter. Without alignment, it is very difficult for separate systems, let alone local areas and individual institutions, to pull together.
Everyone involved in health and social care wants the same thing – to provide high quality, responsive care and the ability to innovate and promote wellbeing. However the different accountabilities, imperatives and responsibilities, set against a structurally fragmented backdrop which dictates competing priorities, often undermine these efforts. We need to complete the integration journey.
In the meantime, we should respect the importance of both services, argue that they both have to be fully funded, resist attempts to rob Peter to pay Paul, and avoid being divided and ruled.
Saffron Cordery is director of policy and strategy for NHS Providers