Something that was striking in the noisy, but not always well-informed debate about the Health and Social Care Bill, was how the legislation appeared so often to miss the most important issues.
One example was the focus on which sector will deliver health care – private or public – when a more fundamental issue is which sector will commission healthcare. Another was that both supporters and opponents often talked as if better commissioning of traditional health services was all that matters, when it is apparent that traditional services will deliver neither the health nor the savings we are in need of.
In the margins there has, however, been a much quieter, but perhaps more important debate going on about what kind of interventions will be needed to deliver a healthier nation, rather than just an effectively treated one, and what sort of interventions are needed from beyond the traditional boundaries of the NHS.
Former Health Secretary and chairman of the Health Select Committee Stephen Dorrell has talked about the primacy of integration between health and social care, which he and others have suggested might be much more important to putting the NHS on a sustainable footing than some much more well-publicised approaches.
Moves towards a higher profile and more integrated approach to public health, with a strong role for councils, are welcome. But the legislation does not do enough to challenge the primacy of hospital-based treatment services, with substantive reform of social care yet to come.
One challenge inherent in integrating health and social care is that the two sectors have different visions. The NHS vision is for expert clinicians in the lead at every level, including commissioning services, with patients as informed consumers. The social care vision is much more radical. It places citizens in the lead, with the opportunity not only to exercise control over the money allocated to their support, but also to influence or even take charge of commissioning.
There are plenty of examples of this approach within social care. It is built on an "asset-based" approach to working with people who use services and their communities which is particularly relevant to public health goals and can only be achieved by people taking responsibility for making changes, not by professionals acting on their behalf.
Asset-based approaches look for people's gifts, skills and resources first, rather than their needs and vulnerability. It sees people's connectedness to their family and community as a crucial part of their ability to make and sustain changes in their lives.
Whereas lots of thinking about community has a tendency to see it as being out there somewhere if only we could find it and capture it without killing it, asset-based community development tends to look for the building blocks of community in people's close relationships.
For instance, much social care is provided by care homes and paid-by-the-hour (or more often by the 15 minutes) home care workers, but Shared Lives is a form of care and support which involves matching regulated carers with adults who need support. An older person might visit their carer instead of visiting a day centre. An adult with learning disabilities or long-term mental health problems might move in with a carer rather than live in a care home. This system is already used by around 15,000 people in the UK and has the potential to be developed in the NHS as a hospital discharge and rehabilitation service, particularly for older people who expect to be in and out of hospital frequently and would prefer their intermediate care to take place in a consistent family setting rather than a succession of care homes.
Spin outs are often thought of as involving setting up cooperatives or similarly complex organisational structures, but some former frontline workers have set up as sole traders or in very small groups to build social care services around the needs of a small group of disabled or older people. These micro-enterprises aim to remain small and personal and some are mutually owned by those who use them, while a few have been set up and run by adults with learning disabilities, not previously seen as being able to become entrepreneurs.
At the early intervention and wider population level, Leeds City Council has seconded social workers into three of its 39 Neighbourhood Networks, and is experimenting with bringing personal budget holders and these grassroots community groups together to plan more cost-effective services and more inclusive communities. Derby is introducing Local Area Coordination, in which local coordinators have access to small amounts of money and a remit to help people to find non-service ways of living a good life, with links into other agencies when services are the only option.
Approaches that stop seeing people as patients, and instead put citizens in charge, will not always be a good fit with the NHS. If I ever need brain surgery, I don't want to advise my surgeon, or even have to work out which surgeon I prefer. I will just want an expert to take charge and do a good job. But we all know that health – as opposed to illness – services don't work like that.
We fail to make alterations in our lifestyles to become healthier because we don't feel the responsibility to do so. So whoever ends up running our hospitals, it may not be as important as the ability of those delivering public health interventions to connect with us in entirely new ways.
Something that was striking in the noisy, but not always well-informed debate about the Health and Social Care Bill, was how the legislation appeared so often to miss the most important issues.
One example was the focus on which sector will deliver health care – private or public – when a more fundamental issue is which sector will commission healthcare. Another was that both supporters and opponents often talked as if better commissioning of traditional health services was all that matters, when it is apparent that traditional services will deliver neither the health nor the savings we are in need of.
In the margins there has, however, been a much quieter, but perhaps more important debate going on about what kind of interventions will be needed to deliver a healthier nation, rather than just an effectively treated one, and what sort of interventions are needed from beyond the traditional boundaries of the NHS.
Former Health Secretary and chairman of the Health Select Committee Stephen Dorrell has talked about the primacy of integration between health and social care, which he and others have suggested might be much more important to putting the NHS on a sustainable footing than some much more well-publicised approaches.
Moves towards a higher profile and more integrated approach to public health, with a strong role for councils, are welcome. But the legislation does not do enough to challenge the primacy of hospital-based treatment services, with substantive reform of social care yet to come.
One challenge inherent in integrating health and social care is that the two sectors have different visions. The NHS vision is for expert clinicians in the lead at every level, including commissioning services, with patients as informed consumers. The social care vision is much more radical. It places citizens in the lead, with the opportunity not only to exercise control over the money allocated to their support, but also to influence or even take charge of commissioning.
There are plenty of examples of this approach within social care. It is built on an "asset-based" approach to working with people who use services and their communities which is particularly relevant to public health goals and can only be achieved by people taking responsibility for making changes, not by professionals acting on their behalf.
Asset-based approaches look for people's gifts, skills and resources first, rather than their needs and vulnerability. It sees people's connectedness to their family and community as a crucial part of their ability to make and sustain changes in their lives.
Whereas lots of thinking about community has a tendency to see it as being out there somewhere if only we could find it and capture it without killing it, asset-based community development tends to look for the building blocks of community in people's close relationships.
For instance, much social care is provided by care homes and paid-by-the-hour (or more often by the 15 minutes) home care workers, but Shared Lives is a form of care and support which involves matching regulated carers with adults who need support. An older person might visit their carer instead of visiting a day centre. An adult with learning disabilities or long-term mental health problems might move in with a carer rather than live in a care home. This system is already used by around 15,000 people in the UK and has the potential to be developed in the NHS as a hospital discharge and rehabilitation service, particularly for older people who expect to be in and out of hospital frequently and would prefer their intermediate care to take place in a consistent family setting rather than a succession of care homes.
Spin outs are often thought of as involving setting up cooperatives or similarly complex organisational structures, but some former frontline workers have set up as sole traders or in very small groups to build social care services around the needs of a small group of disabled or older people. These micro-enterprises aim to remain small and personal and some are mutually owned by those who use them, while a few have been set up and run by adults with learning disabilities, not previously seen as being able to become entrepreneurs.
At the early intervention and wider population level, Leeds City Council has seconded social workers into three of its 39 Neighbourhood Networks, and is experimenting with bringing personal budget holders and these grassroots community groups together to plan more cost-effective services and more inclusive communities. Derby is introducing Local Area Coordination, in which local coordinators have access to small amounts of money and a remit to help people to find non-service ways of living a good life, with links into other agencies when services are the only option.
Approaches that stop seeing people as patients, and instead put citizens in charge, will not always be a good fit with the NHS. If I ever need brain surgery, I don't want to advise my surgeon, or even have to work out which surgeon I prefer. I will just want an expert to take charge and do a good job. But we all know that health – as opposed to illness – services don't work like that.
We fail to make alterations in our lifestyles to become healthier because we don't feel the responsibility to do so. So whoever ends up running our hospitals, it may not be as important as the ability of those delivering public health interventions to connect with us in entirely new ways.
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