Saturday, February 11, 2012

How localism can solve the health and social care crisis in the UK

If you're reading the newspapers, you'll be hearing both about the planned Lansley reforms and a parallel discussion about the need to integrate health and social care funding in response to what Government Minister Paul Burstow admits is a 'timebomb'.

But the two are seldom discussed together, for some reason, probably because most journalists struggle to get a full handle. Health and social care are currently separately provided for in law. You get health care for free while you normally pay for social care. Councils determine who gets what in social care and carries statutory responsibility.

In some areas, for example, Bath, NE Lincs, Torbay, Swindon and a few others, health and social care commissioning has, for some time, been placed under one body, normally the Council with a Joint Director of Social Care / CEO of the PCT. Where Council and PCT areas are contiguous this makes a lot of sense because it means that those spending the health and social care pound can see the whole picture and are not slavishly wedded to one or other worldview, health or social care.

Integration at this level also means that local democracy gets a look in. For however flawed and unrepresentative most councils are (hardly anyone young or black, essentially) they are voted in, unlike most health bodies which, while governed by a board, a not particularly accountable to the community, in reality

So why not make this the national policy? Rather than trying to delegate budgets to GP groups, which are, by now evolving into mini PCTs, and also having rump-PCT clusters running alongside (and I won't get into Commissioning Support Groups) - why don't we take localism to its logical conclusion and do the following:

1. Give Councils statutory responsibility for health and social care in their jurisdiction.
2. Make the Health and Well-Being Board being set up anyway by Councils the delegated bodies which oversee the commissioning and procurement of local health and social care. Pool the budget so that there is no distinction between health and social care spend.
3. Set up all staturory health and social care providers as either independent local healthcare trusts or social enterprises which have contractual relationships with the council.
4. Let each local council and its Health and Well-Being board shape local priorities and allow the council to be accountable for health and social care outcomes in its area.
5. Allow the centre to retain powers of intervention if a council is failing it its statutory duties.

The net effect of all of this will be to force local Councils to grab the nettle of the democraphic pressure and problems caused by the imbalance of acute and primary investment in their areas. Decisions will need to be made around what the local health service will and won't fund and where self-payment has to play a role.

At the moment, we're in the ridiculous situation whereby a person with quite profound social care needs who has some means to pay has to practically bankrupt themselves to get the support they need while another person who wants a sex change can get one done on the NHS. Merging of budgets allows some balance to be put into the question of where funding of different needs is placed.

Of course this wouldn't be a perfect system. The funding would still need to come mainly from central government and even in the event of a more localised system of taxation there would be a need for transfers from Surrey to Sunderland. That's what central government, really, should be mainly about doing. Plus the same political nonsense would happen at local level as you see nationally.

But this system, where health and social care is integrated at commissioning level and placed under LA control is, compared to what we have now, quite a sensible approach and places central government in the role of overseer, rather than controller. Would this still be a national health service. Yes, but also a local health and social care service too, with stronger local accountability and scope for appropriate local variation.

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