It's amazing isn't it? The coalition government came to power with David Cameron's 'promise' of "No top-down reorganisation of the NHS" and, as practically its first act, carried out the biggest reorganisation of the service since its inception in 1948. Despite the deep reservations of many within and outwith the service, the government ploughed ahead with Andrew Lansley's unworkable plans for 'reform'. Eventually, even Cameron realised that the plans were deeply flawed and Lansley was dropped, Hunt brought in and the plan swiftly reworked into the Health and Social Care Act that we all love so much today (the irony klaxon is sounding in the background at this point). The total cost for the non-reorganisation is estimated to be £3 billion, a not insignificant amount for a government imposing austerity measures on the country because of a lack of funds for public services. Still, if it improves the service, it'd be money well-spent, wouldn't it?
Three years on from the Act and the NHS is in crisis (or not if you are Jeremy Hunt) with several key indicators being failed at local and national levels, month after month; mental health services stretched so thin that waiting lists for 'upstream' interventions are growing which, in turn, contributes to the increased acuity of cases requiring more intensive interventions or admission; staff shortages and low staff morale compounding the problems. But, is this all the fault of the Act? In part, possibly. The Act was, on the face of it, a big change to the way the NHS is organised: cutting out a level of bureaucracy, putting commissioning power into the hands of clinicians and improving quality through a tougher inspection regime. The reality is rather different. Yes, clinicians did take the reins when it comes to commissioning local healthcare, however, such a change could have been achieved without the Health and Social care Act by simply amending the mandated structure of Primary Care Trust Boards and requiring them to include more clinicians and put them in charge of commissioning. No costly, complex Act required. On the removal of bureaucracy and increased inspection, I think the Act has failed in a spectacular manner. Taking out one tier of the command chain but then introducing several new bodies that complicate that fairly simple chain, results in a confusing mess. Responsibilities that lay, in the past, with one body, have now been split between multiple bodies. Control of the NHS, which was previously ultimately in the hands of the Secretary of State, now seems split between several bodies leading to a lack of clarity and focus. Finally, the increase in inspection and oversight by three - count 'em - three regulatory bodies is costing a fortune and acts only to point out where the service has gone wrong. The bigger, more important function - what to do about such failure and how to build good quality into the everyday work of healthcare providers - seems a much lesser aspect of their work. Finding fault is seemingly easier to measure than ensuring quality and success. As at least one commentator on all things NHS has said, "You cannot inspect quality into a system".
So, in part, the act has failed. However, the other, bigger reasons for the crisis in the service are lack of cash and lack of integration with social care. On the latter, the Health and Social Care Act was the ideal opportunity to address the point but it did nothing about integration. Right now, A&Es are failing to meet their 4 hour waiting targets because people ready for discharge from hospital are blocking beds as the services to allow them to be safely discharged are not in place in the community. Health providers need to work much more closely with social care providers, especially in time of cash shortage. On the matter of money, I am not suggesting that merely throwing money at the NHS is the answer. However, the lie that the coalition have somehow 'protected' NHS funding has to be exposed: funding the service with a 0.5% budget increase when inflation is running at 4% sounds to me like a cut in the available cash. The £20 billion that the NHS had to save over the five years 2010 - 2015 pales into insignificance alongside the additional £30 billion that will need to be saved over the next five years if current funding trajectories are followed. Different thinking needs to be applied.
I know that putting together two leaky buckets does not make one good bucket and, by analogy, putting together a cash-strapped NHS with cash-strapped social services will not produce an instant financial miracle, solving the money worries of both parties. However, the announcement of the devolvement of the £6 billion health budget to the control of the Greater Manchester local authorities may, perhaps, allow that co-ordination of health and social care, to produce some economies through shared services such as back-office functions and just, overall, allow us to think about 'health' and wellbeing on a wider scale than just in terms of the biomedical model. There will be problems: council and health cultures are very different, many social care items are means tested and paid-for while healthcare is free and there will, potentially, be redundancies ahead but, overall, the Greater Manchester health and social care partnership would seem to be a positive move.
What really is amazing, though, is that it has taken so long for this partnership model to be tried in some shape or form. In health, we have talked for years and years about 'ensuring no-one slips through the gaps', providing 'joined-up services' and so on and so forth but it has proved to be extremely difficult working across the divide caused by two very different bodies, each covered by very different rules and regulations and with separate budgets that encourages silo thinking. Perhaps - just perhaps - now that health and social care are going to be on the 'same side' in Greater Manchester, patients and the public are going to see some benefits. That is, after all, what this is all about isn't it?
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