The Way Ahead (according to Irwin)

SHA policy

In  2015 austerity continues and we will still be recovering from the disastrous reorganisation of the NHS, the impact of the chronic under funding of social care and major issues over housing.  From 2015 our care system will have to develop in ways very different to the approach when there was relative prosperity and increased investment on a significant scale.  What must determine our approach to policy – 20 points to consider?

  1. We live in a society which is too unequal and must look to improve well being overall by tackling the social determinants of poor health and wider inequality.
  2. We need a shared vision of where we want to be in ten year time – a 10 year strategy or plan – signed up to by as wide a collection of stakeholders as possible.  This is not to drive reform (horribly overworked idea) but to bring stability and to emphasise steady progress over time not magic solutions.
  3. Our approach to a care or wellbeing system must be driven by core values of social solidarity which make it a public service not a market.  It balances lifetime risks across the whole population – as a form of social insurance but funded through general taxation not premiums.
  4. As with health care, free-at-the-point-of-need personal social care[1] should be provided to pool the risks; it is accepted this will have to be achieved over a period by increasing the scope of who gets free care[2] as the economy improves and funding can be obtained.
  5. We are in the information age and should free up as much “public” information as possible, looking to remove barriers to access, allowing a plethora of organisations to conduct analysis and reporting.
  6. We are now in the era where we need shared decision making (co-production) – where the views and opinions of the “patient” (their carer(s) and if necessary their advocate) have to be as important as those of the “professionals”.
  7. And as key to this (5) we need joined up records and sophisticated secure access – we have to overcome the barriers that still block development of electronic medical (care) records – barriers which are now institutional, professional and societal not technical.
  8. We should recognise there is such a thing as society and also community; valuing the contribution communities can make if they have initial support and encouragement – and communities now are not just geographical – they can be virtual or shared interest.
  9. We should go back to championing the value of our public services not denigrating them, to making them better and exemplars of good practice, not privatising them.  We should think of social care, health care, housing, education and other public services as part of one system not as disparate systems.
  10. We should have a national care system not a federal or local one.  What we are entitled to is defined nationally and assessments and entitlements are national.  What has to be provided for free is settled nationally.
  11. But we should go back to championing the value of local democracy and give both real and enabling powers back to local authorities.  There should be considerable flexibility about how services are provided locally with great emphasis on coordination and cooperation across all public services, and across the voluntary and private sectors when they also provide public services.
  12. We should allow different localities to organise both planning/commissioning and provision in ways which suit them best – not proscribe a fixed model as one size fits all.  If providers collaborate or form integrated arrangements or if commissioning and provisions are combined locally or if payment mechanisms are altered – so be it.
  13. We should go further and accept the value of sub regional planning and collaboration structures and allow flexibility over how such arrangements are made.
  14. We should provide whole person care services in a manner which ensures the recipient is unaware of which organisations and which parts actually do the providing – we should adopt and put into the NHS constitution the definition from Patient Voices or similar.
  15. We should stop denigrating public servants of all kinds and ensure those who provide public services (through whatever organisational form) get proper terms and conditions including adequate training and development to carry out their important roles.
  16. We cannot have a fully publicly provided care system nor can we buy out or renege on the many thousands of existing contracts with non-public providers of all kinds  – so we have to define and accept the roles that can be played by voluntary and private sector organisation in providing public services and on what terms[3].
  17. We should end the idea of legally enforceable contracts between parts of the public sector and go back to service level agreements or “NHS contracts” which have no legal force – thus removing the scope for any interference from competition law – domestic or EU.
  18. We should look to build governance structures within our public services which allow genuine involvement of service users and the wider public.  Where decisions are made about setting local priorities or allocating resources (at scale) then the process used must be under democratic control with full transparency.
  19. We must encourage the widest possible open dissemination of information from the providers of public services about best practice and allow publication of comparative information on performance; we should not rely on top down performance management.  All providers of public services must be fully covered by FoI and (once a contract is signed) non-public providers cannot claim any commercial confidentiality.
  20. We do not need market regulation – this is not a market.  We do need regulation and licensing to prevent abuse and remove unsuitable providers – but we need good local oversight more – through some modernised version of properly funded and independent Community Care Councils with teeth.

These would require a revolution in the way we think about care and how we train and develop those who will help co-produce greater wellbeing – but it can be achieved incrementally over time, with different localities doing different things at different speeds – still with an overall system of entitlements.  It does not imply or require any one-off top-down reorganisation and almost every part of what we need to know is already out there somewhere.

[1] It is accepted that this needs developing to define what is and is not personal social care, who can carry out assessments and write prescriptions, whether top ups are allowed and a host of irritating technical issues.

[2] The principle that some get free care not just because of means testing is now being firmly established through the Care Bill.

[3] We should view non-public providers as a resource to be used only when the public service is unable to provide what is required, not as an alternative competitor for services.