It’s not just about the money:

5 dilemmas underpinning health and social care reform

Open any national newspaper or turn on the news and (Trump and Brexit aside) there is likely to be coverage of the intense pressures facing the NHS.

Throughout the winter, there have been stories of hospitals at breaking point, an ambulance service struggling to cope, major problems in general practice and significant financial challenges.

For many commentators, this is one of the significant crises the NHS has faced for many years, and quite possibly the longest period of sustained disinvestment in its history.

“Draconian funding cuts have decimated services at the very time that need is increasing.”

In adult social care, the situation is even worse. Draconian funding cuts have decimated services at the very time that need is increasing with an ageing population, a rise in the number of people with multiple long-term conditions and growing numbers of young people surviving into adulthood with complex needs.

Increasingly, NHS leaders have argued that if any extra money is to be found, it should go to adult social care – otherwise the system as a whole could simply clog health and social careup, fall over and fail.

However, we can’t keep doing more of the same. Health and social care provision must align with how we live other aspects of our lives in the 21st century.

While we need a funding settlement which gives some certainty for the future, we also need to address the underlying tensions that continue to dominate many of our services.

As explained in the new edition of Understanding health and social care, five key dilemmas are:

1. How best to promote more joined-up responses to need in a system that continues to assume that it is possible to distinguish between people who are ‘sick’ and those who are ‘frail and disabled’.

2. Whether to support people with long-term conditions because they are citizens with a right to independent living, or simply as a means of reducing reliance on expensive hospital services.

3. Whether to focus on challenging discrimination in health and social care or in wider society, and whether to do so via specialist initiatives or via general approaches.

4. Whether to involve people with experience of using services because they are ‘customers’ who can help improve the ‘product’ or because they are citizens with a right to greater choice and control.

5. Whether to support carers because they run the risk of being exploited by formal services and deserve the same access to a meaningful and stimulating life as everyone else, or because this is a cheap way of helping the ‘service user’ and reducing demands on formal services.

In the short term, it is probably possible to do a little of each of these ‘either-ors’ – to promote partnership in a system that is deeply divided; to tackle discrimination in formal services and in wider society; and to support people with long-term conditions, involve service users and support carers for a mixture of (not necessarily compatible) motives.

In the long run, however, the jury must remain out on the extent to which the current system can continue to contain these contradictions and tensions.

The second edition of Understanding health and social care appeared part-way through the Coalition government of 2010-15, asking whether massive public spending cuts and an uncertain economic outlook would lead to radical new ways of working in health and social care.

“Evidence of genuine and long-lasting reform still seems lacking.”

The third edition now appears under a Conservative government, when the full force of these cuts is being felt, and when austerity is feeling to many like a long-term state of affairs.

east_midlands_ambulance_service_nhs_trustEvidence of genuine and long-lasting reform still seems lacking.

Government remains committed in principle to further joint working between health and social care, but not to removing the underlying distinction between free health care and means-tested social care altogether.

There is talk of greater choice and control, but a very real risk of simply co-opting this language and creating little more than ‘zombie personalisation’ (a phrase coined by leading personalisation expert, Simon Duffy).

Discrimination remains widespread, the focus is often on ‘user involvement’ rather than on human rights, and support for carers continues to evolve but with longstanding and significant barriers remaining.

“Every problem can also be an opportunity.”

Choices still need to be made, but, in the meantime, every problem can also be an opportunity.

For example, the current policy rhetoric around ‘integrated care’ is a helpful hook for local partners keen to promote more effective joint working, while the personalisation agenda could still be transformative if we could implement it in a way that is true to its original values and ideals.

The Equality Act gives significant scope to take positive action to promote equality (not just avoid discrimination), while the importance of user involvement and the need to support carers are now so widely recognised that the genie feels well and truly out of the bottle.

Understanding Health and Social Care helps to explain these opportunities and tensions, thus supporting students and practitioners to change future practice and attitudes for the better, whatever the choices made by those at the helm.

First published on the Policy Press blog