As Matt Hancock hurriedly brings forward his announcement of plans to reform the NHS and social care in England following the pandemic, what should we be looking for?
The Department of Health and Social Care has today published a White Paper, titled Integration and Innovation: Working Together to Improve Health and Social Care for All, which sets out a series of new proposals that aim to reform the NHS and build on its successful response to the pandemic.
The CSP views the proposals as a welcome shift away from competition, and towards greater collaboration and integration, and we believe the reforms are essential to strengthen accountability at every level - from the Secretary of State and Parliament to NHS bodies that are part of local systems.
However, we are also urging caution, as any reorganisation must not detract from the acute need to resolve the significant workforce issues that currently exist across the NHS and social care, as well as the ongoing and vital issue of recovery and rehabilitation from Covid-19.
As a result, we are calling for all Integrated Care Systems to be required to have a rehabilitation lead at a senior level and representation of staff through their trade unions and professional bodies within their structures.
Furthermore, the last twelve months have highlighted a need to build public trust in NHS procurement through due process and transparency about funding.
But will the new reforms lead to changes that bring about significant improvements, for both patients and staff, or will they have little impact and cause unnecessary disruption?
Here are the CSP’s four key questions about the proposals:
1) Will the proposed changes mean greater accountability for workforce planning and development?
NHS staff are the greatest asset to the system, but they are also the biggest challenge. Workforce issues that need to be addressed include massive vacancy rates, a growth in demand, systematic inequality and a need for respite for staff post-Covid.
At present, there is no clear line of accountability for the workforce
Local services actually employ people, but sub-regional organisations also have a role, as do NHS England and NHS Health Education England.
As a result, ministers and whole agencies are currently able to “pass the buck” and fail to address urgent challenges.
2 ) Will the changes stop the NHS “playing shops”?
The key element of the last NHS reorganisation was the imposition of an internal market and competition. This has led to multiple failings, with competition rules preventing local service redesign being, perhaps, the most prominent one in NHS bosses minds.
However, there are other issues here to address. Too often, the hard boundaries between NHS bodies gets in the way of doing what is right for patients.
Investing in improvements, including those which would save money overall, does not happen because the wrong body holds the budget.
As a result, collaboration can be halted by budget parochialism. For instance, three physiotherapy services may want to share rotations, but one trust might want to charge the others a fee for its involvement.
If the proposed reforms can refocus on population need, rather than individual budgets, then that will be a big step forward
The ending ofcompulsory tendering would also be a major step forward. In some areas, it has resulted in overly complicated service provision (e.g. seven different MSK providers with different pathways in one area). Again, a population health perspective based on collaboration would be much better.
The reforms are unlikely to prevent sub-contracting to the not for profit or private sector, but they are likely to make this a more deliberate decision where speciation support or capacity is needed, rather than the result of a cost-driven tendering exercise.
3) Will the changes help collaboration and integration between health and social care?
In some ways, this is the most difficult challenge. Giving a proper legal standing to the bodies where the NHS and council formally collaborate is desirable.
However, a legal basis for integrated care systems (ICSs) will fail to address the most fundamental barrier to better integration, which is the NHS and social care being funded and based on a totally different basis.
Whilst care is rationed and users pay, integration is problematic.
4) Will the changes open up decision-making locally?
National accountability through ministers to Parliament is one thing, but in a system where local decisions are arguably more immediately important for patients and staff, will the changes free up local decision-making bodies?
From patients, to local community representatives to staff there are a range of stakeholders who feel removed from the decisions that affect them.
This is a chance to address this. The reform should include provision for AHP leaders to be at the table, and create directors responsible for rehab.
Commit to social partnership arrangements at all levels and give a real voice to unions and professional bodies in regional and local workforce planning. Make patient engagement more than mere window dressing
In reality, much of the key local dimension may not be covered by detailed legislation but this is a key time to secure commitments from ministers, NHS England and others that part of the reform will be to improve patient and staff engagement.
Many people have questioned the timing of these changes, and question whether staff and stakeholders want more change.
For years, the CSP argued that constant reorganisation was disruptive, whilst also highlighting the failings of the current system.
However, if they are implemented well, the proposed changes need not be too disruptive. They may well, in time, lead to changes at service level. But, initially at least, they would largely affect national and regional bodies and CCGs, rather than frontline services.
But both patients and staff will be looking for assurance that these reforms will not lead to any overnight restructuring of services, and that any future changes will genuinely be in service of better health, and not just change for changes sake.
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