It is one small step, when what is required is a giant leap. The SNP government’s Adult Health and Social Care Integration Bill does little more than set in moonstone what is already happening. Scotland’s 36 Community Health Partnerships are to be re-branded as Health and Social Care Partnerships when what is needed is a full integration of the NHS with local councils.
Community Health Partnerships were formed in 2004 in response to the bed-blocking crisis when elderly patients were stuck in hospital for up to six weeks because there were no places for them in nursing homes or care services in their own homes. The 14 local health boards were urged to work with the 32 local authorities to try to solve the problem -costing up to £50m a year – and bed-blocking has indeed become much less of an issue.
Since then, the CHPs have gone on to form permanent teams of doctors, community nurses, care workers, social workers and housing officials to try to integrate the care given to older people and prevent them landing up as emergency cases in hospital. In a report last year, Audit Scotland found that such partnerships now manage £3.2 billion of health and social care, over a quarter of the total health budget. They employ 28,500 health staff and 5,300 social care staff.
Audit Scotland did not question the overall strategy of local care but it did conclude that “there is now a cluttered partnership landscape” which has resulted in duplication and a lack of clarity about how the money is being spent and what the objectives really are.
The new bill will, no doubt, address these complaints. It will also “strengthen the role of clinicians and care professional, along with third and independent sectors, in the planning and delivery of services.” We await details of what exactly all this means.
But one thing it will undoubtedly mean is that there will be less work for local health boards to do. In fact, it seems to me, they will just get in the way and we would be better abolishing them altogether. The think-tank Reform Scotland has already proposed such a move, pointing out that a local authority health and social care system works well in Scandinavian countries.
Afterall, most other public services are provided by our local councils…schools, public health, social work, environmental services and, until the SNP came along, police and fire protection. It makes sense to me to integrate health and social care with this total package of services, so that we don’t have public agencies tripping over each other to solve problems and provide an efficient local infrastructure to our lives.
Integration would also mean that councils could get a grip of spiralling health costs and do so in a democratic fashion. We are facing a huge increase in the number of older people – a 12 per cent rise in the next five years to nearly one million, and an 18 per cent rise in the number of over-85s – all of them demanding increasingly expensive treatments. At some point, the politicians will have to say “No” and that rationing is best done at a local level where the trade-offs are more obvious and the politicians are more accountable.
Where would this leave our hospitals and other specialist services? It makes sense to have these remain in a small number of “hubs”. Councils immediately around them would need to co-operate in using their services. But each hospital or service could be run by its own manager or managing committee, without the superstructure of a health board. Councils, under this system, would contribute to their nearest hospital in proportion to how much they use them – an incentive to keep hospital stays down to a minimum, which is best for everyone concerned….. especially the patients and the taxpayers.
In many ways, this is to turn the NHS up-side down. But it is what many people are now calling for. The health service would be bottom-up rather than top-down, it would abolish one layer of administration, it would be centred on prevention rather than cure and it would be holistic not just clinical. It would do what the title of the government’s bill aspires to do….integrate health and social care.
– John Knox is a political writer and former BBC political journalist and Parliamentary commentator.