There is a risk that when the case for change finally lands with politicians and the public in the midst of a crisis, the lens by which solutions are assessed is also through a health care crisis. We could end up creating a new social care system fit for a crisis but not fit for its purpose. The idea of moving social care into the NHS, an idea almost as old as time itself that is again circulating as a solution, may well encapsulate that dilemma.
It’s not clear what is meant when people say ‘let’s bring social care into the NHS’. For some, it means introducing into social care the same principle of care being free at the point of use (although there are user chargers in the NHS). For others it means moving social care into the NHS, being commissioned and delivered by the NHS, or it’s a hybrid, where social care is free, commissioned by local government and delivered by the NHS. Across these options, there is confusion about what is determined nationally, between delivery, funding and entitlement. The fact that there isn’t agreement on what moving social care into the NHS means might suggest it is not the panacea some hold it to be.
There would be benefits to bringing social care more firmly into the NHS. Benefits that come at considerable cost, and each could be delivered with other types of reform too.
The strongly felt sense of unfairness that our health needs are paid in full, but for our social care needs we get little or no support would be eradicated. We would all have the peace of mind that whatever our condition – be it cancer, dementia or MS – we would have all of our heath and care needs covered.
Our social care workforce would also benefit from better terms and conditions if delivery was part of the NHS provider structure. Care workers, who do critical work every day, are now being recognised as key workers by the community. They deserve better pay, better reward and better recognition, all of which would come with the NHS brand and the Agenda for Pay pay structure.
But, if we wanted to, we could give people a universal entitlement to social care without bringing it into the NHS, and likewise create better pay and career structures without moving it to the NHS.
The argument goes that we would also see more integration between health and social care if social care was part of the NHS. There is potential here, although it’s worth noting that the join-up between different NHS services is by no means perfect, so there is no guarantee that being within the NHS tent would make services more joined up by default. Just look at the historically poor link between physical and mental health, or that more delayed transfers of care arise from health needs than social care needs and you will see better integration is not guaranteed.
There is also an emerging narrative that it would just be ‘easier to get things done’ in social care if it was more like the NHS – more able to respond to a single command and control structure, with it being possible to pull levers nationally and see consistent change locally. But even in normal times, ‘national’ health services do not mean there is no variation in access or quality of services. Whether more national control would make it more resilient in the face of future crises is open to debate – we can just look to local government’s ability to respond from within communities locally across a huge range of Covid-19 issues to see there are other ways to effectively respond to crisis.
But moving social care into the NHS brings with it major concerns. These concerns have long been held by people who rely on care and support and by people who pride themselves on delivering person-centred care in the sector. These voices must be at the heart of the debate, and heard loud and clear as reform options are considered.
There is a real risk that shifting social care to the NHS will see the model of care move to a medicalised model. Much of the NHS defaults to this type of approach, and it is very good at it. But it isn’t the type of care and support people want. Social care should be about helping people live the lives they want to live. It’s not about medical interventions; it’s about a type of care and support and a type of philosophy that the NHS does not have a good history of.
There is also a risk that there would be a shift away from services that – when social care is at its best – are person-centred, based on skills and assets within the community that allow for many different services to develop to meet people’s diverse needs and aspirations. While there have been some encouraging early signs that primary care networks (PCNs) could be strong allies in this way of thinking, we are long way off this being the default in how the NHS thinks and behaves. Until it is, we risk a detachment from local community strengths, which would mean the quality of life of those needing care and support would be poorer. Whatever the intention of numerous policy initiatives over the years, the NHS has a long-held tendency to favour building-based services at expense of community services and development.
When we think about social care reform, too often the framing of the problem has been how to pay for care. Now, the frame may shift to how can the sector be more resilient to future crises and how it can be a better support structure to the NHS. But this would miss the point. When we turn our collective minds to social care reform once more, our thinking should have at its heart two questions. How can we help those that need care and support – now and in the future – live the lives they want to lead? And how can staff working in the sector have the recognition and reward they deserve for supporting those who need care and support to live the lives they want to? In plotting a path to long term reform, we will need to make trade-offs and compromises along the way, but if we hold those two questions close, we stand a chance of creating a new system that is fit for purpose.
I think this piece from Sally deserves some real action focused roundtable type of discussion with hands on, real time, credible social care activists - not the usual high level, safe distance, well dressed, senior representatives of our sector At risk of upsetting many of those that quite ably 'talk the talk' on our behalf, the nature of resilience, a point well made in this blog, must be aired by those that see the fluctuating nature of everyday life for care staff. My staff are kind, keen, proud but often feel heavily burdened by unrealistic idealised expectation and can have bad days too. I will always defend them but know none of us are the finished article and there is much imperfection across all health and care systems including and especially right now when many are really struggling to keep spirits up, stay strong, keep beds filled with well looked after people being safe and having fun and that homes remain viable. I like the 2 key questions made here and as you would expect in that I claim to be one of those hands on frontline owners who knows all of the residents really well in my 2 care homes in Devon - I have some thoughts on what we need to do during and beyond the current Covid crisis
What we need, and I have had previous very successful experience of is a joint social care and NHS assessment service and then each arm providing the agreed care needed - so our social work teams had a community nurse and a community psychiatric nurse embedded in the assessment team so that each could command access to appropriate resources and get doctors / psychiatrists involved as necessary. The only other issues are charging for social care which needs a national agreement and joint funding social services and health to have home care/ care home rehabilitation services that work and reduce the need for long term care. And of course if social services still owned all the care homes the current tragedy might well have been averted, or at least known and monitored and dealt with much more quickly
Although the author scores points about 'medicalisation' - if social care were transferred to the NHS -- she still writes from inside a health view of the world. Look at it from local government's viewpoint. In England, social care is now the major (residual) responsibility of councils. Take it away and what's left? Communities are not self-organising, community care ditto. Once councils ceased to have statutory responsibility, any remaining oversight role would dwindle, which would a) reduce accountability and b) potentially diminish community involvement (which the author mentions).