Given that history, it is perhaps unsurprising that the current government has not exactly been shouting from the rooftops about the latest set of proposed reforms. Its view seems to be that the proposals are complex ‘behind-the-scenes’ changes that are unlikely to capture the public’s imagination – so why bother talking about them?
The result is that few people inside or outside parliament understand what the purpose of the proposals is, and in that vacuum all sorts of ideas can take hold. Reforms succeed when people get behind a vision. The need for clarity of purpose is all the greater with a highly technical set of changes like this one, about which the first question people reasonably tend to ask is ‘What difference will any of this make to patients and service users?’
This is one of the questions we seek to address in a new vision statement produced jointly by National Voices, The Richmond Group of Charities, Age UK and The King’s Fund and supported by a wide range of organisations. The vision statement attempts to describe what a successful outcome for the reforms would look like from the perspective of patients and service users, people working in health and care, and the wider public. It also suggests actions that integrated care systems and others will need to take to make this positive outcome more likely.
One of the reasons a clearer narrative is needed is that the reforms aim to solve a problem that people are not always aware exists. It is often only when people need to use health and social care services, and particularly when they have multiple issues that need addressing, that they discover that rather than there being a single integrated system of care, services are provided by a patchwork of organisations that sometimes work together well but sometimes, unfortunately, do not.
In recent years, and particularly since the publication of the NHS Five Year Forward View in 2014, local health and care leaders have been trying to weave services together more tightly. The Forward View aimed to ‘break down the barriers’ between primary care and hospitals, between physical and mental health services, and between health and social care – and there has been some real progress in the years since. But those leading these improvements locally have been going against the grain of the Health and Social Care Act 2012, which is predicated on the principle that quality is driven up primarily by having organisations compete against each other rather than working together for the common good. This dissonance between legislation and practice cannot go on indefinitely.
In the vision statement we describe the benefits that could come if the reforms succeed in creating an environment where it is easier for health and care organisations of all kinds to pull together in a common direction. Our vision for the reforms is one in which NHS organisations, local authorities, social care providers, voluntary sector organisations, community leaders and others work together closely to influence the wider factors that shape health and wellbeing. Teams providing local services would be supported to work collaboratively to provide joined-up, co-ordinated care that meets individuals’ needs in a flexible way. And local organisations would collectively ensure that people working in health and care are well supported and can use their skills to greatest effect, whichever part of the system they work in.
The history of NHS reforms would caution against over-promising. We cannot say with any certainty that this legislation will succeed in bringing about these changes, not least because the government risks torpedoing its own reforms if it fails to tackle the workforce crisis or to put forwards a fair and sustainable way of funding social care. But we can at least say that if this legislation passes, those seeking to develop better, more integrated services locally will have the law on their side rather than continuing to work in spite of it.