While this Act has been less contentious than the 2012 reforms, that’s not to say there weren’t disagreements. From The King’s Fund’s perspective, there were two key areas that remained a problem right down to the end. These were workforce (the government’s refusal to commit to regular forecasts on state of workforce supply and demand) and social care (the regressive change to the Dilnot reforms that make the new cap on care costs less generous to those with lower assets). Both appear to reveal HM Treasury’s continued power to say ‘no’.
On workforce, the refusal to commit to regular forecasts is despite the unarguable fact that you cannot run a health and care service without a workforce and the evidence that shows that years of poor planning have left deep shortages that leave the government struggling to deliver across the breadth of its health and care ambitions. We now need to re-group to support the full and unredacted publication of Health Education England’s Framework 15 document on workforce planning as well as the nascent workforce plan that has been commissioned by Secretary of State from NHS England. The commissioning of this plan strongly suggesting that at least Department of Health and Social Care ministers have got the point on workforce even if the Treasury has not. And on social care, the refusal to budge on the cap came despite the clear evidence that the government’s change to the original proposals flew in the face of the Levelling Up agenda by disadvantaging poorer people in the North and Midlands. At least for now, attention must switch back to confronting the short-term challenges of funding and workforce facing those who work in, and rely on, social care.
On the plus side – and despite the size of the government’s majority – Department of Health and Social Care ministers and officials did prove open to debate and compromise on other important areas. In response to feedback from The King’s Fund and others, they agreed that reducing health inequalities needed to sit within the ‘triple aim’ of guiding objectives for NHS organisations. They accepted our calls for substantial changes to ministerial powers over reconfigurations that otherwise risked a bureaucratic nightmare just when the NHS and its partners needed to think more deeply about transformation. The reforms also kept the permissive and flexible approach local leaders need to better integrate services, something NHS England and others (including us) argued for. There were exceptions to this permissive approach: the government did add protections around the participation of private sector organisations in integrated care boards (ICBs) and local place-level committees, reflecting a sensitivity around the privatisation debate (even if it’s hard to believe any sensible ICBs couldn’t have managed this all by themselves). This is not an exhaustive list of where the government looked for agreement with peers and stakeholders. The engagement was helped by the unfailing good humour and professionalism of the team of civil servants working on the Bill and does mean relationships with many stakeholders – despite the undoubted disagreements – are intact and given the scale of the challenges facing health and care this is surely better than frosty silence.
What is left to do? For the vast majority of people who work in the NHS and social care the answer is ‘everything’. The day-to-day pressures of dealing with recovery from the Covid-19 pandemic, recurrent staff shortages, rising demand and tight budgets are enough to keep everyone busy (far too busy). This remains true despite the reforms holding out the opportunity of a more integrated system that can provide longer-term focus on improving population health and reducing inequalities. It’s an opportunity that leaves much discretion to local leaders rather than imposing a rigid one-size fits all that suits no-one. But this is just an opportunity – whether it is realised into actual benefits relies on the changes in practice and cultures that underpin a more collaborative, integrated system. That includes changes in national bodies such that they don’t replace the permissiveness granted by parliament with their own rigid national blueprint. Most importantly it relies on people in systems and places continuing to learn how to work together, and that will need support, endurance and commitment long after the ink is dry on this Health and Care Act.
Thank you so much for paying tribute to the work of civil servants who so often get a bad press from people who are ignorant of their role and fail to value their expertise.
For as long as I can remember in my 45 year career in health and social care there has never been a workforce plan that resolved the gaps - as someone who had responsibility for workforce planning across a large geographical area my conclusion is it was a definite "art" as opposed to a science - it would be far more helpful if academic commentators could apply their intellectual skills to designing solutions to this "wicked" problem that has existed forever. On the social care point - far more people in the south of England fund their own care - I am personally more concerned that the trials of the new approach will mostly occur in the north of England giving little insight into how it will work in less deprived areas