Integrating health and social care in the Covid-19 (coronavirus) response

‘It was the best of times, it was the worst of times’ was how Charles Dickens described, in the opening lines of A tale of two cities, the contrasting state of London and Paris in the years before the French Revolution.

Although the full impact of the Covid-19 (coronavirus) outbreak has yet to be felt, his words have a contemporary resonance, considering how the daily rhythms and routines of our lives have been turned upside down in a matter of days.

Examples abound of ‘the best’. There has been a remarkable explosion in acts of communal and individual altruism – in less than 2 days 700,000 people registered to be an NHS volunteer, alongside a proliferation of volunteering start-ups to help vulnerable neighbours with shopping, collecting medicine and such like. We have reminded ourselves of our capacity for kindness. Parish councils, the smallest and often overlooked units of local government, have spearheaded this resurgence of community spirit in many places. The public’s use of hospital emergency departments appears to have plummeted and the plea to ‘stay at home and protect the NHS’ has been widely respected – it’s as though the Wigan Deal has replicated itself spontaneously across the country. And who could be unmoved by the sound of ‘Clap for Carers’ echoing through towns, cities and villages throughout the land?

The sheer pace of transformation has been breathtaking, notably the construction of new Nightingale hospitals.

The Covid-19 outbreak has also seen some superb examples of joined-up working across the NHS and local government, with imaginative efforts to support the workforce by, for example, making all council-run car parks free for frontline staff. The centre has suddenly been able to quickly remove obstacles in areas such as information governance that for years have bedevilled integration. It is good that many are heeding the words of Rahm Emanuel and not allowing a good crisis to go to waste. The sheer pace of transformation has been breathtaking, notably the construction of new Nightingale hospitals and the total redesign of acute hospital services within weeks. We have rediscovered the importance of local government as a uniquely positioned place-based convener of local agencies and hub for local resilience plans. And directors of public health have played a pivotal role. Without local government at the centre, we cannot get things done. This will have been a good crisis for localism.

Hopefully the Covid-19 outbreak will bust the myth forever that low pay means low skill and low value.

But above all we are learning that many of the people we value the most at this time of national emergency are those who are paid the least – the vast army of care worker, cleaners, refuse collectors, food delivery drivers and others whose contribution to maintaining the quality of our daily lives, and the essential services on which we depend, is indispensible. Hopefully the Covid-19 outbreak will bust the myth forever that low pay means low skill and low value, and will pave the way to a reappraisal of which jobs are most important in a modern economy.

Finally, fiscal austerity has been rapidly replaced with Keynesian levels of public spending and state intervention that makes the 1948 welfare state look neoliberal in comparison. Whether this Damascene conversion to big state thinking can be sustained in the long term is another matter, but many will welcome the prospects of higher investment in public services in the short term.

Covid-19 has exposed once again the deep-rooted differences between the NHS and social care.

But sadly, examples of this being ‘the worst of times’ are not hard to find in a system that was already overstretched before Covid-19 struck. After four decades of policy initiatives on integrated care, Covid-19 has exposed once again the deep-rooted differences between the NHS and social care, even though their undisputed inter-dependency will be tested to the limit in the days and weeks to come.

Procurement and planning for a national, centrally managed service like the NHS will not work for social care services, which involve 152 local authorities and 18,000 independent providers. Many providers have described ‘going round in circles’ trying to procure essential personal and protective equipment (PPE) for their staff and the people they support; the Local Government Association and the Association of Directors of Adult Social Services have written to the Secretary of State for Health and Social Care to express their concern. Even though care homes have three times as many places as hospitals and offer a massive potential resource to the system, many feel they are an afterthought in Covid-19 planning. Big national bodies charged with planning the NHS response cannot be sufficiently fleet of foot to recognise the nuances of particular kinds of needs, for example for hospices and personal assistants directly employed by disabled people who have also struggled to get PPE because they are ‘outside’ the system.

Both PPE and testing for Covid-19 seem to be the hottest issues in how the government is managing the crisis, and the interface with care homes is a particular flashpoint on both counts. There is a danger that the rapid discharge of people into care homes without appropriate testing will simply transfer the risk from one part of the system to another.

Social care has not fared well under austerity so many will be anxious if their hard-won rights were to be eroded further.

Another big worry is the potential impact of ‘easements’ to the Care Act 2014 as a result of the emergency Covid-19 legislation, giving councils the power in certain circumstances not to comply with some its legal duties. The Care Act created a modern and much-needed statutory framework for social care and gave disabled and older people and carers important new rights to assessment, information and advocacy. Social care has not fared well under austerity so many will be anxious if their hard-won rights were to be eroded further. Whether to exercise these new powers places a heavy responsibility on directors of adult social care, as sector leaders have acknowledged, as there is no requirement for approval by elected members.

That our experience of Covid-19 so far offers a mix of the ‘best’ and ‘worst’ of times – including some powerful reminders of what we already know – is perhaps unsurprising. In our lifetimes this is the first time we have experienced a global pandemic. It is calling for judgements and decision-making – at national and local levels – with little past experience to draw upon, with very limited information and without the luxury of hindsight. With the worst of the crisis yet to come it is far too early to rush to judgement. One of the most humbling aspects of the Covid-19 story so far is the willingness of over three million people who work in health and social care to risk their own health and wellbeing so that we can receive the care, support and treatment we may need. Our immediate focus should surely be to ensure that they get the help and support they need. The rest can wait.