27 May 2020

I was particularly interested and welcomed the thoughtful paper prepared by the Sally Warren at the King’s Fund (find out more here) on possible pressures for the future integration of the health and social care services.  After forty years or so in the statutory health and social care sector, of which, the last twenty have been running an independent consultancy, I offer some initial thoughts about the possible reorganisation of some aspects of social care services within an expanded National Health Service.

Social Care and Health are not natural bedfellows. Social Care has its roots in the political framework of local government. Although informed by legislation and national guidance these roots have enabled the shaping and refinement of service to reflect community led priorities and strengths. Localisation is something to be celebrated, as is the voice of the local elected representative and citizens who utilise services.

The Health Services, on the other hand are largely institutionally based specialist services which, except for primary and community care services, have limited opportunity overall of reaching out into the communities they serve.

The NHS has been critically important during this time of crisis. Amazing people, doctors, nurses, paramedics, ancillary staff and volunteers have determinedly worked to control and limit the spread of Covid-19 here in Wales.

Along with first-rate efforts of colleagues in the health service, many of us have seen unpaid family carers, both young and old, helping to ensure loved ones stay safe. We have seen neighbours supporting the most vulnerable with or without close family. We have also learned, often through social media, of the dedication of a social care workforce, public, private or voluntary, working in care homes and the community to compliment the work of health services. Despite early difficulties with PPE, which may continue, this group of people have shown themselves to be selfless, dedicated and often courageous.

Covid-19 will have taken its toll on the emotional and physical well-being of workers in the health and social care sectors. Although the immediate crisis phase seems to be passing, it is unlikely that the long-term health impacts for staff, seeing so many die, will be eased for some time to come.

Decisive leadership needs to ensure partners remain positive, connected and trusting. Allegedly early mistakes were made. Some perhaps relate to decisions to discharge older people from hospital to care homes and the community, anecdotally, without prior testing or regard to the impact on other older people.

Attributing blame at this time will sap collective energy, waste valuable time and drive a wedge between those who, ever more so, need to work together. Although, a future postmortem/public enquiry will help with understanding why and how decisions were made.

We need to use and value the knowledge and experience we have now, to improve the way we work together for the future.

Trust and reliable information are critical to continued success now and in the future. Trust has not always been helped by the actions of some, in powerful positions, ignoring the national lockdown guidance. As we move from lockdown to recovery the need for inflexible top-down direction will diminish. Although the actions of some powerful people strike at the very heart of credibility, it is hoped the damage to our prospects for recovery will be limited.

It has been assumed that improving consistency between the parts improves efficiency and more efficiency converts to sustainable services and use of resources.

Barriers to growth of trust can often be found in conflicting values, lack of a shared vision, differing priorities and confusing mandates.

Failure to acknowledge or deal with these submerged issues will often lead to avoidance, continuing dispute and conflicting actions.

Successful high performing businesses require high performing leaders who recognise the importance of trust, refuse to allow the small minority, who cannot be trusted, to define the majority who can.

The post Covid-19 world is likely to be a battlefield for the scarce resources to rebuild communities. This has been a challenge, in some communities in Wales, as we sought to rebuild after devastating floods earlier in the year.

The most important starting point for any future collaboration is the willingness to develop relationships based on trust.

Despite past negative experiences, we can decide to make trust a default position and by doing so we can realise a mutual benefit in terms of efficiency, energy and the creative use of limited resources.

‘The status of social care: a review’ produced by Dame Denise Platt for the Department of Health (2007) concluded that adult social care was poorly understood and that there needed to be a high degree of agreement about what constitutes social care.

Cultural and conceptual change must underpin how we deliver public services. Relationships between agencies, professions and citizens need to be creative, innovative and reliable.

In consequence, I believe any future investment of time or money should go towards supporting and developing the community led development of social care in which assets, opportunities and abilities are identified in terms of citizens as co-producers and co-owners of local initiatives. The underpinning model should be trust and relationship driven, with the intention of creating environments where people live safely in the knowledge that they are treated with dignity and respect, along with attention given to “what matters to them.”

Modelling demand and outcomes must be the first step in properly understanding the economics before identifying the need for more money. These models will guide and shape how finance is deployed.

Without rising to this challenge, our health and social care services will become increasingly rationed, fragmented and will fail to attract the most talented and committed staff. A major cultural change is needed, and this requires the same courage and creativity that has been so ably demonstrated by individuals, communities, organisations and government working together since the beginning of the pandemic. What we don’t need is a top-down reorganisation bringing together the unnatural bedfellows of health and local government social care.

Collaboration and partnership must be underpinned by a combined public health and social care approach, taking a long-term and systematic view, where benefits are anticipated over years. Such a collaboration should also set out what will have the greatest health, social care and economic impacts.

The Covid-19 recovery is an opportunity to re-think the notion of partnership in public life. This partnership must involve the public, 3rd and private sectors, primary care, local people, community groups and be led by our local elected representatives. It should be built on trust, have shared values, shared priorities and shared outcomes.

The challenge for this partnership must be to deliver sustainable change within a future constrained by reduced financial resources. I urge organisations to now begin these conversations, no matter how difficult, to start the reimagining of services that ensure a brighter future for all.

Gabe Conlon 
Chairman and Founder of Practice Solutions

Contributions from Associates: Danny Antebi and Geoff Sherlock.

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