Era 3 Update 17th February 2019

Little or no progress had been made (by either party) in progressing policy around what defines social care and the issues around who pays, how funding flows and how providers are managed still wait to be addressed.

Convergence of (free?) social care and the NHS and the lack of connection to other services such as housing pose major issues at system level which were not being explored but would be profound.

This meeting discussed some specific problems and possible steps to address them.  

  1. The NHS is a stalled bureaucracy, unable to adapt to demographic change, struggling to sustain service innovations, slow to adopt IT solutions to patient or system management, and resistant to service re-organisation (e.g. rationalisation of paediatric cardiac surgery).
  2. Market mechanisms have failed to reshape services, but commercial providers could contribute to NHS performance (e.g. reduce waiting times for elective surgery) and could be brought into the public domain (but not the public sector).
  3. The current purchaser-provider split has not been a success in levering large-scale change, but some separation of provision and commissioning is needed to manage competing demands for resources. Local authorities have experience of commissioning but have been weakened by austerity policies, so investment in LAs may be needed for them to take up commissioning of health services (see below).
  4. The NHS acute sector absorbs funding preferentially and jeopardises the development of the community-based services required to manage demographic change.
  5. Despite the rhetoric spending on acute services is prioritised above other care services, Public Health and spending on prevention.

Possible solutions include:

  1. Changing the language which reinforces the divide between social and health care.  Much of social care could be called community nursing! (Similar to parity of esteem argument.)
  2. Redefine the boundary that defines continuing healthcare.
  3. Removing the legislation that requires enforce competition and complex funding flows such as PbR.
  4. Making other legislative changes necessary to reduce the consequences of fragmentation but without any top down reorganisation.
  5. Adoption of a long-term, evolutionary approach to promote all mechanisms that facilitate inter-agency dialogue and collaboration (e.g. by giving legal status to STPs and ICS).
  6. Prioritising investment in LAs to allow expansion of social services, and to permit transfer of the NHS commissioning role to them. This could wipe out the NHS’ democratic deficit, but might also mean extra funding goes primarily to LAs.
  7. Development of national standards and requirements for health and social care services.
  8. Enabling the NHS to provide some social care services (e.g. a NHS care home franchise) and LAs to provide some health services (e.g. community nursing); as options.
  9. Maintenance of a national commissioning body for NHS tertiary services.
  10. Transferring commissioning from CCGs to LAs in a way that practitioners will experience as seamless and painless.
  11. Write of acute sector debts.
  12. Consciously and explicitly containing budget shifts into the acute sector and resisting mobilisation of public support by professionals to block service reconfiguration.
  13. Having a public sector employee terms and conditions passport so terms and conditions were the same regardless of what part of the system someone was currently working in.


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