Change that leads to better lives

Why You Cannot Put Doctors in Charge of Life

Something different has happened recently in the debate on health and social care integration – something that makes the Government’s wider NHS reforms even less logical and coherent than many have already argued is the case.

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Specifically, the Health Select Committee has called for the integration of health, social care and housing in order to improve both commissioning and service delivery, i.e. going wider than just the NHS and social care systems. Some people have been arguing this for many years. (Speaking personally, I was a mental health Joint Planning Manager in 1985, accountable to a London Health Authority, Social Services Department and Housing Department – so it is nothing new.) However, this is the first time to my knowledge that an influential Parliamentary vehicle, the Health Select Committee, has clearly argued for integration to be wider than just health and social care.

This is really welcome. The integration debate has been stymied by social care concepts rooted in old-fashioned beliefs that all people need is ‘care’, for which read residential, day and home care. Thus it was only Social Services and the NHS that needed to be integrated. (Many years ago a former colleague, Nan Carle, then a Kings Fund Fellow, told me to remember that the paternalistic culture behind services meant that for many disabled people, care was “a four letter word”).

One of the great strides forward of the last ten years has been the policy recognition that social care should be about supporting people to ‘get a life’ – obtain and retain employment (including into older age), have their own house/home, sustain and develop relationships, be a part of community and have their rights as a citizen respected and upheld. This approach is now enshrined in DH definitions of the responsibilities of Directors of Adult Social Care – but those Directors do not have access to much of what they need to make this happen.

The public bodies responsible for resources and decisions around these life elements are generally not the local authority’s social care function. Jobs, proper housing and community development (to name but three) are all subject to governmental policy direction beyond the Department of Health, whilst delivery mechanisms are sometimes part of the same local authority as social care, but often controlled by a completely different vehicle.

No matter what organisational structure you introduce to achieve integration, each removed barrier risks putting in place a new one. For example, moving mental health social workers into NHS-led Care/Partnership Trusts reduced the NHS/Social Services barrier but instituted new ones to be negotiated with the local authority functions responsible for housing, economic regeneration and community development. You can’t fully win the integration conundrum unless all public services are delivered through one agency and one government department (which is totally impracticable).

So, bringing housing into the equation does mark a step forward in recognising the wider supports people need. But hang on a minute – isn’t the Government in the process of putting GPs in charge of healthcare delivery? Does this mean that GPs are also to be in charge of major decision making on social care and housing as well? This raises fundamental questions about competence and democracy.

From a competence angle, irrespective of your views on whether GPs have the skills and training to commission local healthcare, expanding that to social care and housing is surely stretching a point – particularly if social care is defined as getting a life through jobs, housing and community. I’m sure that many GPs do understand and want to promote this wider agenda. I’m the not-so-proud possessor of a thirty-year-old unfinished PhD studying why people wanted to become MPs. (I decided to leave and do something of social relevance instead.) I recall the passionate Parliamentary Candidate who was a GP. He was fed up with being the last line of public sector response – for example prescribing medication when the real issue was poor quality, damp housing. He wanted to intervene ‘higher up the chain’ of deprivation.

However, he is an exception. The medical curriculum does not address how to combat social disadvantage and promote community development. Then there is the question of democracy. Call me old fashioned if you like, but shouldn’t key decision making around these factors be subject to local democratic control and influence rather than being driven by local businessmen and women (i.e. GPs) – no matter how public spirited those people are?

Which leads me back to where I started. If health, social care and housing (and hopefully more) are to be fully integrated, and the objective of social care is to help people get and retain a life, then the organisational model of the Clinical Commissioning Group is clearly not the right vehicle. GPs may be the right people to be responsible for saving lives, but not for helping people to get a life. The Health Select Committee proposed leaving exact mechanisms for integration to local decision-making – but how is that different to the Health Act flexibilities that have significantly failed to deliver? All of this means that if the their call for health, social care and housing integration is to be achieved, we will just have finished recovering from and bedding down the organisational restructuring around CCGs, when it will prove necessary to institute another re-organisation that has integration as the driver. What a mess. Another reason for stopping the current NHS and Social Care Bill?

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