Covid-19 has asked four searching questions about our health services. Phil Hope, Director of the Health Devolution Commission, argues health devolution has some of the answers.
The coronavirus outbreak has shone a harsh searchlight on our health and social care system. It has revealed in stark terms the extent to which the vertical NHS command and control structure is both a strength and weakness; it has exposed the extent to which health and social care are two separate services rather than a single integrated system of delivery, funding and priority; it has highlighted that the health of people in the community impacts directly upon their vulnerability to disease; and finally that the nation’s economic prosperity is directly linked to the nation’s health. The challenges that Covid-19 has left us with are clear.
Firstly, national leadership by the NHS and the government to combat Covid-19 has shown how resources can be found and mobilised in an incredibly short time to provide extra clinical care and to successfully deliver vital public health messages about social isolation. But this vertical command and control structure of the NHS has also engaged with and relied upon local leaders to shape the delivery at local levels and to marshal the wider public services of social care, the police, fire services and housing to help deliver a coherent and comprehensive response tailored to the circumstances of local communities. So, challenge one – should we develop stronger and permanent local partnerships between the NHS and other public services in every part of the country?
Second, our attempts at integration of health and social care services are clearly not sufficiently robust when the pressure is on. Extra funding of services to respond to Covid-19 has largely flowed to the NHS, the extra equipment has flowed to the NHS, and the key metrics are all those of the NHS not social care. The national efforts, belatedly, to recognise and give support to domiciliary care and residential care services have been hopelessly inadequate. They serve only to highlight the extent to which the goal held by successive governments to integrate health and social services have failed. So, challenge two – should we now fully fund social care as a service free at the point of need, fully integrate it with the NHS, and establish robust NHS/local authority partnerships to deliver it?
Third, our health and social care services are not financially sustainable if the pressure on them from an unhealthy population is too great. Improving the community’s health through targeted prevention and public health services is essential if we are to reduce unsustainable demand upon services to treat ill-health and deliver social care. Challenge three – should we now invest substantially in services to improve community health and prevent physical and mental ill-health in order to to build stronger and healthier populations in every community?
Fourth, a sustainable economy requires a robust health and social care system. The demographics of the highest number of deaths from Covid-19 show all too clearly the impact of poverty and social class on the health of our population. There is not a choice between health and prosperity. They are directly interlinked. A healthy population is essential to a healthy economy; and a healthy economy with better quality jobs and a smaller environmental impact is essential for a healthy local population. The role of health and social care institutions as employers and purchasers in local economies is huge. Challenge four – should we fully recognise that health and prosperity are two sides of the same coin and give local partnerships such as Mayoral Combined Authorities the responsibility, funding and mandate to deliver joint health and economic prosperity strategies that embrace the NHS, health and social care integration, community health and economic prosperity?
It could rightly be said that none of this is particularly new. Many strategies and pilot schemes have been put in place to integrate health and social care, to improve public health, and to devolve powers to local areas to act more collaboratively across a range of public services and put decision making closer to local communities. But Covid-19 has shown in just a few weeks that permanent and sustainable change in these areas has not happened. More importantly it has shown that ‘getting back to normal’ and returning to the status quo simply won’t provide us with a robust enough platform when the next health crisis happens.
The Health Devolution Commission, which began before the coronavirus crisis, asked ‘what does good health devolution look like?’. It is halfway through its work but in the light of the four fundamental challenges Covid-19 has raised the key question increasingly seems to be ‘how important is health devolution to building strong health and economic partnerships in every part of the country, to providing a long lasting solution to the integration of NHS and social care, to empowering communities, prioritising public and mental health, and helping make our NHS and social care services better and more resilient in the future?’.
Phil Hope, Director of the Health Devolution Commission
Senior Associate, DevoConnect & Commissioner, the Health Devolution Commission