Never let a crisis go to waste

Dr Eleanor Roy, Health and Social Care Policy Manager at CIPFA, explores the benefits of joined up policy making across health and care

If there are any benefits to be realised from the Covid-19 crisis, chief among them would be that the financial issues facing health and social care have been brought to the forefront of public discourse. However, while it is fantastic to see engagement on these vital issues, a decade of austerity has meant that our health and social care systems were not adequately prepared for recent events.

The NHS has faced particular difficulties in mobilising capital. Reductions to capital limits and transferring capital to revenue have contributed to a phenomenal £6.5 billion backlog maintenance bill. This has been further exacerbated by the removal of Private Finance Initiative (PFI) as an option to access private sector investment – with no alternative option on the horizon. While the government has recognised the need to reform the capital system, this continues to be delayed. Meanwhile, social care has long been in a state of crisis, with the sector facing increasing levels of demand, workforce shortages, a fragile provider market and significant under-funding. While the need for reform has been recognised for over 20 years, the political will to grasp the nettle of social care reform has been lacking.

These systemic problems had been trundling along largely in the background of political debate until Covid-19 hit the UK. In the face of the pandemic, existing fragilities that had flown under the radar or been placed in the ‘too difficult’ bucket were exposed and exacerbated. At the same time, the pandemic has brought the interdependencies between the health and social care systems into sharp relief.

National policy decisions impacting the resilience of one service have implications for the other, and Covid-19 has highlighted this for health and social care in particular. It has also revealed some of the problems with centralised ‘command and control’, which we have seen in the national PPE distribution and testing programmes. The experience has demonstrated what has been clear to those working across the public sector for many years - that integrated systems and a place-based approach are key to delivering the best outcomes – and best value - for communities.

The crisis has gone some way to breaking down institutional silos that had inhibited integration – necessitating a move away from focusing on the barriers of process and encouraging shared goals and outcomes. We’ve started seeing some really solid examples of joined-up working across the sector, with transformation that previously would have taken years getting off the ground in weeks. In areas where collaborative and integrated approaches were already more developed, this has enhanced their ability to respond to the crisis. We have seen localities remove obstacles in areas such as information governance that have long created difficulties for integration. In partnership with the NHS, directors of public health have been at the heart of the response.

While this is great to see, more needs to be done from the top to enable joint working. Joined-up policy-making, and the ability to plan effectively in a crisis, are dependent on leadership, clarity and transparency at the national level that has not always been forthcoming. In 2016, government conducted a national exercise modelling the impact of a flu pandemic – Exercise Cygnus. This highlighted that the social care sector would struggle to cope if the NHS implemented a rapid discharge scheme. However, the findings of Exercise Cygnus were never published in full. When Covid-19 hit, the NHS was enabled to discharge non-critical patients into social care settings without assessment and, in many cases, without testing. You only have to look to the headlines to see the tragic impact of this failure to share and learn the lessons of previous planning exercises.

Difficulties were further compounded by the efficacy of government guidance for social care. A clear action plan for social care did not emerge until April (a month after accelerated discharge began), while guidance on procedures and use of PPE was frequently changed and updated, leading to widespread confusion and frustration. Lack of transparency, both past and present, as well as failure to share clear and timely information and guidance, have hindered the ability of health and care services to respond as effectively as they could.

In addition to the need for greater clarity and transparency, there is a need to provide an equitable approach to financial support across both services. Over the course of the pandemic, the government has committed to ensuring the NHS has the funds it needs to cope. This is of course welcome. However, while local government has benefited from some additional funding, this has been insufficient to meet additional costs and cover lost income.

The Association of Directors of Adult Social Services in England’s annual budget survey found that only four per cent of adult social services directors are confident their budgets are sufficient to meet their statutory duties. Last year it was 35 per cent. It is therefore unsurprising that many councils are struggling to balance their books. If local authorities do not receive adequate funding from government, they may be forced to retender critical community and public health services at a time when those very services are critical for a robust health response.

The ability of our health and care systems to respond in crisis is also thwarted by a lack of investment in preventative services. Countries that have experienced similar public health crises have performed better where there were preventative measures already in place. Such measures across all services could help safeguard organisations from the impact of another crisis. Even in the absence of a crisis, investment in prevention can reduce both cost and demand, increasing the resilience and sustainability of our public services.

Addressing these issues will be key not only to the health outcomes of citizens across the UK, but to our ability to cope with the expected economic downturn. Evidence shows that economic depressions and unemployment are inversely correlated with chronic health conditions. To put it simply, as money in people’s pockets goes down, demand on health and care services go up. Without a sustainable health and care system with strategies in place to cope with this increase in demand, the vicious cycle of unemployment and poor health will only spiral further, leading to reduced growth and increases in welfare spending – further widening the  health inequalities that already exist.

There are clear lessons to be learned from the present crisis. At CIPFA, we want to see the positive examples of joined up working in parts of the health and social care system become business as usual across the country. We want to see prevention viewed as a true investment – money paid in now to improve outcomes and reap future benefits. But most of all, we want to see leadership from the top that enables these lessons to be applied consistently. Government needs to view health and social care as parts of a cradle-to-grave system, where weaknesses in one will lead to failure in the other, and fund both services accordingly. This does not mean more centralisation – it means joined-up, coherent policy, adequate funding to meet demand and ensure sustainability of vital services, and recognition that localities are best placed to determine what works in their area.

But as we begin to return to some sense of normality, potential tensions are already beginning to emerge. The Community Network, part of the NHS Confederation, have called for a pause on the retendering of community and public health contracts to give providers more stability. While this would indeed provide certainty for the healthcare sector, it also limits the ability of local authorities to deliver savings that could enable them to balance their books. While a pledge from government to fully fund the additional costs that Covid has created for local government could help overcome this, MHCLG has moved away from such commitments, instead promising future funding in the context of 'burden sharing'.

Covid-19 has created a huge amount of debate around the issues facing health and social care. The upcoming spending review will offer an opportunity to reflect on what the future shape of these vital sectors should be. However only time will tell whether we will let the crisis go to waste, or use the momentum gained over the last few months to build meaningful reform that puts both the NHS and social care on a sustainable footing.