This article forms part of the LGA think piece series 'Towards a sustainable adult social care and support system'.
The key question which we need to address if we are to develop high quality care and support services for people of any age is the relationship between the NHS and local government. It is a question which is as old as the NHS itself.
In the Atlee Cabinet of the 1940’s Herbert Morrison, a former Leader of the London County Council, argued strongly that the NHS needed to retain its roots as a local service, but Aneurin Bevan insisted on a more centralized approach. Bevan prevailed, and his approach was followed through by all his successors until Ken Clarke finally removed the last vestiges of Local Government representation from NHS management in 1990.
It is a striking illustration of how changes of party political control have made surprisingly little difference to the structure of health policy. Aneurin Bevan, Enoch Powell, Keith Joseph, Barbara Castle and Ken Clarke would hardly be regarded political soulmates, but they all pursued broadly the same Bevanite agenda for the structure of the NHS.
More recent events suggest that this progressive divorce of healthcare from the rest of local services has at last been recognized to be the dead-end which Morrison predicted that it would be and has started to go into reverse.
The unlikely, and largely accidental, cause of this conversion was Andrew Lansley. I am no champion of his 2012 Act, but its provisions which return public health responsibility to local government and establish Health and Wellbeing Boards were early evidence of an important change of direction. The alphabet soup of structures now being sponsored by NHS England and known variously as an STP, ACS, ACO or ICS reflects a developing momentum in the direction of this different, more localized view.
We should not underestimate the significance of these developments. They may be the brainchild of Simon Stevens, rather than the politicians, and the theoretical emphasis laid on the importance of the relationship with local government may not always be reflected in reality – but the change of approach is unmistakable and likely to prove enduring.
It represents a move away from the view that the NHS should be a national monolith, providing specialized services to local communities, but ultimately responsible only through the Secretary of State to Parliament. Morrison may have been ahead of his time, but he was surely right to say that healthcare services need to have local roots, and that key decisions about the future shape of services provided to a community need to involve their locally elected representatives.
It is not only a question of who makes the decisions – the more important question concerns the shape of the decisions themselves.
Three facts stand out about these decisions in recent years.
Firstly, ministers of health from all political parties have spoken repeatedly about the importance of developing primary and community services which enable people, wherever possible, to lead normal independent lives.
Secondly demand for these community services has been on a sharply rising trend as the population who rely on them has been increasing. Many of these are older people but improving outcomes for younger people has also led to rising demand for community services among children and working age adults.
Thirdly, however, despite consistent ministerial support, and consistently rising demand, the stark fact is that the resources available to these community-based health and care services have been falling for a decade at a time when the resources available to hospital services have been rising.
By any standards this is a perverse outcome; it reflects neither demand patterns nor ministerial policy and has the effect of undermining both the quality and the value of the services provided to local communities.
This is not simply a matter of questionable priorities; the relatively protected status of hospital services is in fact self-defeating because it has the effect of diverting demand into hospitals from other less generously funded services.
This is now widely acknowledged to be true of social care. Inadequate home help services lead to additional demand for residential care; inadequate residential care provision leads to hospitals being used as care homes.
But the same argument applies in social housing, schools and other local public services.
When social support is most easily available to vulnerable people through the hospital, that is where they will go.
It is a good illustration of the principle of unintended consequences; by protecting hospital budgets from the full effect of the austerity of the last decade, policy makers have undermined the effectiveness of public services as a whole – including the hospital service they were trying to protect.
Even when this “diversion effect” is recognized it is too often expressed in economic terms. It is said to be “wasteful” to use acute hospitals to provide social care, or to provide residential care to people who simply need home care or support for their carer.
This analysis surely misses the point. It is true that it is bad economics, but the key point must be that failure to provide support which allows vulnerable and dependent people to lead more independent lives is bad social policy.
The challenge is to develop a new relationship between the NHS and local government which addresses these failures. That will require changes on both sides.
The NHS needs to embrace new relationships with local communities. That doesn’t mean losing its essential commitment to national standards of clinical and service excellence, nor does it mean fragmenting secondary and tertiary pathways which are essential to high quality care, but it does mean developing new relationships with service providers who are not part of the NHS, and it also means learning new habits of accountability to local decision makers.
For local government it means relearning the oldest lesson in public health – that the most important influence on an individual’s health is the social context in which they live. Doctors and nurses can treat illness, but they cannot deliver health.
Only healthy local communities can do that – and that is the role of local government.
Rt Hon Stephen Dorrell, Chairman, NHS Confederation