This is a discussion document not agreed policy.

1. Purpose

1.1.This paper supports the bringing together of our separate health and social care systems to become one unified care system driven by the political values and professional / organisational principles that underpin the NHS.

1.2. The political values are: a system with national standards; funded largely from progressive taxation1; delivered by locally accountable bodies that rely on committed staff many of whom have professional training and professionally established responsibilities; is evidence based; relies on the notion of “co-production” between service users and professional staff – people playing an active role in their care and professionals welcoming, respecting and responding to that role.

1.3. In summary, the organisational principles are:

  • a national (England, Scotland, NI and Wales) approach to defining the scope of what is to be provided, and at what standard, and which retains oversight of how local machinery (accountable too to local populations for this task) delivers the national aims2
  • a service that is paid for overwhelmingly out of progressive taxation –
  • a service where the duties, rights and responsibilities of professional people are recognised, respected, and supported by supportive managerial and professional machinery
  • a service that directly employs its own staff and owns its physical resources, and may operate through recognised third sector bodies where they are better placed to serve needs, or operates “franchises” operated by independent practitioners or commercial franchise holders. (3.1.5 below)
  • We see the 3rd sector primarily as offering innovation and user-centred approaches. The public sector needs to learn and integrate those insights into routine care.

1.4. The paper sketches out:

  1. what is meant by, and comprises, a unified care model
  2. some options for how such models can be created
  3. the issues that are raised by moving to such a model.

2. What is a unified care model?

Put simply, such a care model is a means of organising resources to meet the medical and social needs of people so that organisational and professional barriers that might hinder the giving of care are kept to a minimum (or even removed totally). It sees the need for care as sitting within the wider social context which individuals and families inhabit.

The exact components of such a care model will always be contested – especially in respect of the wider social determinants of health status which impact upon individuals or groups of individuals – but below are listed at 2.1. those components that the author suggests sit within the care model and at 2.2. those which complement it from outside the model.

2.1. Within the model

2.1.1. Primary care resources

  1. GP, Dental, Pharmaceutical, and Ophthalmic screening, diagnostic, and referral services – 24 hour service for GP cover
  2. Sheltered / supported “own home” provision including adapted housing
  3. Residential and Nursing home care, district nursing and Health Visiting including palliative care
  4. Non-acute hospital “care and watchful waiting” capacity
  5. 24 hour community immediate response teams of carers, district nurses with “admitting rights” to ii) iii) and iv) if necessary
  6. Mobile 24 hour paramedic and social care diagnostic / assessment and treatment capability with “admitting rights” to ii) iii) iv) and v) if necessary
  7. “Fixed site” 24 hour major diagnostic / assessment capability commensurate with suspected and urgent social, surgical, medical, obstetric, traumatic, paediatric and psychiatric episodes also able to access radiology, pathology, ECG, and EEG clinical support, and senior social work expertise3.
  8. Home delivered rehabilitation skills.
  9. Domiciliary care services with complementary day care services
  10. Respite care for carers with significant carer loads
  11. Resources and approaches to build social capital, such as community development

2.1.2. Secondary/tertiary care resources

i) Fixed site ongoing (inpatient / day patient) diagnostic / assessment capability as in vii) above with added skills of physiotherapy, speech therapy and occupational therapy

ii) Fixed site treatment / intervention skills across the range of needs as in a vii)

iii) Fixed site rehabilitation skills

iv) Specialist physical and mental treatment and recovery services operating on a regional basis.

2.2. Outside of, but complementary to, the model

i) Accessible transport arrangements

ii) An effective and fair benefits system

iii) Good occupational health services (and fair employment terms)

iv) Effective primary, secondary, higher, and further / life long learning educational opportunities regarding healthy living

v) A quality “public realm” for social intercourse

vi) adequate housing.

3. How might the unified model be achieved?

Two different options for moving from where we are now to the intended service shape are briefly described below.

3.1. Option 1 : A fully unified planning and delivery vehicle

3.1.1. This option requires legal changes to bring a unified health and care service into being over time – probably over a decade. In simple terms it would create a new public body from the separate components parts of the English health and social care system to replace NHS and local government bodies that currently plan and/ or deliver health and social care services.4

3.1.2. There are variants upon this model but essentially, and subject to local variations because of geography, one all purpose health and social care authority that both plans services and oversees their delivery to ensure the population served receives the level of service promised by Government is suggested for populations of up to 500,000 people.

3.1.3. The governance arrangements need to ensure that:

a) the wishes of Government in terms of the range and volume of services to be provided are realistically matched to the resources available

b) the planning and delivery tasks each iteratively inform the other (the predictive (planning) capability indicating the challenges ahead, and the frontline knowledge feeding back into the planning process about possible means of delivery and service change).

c) managerial, professional and democratic inputs properly feature in the governance arrangements so that the right accountabilities are discharged

d) knowledge about best practice is gained and disseminated with the planning process enabled to embed best practice in local delivery.

3.1.5. Commercial contracts are seen as an inadequate way of seeking to manage dynamically the different components parts of a care “system”; however, the notion of franchised operations is an alternative option in selected situations as a means of moving from the current reliance on privately owned providers towards a publicly owned set of assets.

3.2. Option 2 – non-structural (organic) change

This option would still see the legal basis for the two services being altered so that both were provided on the same terms as the NHS – i.e. free at the point of use on the basis of need, paid for mainly by taxation and / or additional graded national insurance. However existing planning and delivery models would remain in place initially and “softer tools” of increasing managerial and professional collaboration – within a new corporate identity of a National Care Service – would allow a slower pace of organisational change to occur that is driven from below.

1 The paper does not seek to address in detail the many issues surrounding the funding needed to enable the new model to be resourced. It is recognised that work needs to be done to assess the service load that Government wishes to see made available and to provide the necessary financial, human and capital resources. An early decision would be how current co payments are to be phased out and alternative funding (or service reductions) effected. The assumed starting position is that any unified service will inherit the current range and volume of services and cost envelope but would move to the new model over time. Some of the current benefits paid to those r eceiving care might need to be added to the budget for the new National Care Service

2 Here, it is recognised that. since 1999, UK wide machinery for certain functions has to, or ought to be, retained – for example planning of human resources and sensible UK wide location of super specialist clinical care.

3 This capability, whilst physically situated within acute hospital settings, culturally and organisationally should be seen as sitting within, and serving primary care. Only when a decision has been taken to “admit” a citizen to an acute hospital does the secondary care component of the care model come into play.

4 The scale of the changes needed would vary in each devolved administration and the major change would be in England which is furthest away from the intended model. Depending on which approach is used, the financial effects operating through the Barnett formula would shape the pace and nature of the reponses in Wales and Scotland.

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