There is wide agreement that it would be beneficial to integrate social services and local NHS community services.  This could provide “wrap around care” and look after elderly and vulnerable people in a community setting. Such a system could reduce hospital admissions, but the reason for doing it is to improve the welfare of patients. Such scheme are already working well in Durham and other parts of the country.

Where there is not agreement is when such a system could be constrained within a strict financial envelope . A possible consequence could then be the outsourcing of management and the reconfiguration of hospital services.

The SHA does not believe in outsourcing or relying on the private sector unless absolutely necessary. Privatisation of particular parts of an integrated system could undermine the very integration which is desired. Compulsory tendering as prescribed in the 2012 act wastes a considerable amount of NHS time, and can leave the NHS open to legal challenge by a private provider with large pockets which will involve considerable unnecessary expense. Nor is the motive for integration to constrain costs but to improve the welfare of patients.

At present the average patient receives half their total expenditure in the final year of their life.  There needs to be a rebalancing. The elderly and frail should be properly cared for  but some clinical intervention is unnecessary.  More should be spent on the young. This would help reduce health inequalities.

The present system puts too much power in the hands of the acute trusts. There should be  a transfer to community and public health (as recommended by the Selbie Report for the North East)

The national NHS needs to ensure proper standards but organisation of a local integrated system should be jointly in the hands of local authorities and NHS organisations. Possibly a not for profit trust or social enterprise. The management of such a system should give equal weight to the NHS and local authorities, with a neutral chair, perhaps along the lines of an elected commissioner.

GPs should be integrated into a local system.The present  private contract system could be replaced by salaried GPs, Many now prefer this way of working.

There are serious concerns about the state of some care homes.  The provision and management of care homes should be integrated into the system set out above. This would lead to much closer relations between GPs, hospitals and care homes.

Research and innovation is very important.  Hospitals in the North of England are very good at innovation, but undersell themselves.  Universities should work closely with the NHS as is now promoted by the North Health Science Alliance. Funding tends to focus on the South.  Funding for research needs to be rebalanced regionally. The regions outside London also need to promote their research and innovation more loudly.

Devolution proposals could lead to an integration of health and local government as in Manchester.  This development needs to be evaluated as it progresses.

Conclusion

We envisage a situation where local authority social care, NHS hospitals and community care systems, GPs and Care homes are integrated into one system, run as a not for profit trust or cooperative.  Such a system would need representation from the NHS, Local Authority and independent members on the Board, with possibly a neutral chair who could be elected.

Regional networks are necessary for the effective management of hospitals. A specialist hospital in one part of a region would obviously serve the whole region.  Nevertheless the health and care trusts envisaged here should not be too big. In the North East for example Durham would be a good example, or the proposed North of Tyne authority.

 

 

 

David Taylor-Gooby

Feb 14th 2018

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