ResPublica Report | How to improve the Health and Wellbeing of the UK population

25^th June 2020

Devolution and Reform of Health and Social Care

A new report launched today by the independent think tank ResPublica, set out how we can properly refigure our public health system in the light of its successes and failings in the Covid-19 epidemic. Largely completed before the Covid-19 outbreak, this report aims to provide comprehensive and actionable recommendations for the long overdue devolution, integration and reform of health and social care in the UK.

The present crisis has reaffirmed the value of the NHS, the integral role it plays in meeting the health needs of the population, and the unique position it occupies in the public’s consciousness. It has also highlighted the long under-valued skills and selfless dedication of the UK’s frontline health and social care workers.

However, the current emergency has also thrown into sharp relief some of the stark disparities in health outcomes that exist in our society, the difficulties which our highly centralised yet fragmented governance and procurement processes have experienced in responding to the crisis, as well as the persistent fracture lines in our health and social care system and the limits and constraints this puts on our public health capacity.

The UK’s health system had serious unaddressed problems going into the pandemic, flaws that have been cruelly exposed via our manifest failings in dealing with the epidemic. This report sets out proposals for transformational reforms in three sections.

Part 1 recognises the key role of shared life circumstances and the penalties of place in determining health outcomes. It is no coincidence that people in deprived areas are dying of coronavirus at double the rate of affluent areas. It argues for the integration of health and social care with a greater emphasis on prevention by focusing on place-based solutions and the urgent necessity of devolution of health to the ‘local state’.

Director of ResPublica, and co-author, Phillip Blond said:

“The devolved, local state is the institution that can best deliver on total population health. With responsibility for the full spectrum of health outcomes, and the power to address the wider determinants of poor health, to deliver economic growth and tackle poverty, an empowered local state can help make us healthier, more resilient, and better able to cope with any future threats. The future of an improved NHS must lie in taking it out of the hands of an ineffective central state and putting it under the wing of a revivified local state in partnership with all regional actors.”

This section concludes by describing the five key innovations required to transform health care.

1. The integration of health and social care to prevent so many people, especially the vulnerable frail elderly, from having un-addressed chronic problems escalating to acute admission
2. The full pooling of all health and social care funding into a single local ring-fenced budget, with whole area de-commission and re-commissioning.
3. Clear governance and accountability within coherent health and care territories. Making the NHS a regional and responsive public health service
4. Re-defined remits for national bodies, such as the Care Quality Commission, to oversee devolved services.
5. Re-employment at the local level by the new devolved authorities to ensure parity of status, pay and training for local health and care workers.

Part 2 describes the operational measures, using real life clinical examples, that can improve patient outcomes in the near term. It focuses on the four domains of:

1. Community care, requiring increased investment in nursing homes and domiciliary care.
2. Primary care, with GPs becoming responsible for coordinating the chronic care of the most vulnerable in society.
3. The emergency pathway, with improved out-of-hospital care to take the pressure off inundated A&E departments, and to control patient ‘flow’.
4. In-hospital specialities, with expert management from well-trained clinician managers to ensure to improve the efficiency of clinical practice and better manage scarce resources.

Co-author Ian Smith said:

“We owe it to frontline workers to implement measured reforms that smooth the patient journey and enhance the quality of the clinician-patient bond. This report warns against the failed top-down reorganisations of the past and outlines productive change that has been tested and proven in real clinical practice.”

Part 3 addresses population health and the need to streamline complex and fragmented health authorities.

There is currently a jumble of sub-national jurisdictions for health, including Local Authorities, NHS Trusts, Clinical Commissioning Groups and Sustainability and Transformation Partnerships, all operating across different geographies. It is very difficult to identify who is actually in charge and accountable for delivering a coherent, high-quality service.

Building on the emerging NHS evidence about population health and integrated care systems this report recommends primary care networks covering about 50,000 people, integrated health and social care units covering territories of about 350,000 people. With larger Health and Care Systems of 2-5 million people to allow for the efficient organisation of specialised tertiary services. Devolution to the ‘local state’ is required so that the current patchwork of jurisdictions and funding can be integrated into a single patient-centred health service.

Co-author Professor Stephen Smith said:

“Of course, there are no quick or easy answers to improving the UK’s health and social care systems. More investment is needed. But just spending more money is not the answer. The ‘fix’ starts by integrating the funding and operation of health (the NHS) and social care (Local Authorities) in well-structured territories in which executive accountability is crystal clear.”

The paper concludes with a ‘call to arms’ to restore the NHS to a position where it is, once again, the ‘envy of the world’

ENDS

About ResPublica

ResPublica is an independent non-partisan think tank. Through our research and policy innovation, we seek to establish a new economic, social and cultural settlement. We aim to combat the concentration of wealth and power by distributing ownership and agency to all, and by re-instilling culture and virtue across our economy and society. Website www.respublica.org.uk

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