What does the NHS of the future look like? With most of the UK cautiously optimistic that the country is through the worst of the COVID-19 pandemic, senior NHS planners are beginning to look to the future.
To this end, the Government published a White Paper in February, Health and Social Care Integration: Joining Up Care for People, Places and Populations, setting out proposals that aim to provide better, more joined-up health and care services at ‘place’ level, using examples such as smoking cessation services in Manchester as a template (See Box).
‘So, as we recover and level up, it is right that we draw on our experience of the pandemic to bridge the gaps between health and social care, between health outcomes in different places and within society that are holding us back. This is what our white paper aims to achieve by bringing together the NHS and local government to jointly deliver for local communities,’ said Sajid Javid, Health Secretary and Michael Gove, Secretary of State for Levelling Up, Housing and Communities, setting out the intention to make integrated health and social care a universal reality for everyone across England regardless of their condition and of where they live over the course of the next decade.
‘It is very encouraging to see a 10-year strategy laid out that aims to address the many inconsistencies around health and social care delivery,’ said Crystal Oldman, the chief executive of the Queen’s Nursing Institute.
‘Currently health and social care are delivered as two separate systems, but are seen by many families as representing a single whole, if a member of their family needs health and/or social care support. Community nurses are at the heart of the healthcare system, but they also work in tandem with colleagues in social care, as well as voluntary services and unpaid carers.’
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According to the White Paper, care will ultimately be more personalised and accessible for patients, using increased digitisation of patient records, and more ‘joined up’ working between health and social care staff to improve the efficiency of the services that patients receive.
Additionally, there will be a greater focus on ‘place’, integrating local services so patients do not need to travel so far to access different treatments, with the likes of more diabetic clinics in areas of high obesity or more smoking support in communities where there are a higher number of smokers will also be part of a drive for tailored local health services. This ambition was originally set out in the Health and Social Care bill, with the White Paper designed to explain practically how this will be done.
‘Continued investment into community nursing services, in public health, and population health management are of critical importance if the White Paper’s vision is to be translated into success in practice,’ added Dr Oldman.
‘As with all policies related to caring for people in a community setting, the nurses who support the citizens in their local communities in all settings, will be the critical professional in co-ordinating care. How the plans will impact on the community nursing workforce, both in terms of capacity and capability, must be determined and planned as soon as possible.’
While the aims of the white paper have been welcomed, concerns have been raised that, despite its best intentions, there simply are not enough staff to fulfil the ambitions set out by the paper. The hope of the white paper is that, with sufficient change to how services interact with each other, this will allow staff to free up more time.
‘While a more integrated approach clearly will not address all of the challenges facing staff, joining up services around users can also improve job satisfaction for the staff delivering them - removing some of the barriers that stop staff delivering care as they would like. This requires change that builds on improvements made across the health and care sectors in recent years,’ added Mr Javid.
In the meantime, workforce shortages remain the most pressing issue across both health and social care. Providers across NHS England are reporting a shortage of over 100,000 FTE staff. Adult social care is facing even starker recruitment and retention challenges, with an estimated 122,000 FTE vacancies. This equates to a vacancy rate of around 8% for both the NHS and adult social care, compared with a vacancy rate of under 3% for jobs across the UK economy.
Analysis by the King’s Fund suggests the NHS workforce gap could reach almost 250,000 by 2030. Nursing is facing one of the greatest problems with one in eight posts vacant. The Interim NHS People Plan identified nursing shortages as ‘the single biggest and most urgent we need to address.’ This is partly due to the integral role of nurses in delivering the NHS Long Term Plan, but also due to the absolute number of vacancies. There are significant shortages in learning disability, primary and community nursing, whilst the mental health nursing workforce dropped by 11% between 2009 and 2019.
Similarly, in adult social care, around one in 10 social worker and one in 11 care worker roles are reportedly unfilled. The vacancy rate is highest in London. The demand for social care workers is expected to rise in line with the UK’s ageing population. Skills for Care have estimated a need for 650,000 to 950,000 new adult social care jobs by 2035.
‘By itself, this White Paper will do nothing to address the workforce crisis, which is arguably the biggest issue facing the health and social care service at the moment. There are some thing on workforce in the paper, such as improvement to training and development opportunities to help staff work across boundaries. Those are positive but without a serious, long-term commitment to workforce planning, it is not going to meet the crisis that exists,’ add Mr Naylor.
‘The Department of Health and Social Care recognises the scale of the challenge in relation to the workforce. The difficulty is that the Treasury will always be reticent to commit to anything that might commit them to funding decisions in the future. The concern about projecting the workforce requirements over the coming years is that It creates a funding commitment. I think that’s the reason why the government isn’t quite grasping the nettle on this one so far. But they have said that they will say something on this, so we have to hope that something is on its way’
‘Integrating health and care services is a laudable ambition, and innovations such as single, digital care records can be transformative if accessible
24 hours a day. But for integration to be successful, the workforce crisis in both sectors needs to be addressed in parallel,’ said RCN General Secretary and Chief Executive, Pat Cullen.
‘Fixing social care is key to tackling the NHS backlog. Social care must become a more attractive place to work, with salaries for care and nursing staff that at the very least match the NHS. Ministers must come up with ways to boost the domestic recruitment of nursing staff and reduce our disproportionate reliance on valued colleagues from overseas.
Another point raised by the NHS Confederations was that this is the latest in a long line of white papers and policy documents over recent decades that have tried to better integrate services. According to the organisation, the critical question, therefore, is ‘what will this white paper enable which cannot already be done?’
‘The pandemic has shown just how interlinked health and care services are and need to be, and it’s vital that we continue to speed up integrated ways of working. The proposals in the white paper to break down barriers between NHS providers and local authorities, including through better data sharing, will be a big step forward. However, it bears repeating that integration across health and care is not new, it’s already happening on the ground and has been for many years,’ added Mr Taylor.
Another key area raised by the Local Government Association is the pressure on funding for social care that local authorities are already under. Councils’ public health grant has been cut by 24 per cent on a real-terms per capita basis since 2015/16. In our Spending Review submission, we called for £1 billion of funding in 2022/23 rising to £3 billion in 2024/25 for a new Community Investment Fund, with much of the funding likely to be directed through the voluntary and community sector.
‘Adult social care is in a fragile position, with councils struggling to balance budgets and services severely impacted by rising costs and recruitment issues. A long-term funding solution is urgently needed in order to ensure a sustainable, high quality and sufficient care and health workforce to meet needs now and going forward,’ said David Fothergill, Chairman of the Local Government Association’s Community Wellbeing Board.
As the country begins to look beyond the pandemic, the fault lines in health and social care exposed by the pandemic, such as the poor state of social care services have been recognised by all parties. But the prospects of an integrated system will depend heavily on its ability to secure adequate funding from a government facing huge financial pressures. The prescription is there, but will the patient finish the course?