Integrated care and pooling budgets really are the only paths forward at this critical time for the NHS and social care

By nailing its colours to the mast and calling for funds currently allocated to social care via local authorities to be transferred to the NHS, HSJ has done us all a service. The elephant in the room has been spotted and exposed. Fortunately, it’s a big room and a small elephant.

‘A goodly dose of democratic accountability has just been introduced into an area that has traditionally, sadly, lacked it’

There are untold numbers of heads scratched in bewilderment by people gazing at the current, seemingly chaotic distribution of responsibilities, professions, governance and funding within the broad care services. “Why have two services?” they ask. “Why not just combine them?”

HSJ has recommended bringing local government spending into the health services. But the solution most widely suggested in the past was to bring the NHS back into local government.

A while ago David Hinchliffe, then chair of the Commons health committee, pledged to draw the health services and its vast budget into the local authority ambit. And the spokesman for the forerunner of today’s Local Government Association, Peter Westland, campaigned strongly for local government to be given powers to commission health services. Echoes can still be heard in current shadow health secretary Andy Burnham’s discussions on the topic.

Untenable presumptions

Even that doughty secretary of state Barbara Castle, when launching her £16m initiative in 1976 as Joint Finance (compare today’s “better care fund”), was shrewdly aware that the rigid divide between the two systems was becoming increasingly difficult to rationalise or sustain. Equally, echoes of that policy − inadequate and doomed at the time − are very much alive and kicking now in the spirited attempts by Norman Lamb to pioneer integration between the two services to a degree never before attempted.

True, this still sometimes smacks of a policy designed to bail out the NHS at a time of financial stringency, rather than the fully fledged model of coordination and integration that is required. But it is well thought through, coherent and creditable and, with sustained political support, might succeed.

There are two stances that emerged once it became clear that the post-Second World War settlement had made untenable presumptions about the extent to which what we now call welfare could be broadly left to family, church and charity. On the one hand, the all or nothing brigade would organise it all through the top-down, medically dominated NHS, or transfer responsibility entirely to local government.

On the other, people argued to keep up fences between the agencies but build enough gateways between them to enable both to function with optimal efficiency.

Reshape services

Without dwelling on where HSJ gets its sum of £24bn from, some of the immediate implications of the transfer of chunks of funding of this magnitude from local government would, of course, seriously jeopardise the capacity of local government to survive and carry out the many other functions it is responsible for.

‘Throwing money at the solution − integration − will prove far more successful in the long run’

Moreover, it would involve the transfer away from any form of local democratic scrutiny a further £24bn of public money, when pressure to exert even greater scrutiny over public spending is growing month by month. This at a time when, via the health and wellbeing boards and Healthwatch, a goodly dose of additional democratic accountability has just been introduced into an area that has traditionally, sadly, lacked it.

It would further pump into the joint health and care system almost uncontrollable disruption and disaffection at a time when both services need to contend with and bed in recent changes. And above all, it would not address the issues that need to be addressed; it would simply hurl money at one side of the problem rather than carefully tailor it towards the solution.

That solution has to be found not in the deceptive simplicities of wholesale transfers − in either direction − in order to protect services, but in the complexities of reshaping services to protect people. That will be a place by place negotiation.

Squeals of pain

Integration and pooling budgets really are the only paths forward at this critical time, with all their complexities, difficulties and surrenders of absolute silo-managed power and control. By considering investment in the health and wellbeing of citizens as a public duty, mature local decision making can redistribute finance according to need and shared priority. Investment in the NHS, for example, could find its way to support health related social care rather than just bigger institutions.

Meanwhile national reviews of specialist commissioning and the role of primary care could redistribute funding to community based care.

Wholesale transfers of budgets would mean investing in one half of a joint system that has so far failed to keep up with burgeoning demographic and economic realities. Despite the squeals of pain from people unaccustomed to this sort of change, throwing money at the solution − integration − will prove far more successful in the long run.

Sandie Keene is president at the Association of Directors of Adult Social Services