Insider tales and must-read analysis on how integration is reshaping health and care systems, NHS providers, primary care, and commissioning. This week by senior integration correspondent, Sharon Brennan.

The demise of statutory regional NHS bodies, in the shape of strategic health authorities, may have hampered the service’s reponse to coronavirus. That is the view of Dame Barbara Hakin — the former number two at NHS England under Sir Simon Stevens and Sir David Nicholson, former GP, and former SHA chief executive, among other things.

Dame Barbara, who was one of the senior officials tasked with implementing the Lansley Act 2012 — dismantling SHAs and primary care trusts, and creating NHSE and clinical commissioning groups — has said: “Unfortunately the [Health and Social Care Act 2012] reforms stripped out the strategic health authorities and the legitimised working of statutory bodies across the regions.

“SHAs had a major role in emergency planning. When going through something like this, something a bit more structured and rigid would have been helpful.”

Speaking in a webinar organised by Public Policy Projects this week, she added that SHAs — which during their time were often criticised within the local NHS management they oversaw — “have grown in popularity now they are not there”.

Speaking about integrated care systems, which some see as a replacement for some of the benefits of SHAs, she said that if they were to work for “normal circumstances as well as future emergencies” then legislation would be needed to set up bodies with clear accountability, working over a defined and more standardised geography and population.

Her thoughts mirror some of the accusations over why there have been so many problems organising testing and personal protective equipment. The 2012 act fractured the previously closer alignment of government, the Department of Health and the NHS management board — and that this has made national priorities such as testing much harder to deliver. It also took many public health functions out of the regional and local NHS, and created a new national focal point in Public Health England.

While the idea of organisational change may be far from the minds of frontline staff at present, joined up thinking and working will be needed more than before, with the NHS facing issues similar to before the crisis, but now hugely exacerbated.

Dame Barbara said getting ready for what follows the pandemic peak was a “form of emergency planning” in itself.

“One of the biggest issues is how we are going to cope with a huge wave of problems from people who have not necessarily had the optimum treatment because of the virus.

“The number of people on the waiting list would have grown massively, we have stood screening down so people may be found to have a diagnosis at later stages, and people are frightened to go to the GP and A&E and will have problems that have not been attended to. That would have stored us up a wealth of problems for the future.”

The government had been expected to bring foward NHS legislation proposals in the autumn — but they had indicated this would not include creating ICSs as statutory bodies, and scrapping CCGs. But post-covid, while the legal change will now be later, all bets are off as to what it could bring.

Speaking with one voice on social care

A question which should now weigh heavily is: how many lives could have been saved if Matt Hancock — and his colleagues and predecessors — had prioritised social care as much as healthcare?

HSJ reported how worried the care sector was about covid-19 sweeping through its homes and services, 26 days before Mr Hancock announced that testing before admission to homes would become standard.

It will likely be recognised as a mistake that very strict and tough discharge guidance was sent out to trusts on 19 March without any parallel guidance or support given to social care to ensure these discharges happened safely.

In the next few years, the NHS will need social and community care more than ever if it is to keep hospital capacity free for tackling the “mountain” of electives it is facing.

One question posed to Dame Barbara at the same webinar was why it took a pandemic to reduce a 550-bedded hospital’s super stranded patients from 150 to below 100? The questioner said they had been trying to resolve that for two years prior.

While the pressure services and staff were under to prepare for covid-19 should never be forgotten, there may be some hard truths to be learnt too. There was a sense of frustration from some trust leaders that care homes, when raising concerns about admitting new patients, just didn’t get the pressure acute trusts were under and take the patients.

As one source involved in such discussions put it: “Hospitals and care homes should surely have been speaking with one voice on this issue.”

Post-covid, the right beds, right skill set and the right resources will all be needed if these step changes in community care are to continue, and we are not to drift back to the scenario of patients being stuck in acute beds when they need not be. 

But alongside that a change in attitude may be needed so that the health and social care system finally recognises the dependence each part has on the other.

Attitudes too seem to be changing in trusts in some areas. Liverpool City Council is working with the NHS to ensure that additional staff can be deployed into care homes “in extremis” if its numbers fall too low. It has also set up a PPE mutual aid scheme between the council, the NHS and care homes.

Creating the unified voice may be one of the biggest prizes that can come out of this horrendous pandemic.