Phil Hope - Navigating and influencing the new health and social care landscape - 16 February 2018

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“A large part of the core challenge is the problems in the acute care system,” Phil Hope told Care Conversation delegates. High levels of elective and unplanned admissions were leading to longer hospital stays and very high bed occupancy rates, he said. “The problem is we can’t get them out. It’s overheating massively, and when people do come out the question is where do they get their care?”

An aging and growing population was putting great pressure on the system, as was the development of new and expensive treatments, and so the NHS Five Year Forward View had a focus on developing community care and care at home, he said. “There’s lots of work going on around integrated care, the Better Care Fund projects and public health campaigns to try to stop people getting ill in the first place.”

Money was clearly a problem – while NHS funding had stayed relatively flat, social care funding was on a “massive downward curve”, and although there was a great deal of targeted work to try to address unplanned admissions, it could be a difficult area to predict. Another key issue was the connection between acute trusts and community care, he stressed. “It’s a mess. The system is both structurally and organisationally divided, and bolting it together isn’t easy. We know what to do, and where to do it, but the delivery of that is the challenge we’re facing.”

NHS England Chief Executive Simon Stevens had developed Sustainability and Transformation Partnerships (STPs) that were based on patient flows around the system, and had a far larger footprint than that of Clinical Commissioning Groups (CCGs), he said. “It means you can manage more resource, and you don’t need legislation. But that also does leave them vulnerable to possible legal challenges.” There were also Accountable Care Systems that included both commissioners and providers, but these had been paused awaiting the outcome of a judicial review.

“Just pouring more money into a failed, broken system won’t do it,” he stressed. “The system needs to be reformed and realigned – easy words to say, much more difficult to do.” The sheer range of siloed services – some means-tested, some not – was a huge challenge, he said. “How do you go about aligning all of that?” The power in local areas still lay with the acute trusts, he pointed out. “So it’s not just about structures and flows, it’s also about relationships – where the power lies.”

In terms of the politics, it was essential to have 10 Downing Street and the Treasury on board, while the recent renaming of DH as The Department of Health and Social Care was significant. “It may be just a name change, but I think it’s interesting. It does feel like there’s some political traction for creating an integrated health and social care system. The question is can they deliver?”

Other departments such as the Ministry of Housing, Communities and Local Government and Department for Work and Pensions had the ability to “get in the way”, as they controlled areas such as attendance allowances, while Brexit was undoubtedly a huge challenge. “When we leave the cost – direct and indirect – will be immense, and there will be a serious problem in terms of workforce.”  

The current social care green paper was struggling to address all of this, he said, and it was possible that it “could end up being a long-grass exercise”. While the aim of STPs was to boost care in the community and reduce hospital demand, the challenge was the timescale. “Have they got the capacity in the leadership, and will the political support be there when they come up against difficult decisions?” Upcoming council tax increases included a ring-fenced social care levy, however, and there would be also be increasing levels of devolution.  

“Another issue is the adequacy of the evidence base for some services provided by the NHS and social services,” he said. “There’s a real problem in terms of how we decommission stuff that doesn’t work and focus on the stuff that does.” Developments in tech offered huge potential, however, particularly around “big data” and the gathering and use of information. “The original NHS model was very much along the lines of ‘you’re ill, I’ll cure you’. But there’s huge potential for technology to help people manage long-term conditions and their own care and hugely reduce demand.” Developments such as the Patient Activation Measure (PAM), however – with patients able to challenge health professionals – would inevitably require a significant cultural shift for the health service.

It was possible that the green paper would provide a huge opportunity, he said. “Can we find a space where politicians can reach an agreement about what a properly funded health and social care service would look like? There are a number of indicators to suggest it is being taken seriously, but the question is whether it’s a solvable problem. It’s about creating a political narrative that gives you the space to do that. We need to grab this opportunity now – but it needs the whole sector to rise up and make it work.”