The COVID-19 pandemic has highlighted multiple truths, many of them difficult. Chief amongst those, are that marked health inequalities endure more than a decade on from Professor Marmot’s seminal report. Furthermore, COVID has impacted some communities to a much greater extent and the concern is the gap in life expectancy and deprivation may have become wider. It’s even more clear that healthcare and social care cannot be considered in isolation, despite policy demarcation.
Responding to the virus and its impact has, however, also underscored what can be achieved by collaborative action between local leaders; those within healthcare, local government, and the voluntary, community and social enterprise (VCSE) sector.
With the UK facing its biggest peacetime challenge, we saw organisational barriers, unnecessary bureaucracy, and siloed working melt away in large parts of the country. The results stand evidence to the effectiveness of dynamic leadership within communities. In the North, in particular, organisations came together to lead test-and-trace initiatives that far outshone national efforts. Community groups mobilised to ensure the shielding vulnerable received food deliveries. With the rollout of vaccines, physiotherapists, dietitians and other healthcare workers who would not traditionally administer them are lining up to play their part; while willing volunteers from multiple walks of life help steward vaccination centres. In Bolton, for example, communities, services and the army have shown how combined efforts can increase vaccination rates, reduce community transmission and bring infection levels down.
Driven by a common sense of purpose, positive steps which may have been debated and second-guessed ad nauseam have happened with remarkable compassion, commitment and drive. It is understandable, then, that policymakers should look to harness this momentum to accelerate the place-based care agenda. The arrival of two publications championing structural reform in quick succession might have seemed odd to the public while the country was in crisis mode. But to those of us working to effect change in health and social care, the timing of both Integrating care: next steps to building strong and effective integrated care systems across England; and the Government’s subsequent follow up white paper: Integration and innovation: working together to improve health and social care are understandable.
The origin of the phrase ‘never waste a good crisis’ is debated. Some attribute it to Winston Churchill, as he grappled to form the United Nations in the fallout of WWII. Others suggest it originates from Rahm Emanuel, former US president Barack Obama’s chief of staff, in relation to reforming the banking system post-2008 financial crash. Both scenarios required monumental systemic change; with leaders working collaboratively, driven by a desire to forge a better future and avoid repetition of past mistakes.
We should be under no illusion that finally shifting the way we deliver health and social care in this country, to a more place-based, person-centred model, while making overdue progress on health inequalities are undertakings of a similar magnitude. Achieving them will require every organisation involved to hold the gains established during the last 18 months, and use the momentum to ensure that the ICS model finally works for the people it is supposed to.
The whitepaper has been welcomed by most working in health and social care. At a recent virtual roundtable which Aqua convened, the consensus was that placing ICS into legislation and on a statutory footing was an important step; one which would firmly set the direction of travel and establish a sense of accountability to deliver for leaders working within them.
Importantly, the structure provided by the legislation is flexible. It openly states that the aim is to achieve collaborative integration, with allowance for the nuances within each ICS.
This is welcome on two key levels. Firstly, because a one-size-fits-all approach to reorganisation on this scale would be doomed to failure due to the existing variation at an organisational level within ICSs. And secondly, because the drivers behind health inequalities vary so greatly within an ICS. Addressing them effectively requires a granular approach and the ability to flex budgets and resources at a place level.
Any analysis of why health inequalities have proved so difficult to address in so many parts of the country, must acknowledge the role austerity has played. It has been devastating. Since Marmot’s report in 2010, central government funding cuts have seen local authorities lose 60p out of every pound they previously received. But it is reductionist to suggest that the comparative lack of progress in addressing disparity is solely down to cuts.
In her book, Radical Help, pioneering welfare reformist Hillary Cottam explains this well. She cites welfare projects in Wigan, in which families had between a quarter to half a million pounds spent on them, with little impact. A failure to take the time to truly understand the multifaceted issues facing people can render even the most well-funded programmes ineffectual.
These complex factors are unlikely to be improved by a single action, a single person, or even a single organisation. The key is to engage all of the people within a place to understand what will truly make a difference. Services must then be focussed on individuals, families and communities; making them truly person-centred.
This requires organisations to flex and cede responsibility in some areas while accepting more in others.
It means leaders acknowledging that this will be messy and imperfect; accepting that people who have spent decades delivering care in one specific way will be resistant to change. Leaders themselves must lead by example in this new era of integrated delivery. They must build new relationships, strengthen existing ones and repair bridges where necessary. There must be more trust and the adoption of a completely different mindset; one which rejects notions of inflexible boundaries and organisational sovereignty, in favour of simply delivering services that work for people. Siloed working must be consigned to history, replaced by joined-up thinking and the open sharing of data to enable a truly integrated experience for those receiving it; all of this has proved possible during the pandemic and the challenge is to sustain this.
None of this is new. But proponents of integration and place-based care recognise that there may never be a more opportune moment to finally make progress on the agenda. The pandemic has been a burning platform that mandated rapid action out of necessity. The challenge now, is to ensure organisational leaders have the support and space to collaborate; to embed the positive changes and use this new mindset to innovate further. The pandemic is far from over, but there are jinks of light at the end of a long tunnel. We can ill afford for health, social care and voluntary organisations to slip back towards old ways . They could be forgiven for doing so. Their people have been sorely tested by the pandemic and the thought of more disruption, no matter how well-meaning, may be difficult to countenance, with many needing time to both physically and mentally recover. This is where organisations like aqua have a vital role to play. Holding the middle ground and acting as a convener and an enabler; we can bring leaders and teams together to work through barriers and assess what has changed for the better during the pandemic, and how to take that forward.
The initial signs are promising. At our recent roundtable exploring the road ahead for integrated care systems, almost all participants expressed a profound sense of optimism that the momentum behind the agenda showed no signs of slowing down. You can read more about our System Transformation work in the latest issue of The Improver here.
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