The Greater Manchester authorities have big plans to devolve and integrate health and social care. These plans are outlined for public consultation in spring 2016.
To win public support for change, there needs to a clear “offer” with a public convinced that there is no wiggle room for corporate deceit.
The general public mostly knows and understands the current national “offer”:
1. Ambulances with an eight minute target for arrival,
2. A+E with a four hour target for waiting, and
3. GPs with a “days not weeks” target for appointments.
The Greater Manchester “offer” needs to add:
4. a 24/7 pharmacist within five miles,
5. a nurse appointment next working day,
6. a home accidents prevention visit within two working days,
7. a home care assessment and named care manager within five working days,
8. a quality-controlled network of home care providers, and
9. a quality-controlled training network for front-line staff and volunteers.
Guarantees. No disappointing small print, and sanctions for any manager who tries to game the system.
The devolution aims are very good, though beyond five years we should aim to exceed the England averages in all categories. Clearly the strategy is right to say that poverty is a root cause of chronic ill health, though the section on early years development needs more detail, especially for parents with low pay and long hours. Also, there are some areas in health care where the English average is woefully short of the European average, especially in the early detection of cancers. An improvement here will probably require more routine community-based blood testing.
But my main comment is the need to engage the public attention of 2.5m people. The GP and hospital services are clearly understood. Councils less so. Trust in change is low and anxiety is high. Leaflets with initials and long, vague phrases will miss people entirely, except to fuel suspicion.
Of course there will be a public engagement strategy with an exhibition trailer and leaflets to take around town centres, with local radio programmes and newspaper reports. But the content, the “offer” is key, otherwise it risks adding to a general public perception that change cannot be trusted and clever lies will cover the truth. In general, politicians who go on the doorstep at election time probably get this sense of public suspicion more than their staff do, and especially more than some senior staff who are without shop-floor, daily public-serving experiences.
So the devolution of health and social care allows for some fresh thinking
For example, a target of a 24/7 pharmacist within five miles of everyone in Greater Manchester. Some of these could be based within all-night petrol stations. They have ease of access, security, and the safety of existing staff. It would be a source of advice, not just emergency supplies, and would look at sustained health promotion for shift workers and for drivers with long hours. It would play a strong role in promoting men’s health. For security only a limited amount of controlled drugs would be kept, in a time-delay safe.
A pool of salaried pharmacists would be employed to provide a mixed economy of provision and to mitigate the procurement tendency of cartels and of some contractors using service guarantees to push up price negotiations.
For nurse appointments, in other European countries it is common to make such a booking by using a phone app. Even on the outlying islands. We should catch up.
Of course, not every beneficial change can be summarised in a target or clear promise. The role of poverty in determining overall health was covered above. Another key factor is the importance of mental health, and including here substance abuse and addictions, especially alcohol misuse.
Many people have direct or family experiences of living with mental health distress or with addiction-dominated lifestyles. This happens in all walks of life, and at all ages. It is often a great strain on families, and even harder to cope with alone. Too often, impossible. This personal understanding from experience, a rich vein of knowledge running through society, needs to be supported and harnessed.
The need for community support is widely understood, but the means to build that support are not always available. The Greater Manchester devolution of health and social care could make a big difference here.
As practical examples, a programme would include:
A mental health first aiders course for front-line staff (including housing, fire and rescue, transport and especially rail, libraries, schools, custody) and for youth, community and voluntary groups (guides and scouts, sport and leisure, neighbourhood and residents).
A longer course in approaches to addiction reduction would be available for front-line staff and volunteers who form longer term relationships with service users and fellow members. Training providers would be quality assured before they could use the Greater Manchester NHS brand.
These programmes would build on the national and international centres of expertise in mental health in Greater Manchester, such as 42nd Street, the Hearing Voices Network, and innovative work supporting the mental health of refugee and displaced children.
The hospital “estate” also needs some creative change. The need to move away from reactive admissions towards community-based prevention and treatment is understood and highly desirable. Nevertheless, people have a heart-felt connection to their local hospital where their have stayed, where their children were born, where their relatives died. Local hospitals could become more varied, for example with fewer rooms needed for reactive treatment and the rest used as studio space for artists, as repair workshops for recycling groups, as college training rooms and as community function rooms.
Home care is probably the most fraught topic here
Over the years it has become increasingly difficult. Lawyers have left their mark. The laws of thirty years ago – the Council shall provide – has been worn down over the years with case law replacing a person’s absolute right to receive home care with vaguer phrases such as – the Council shall endeavour to provide. To some extent people mostly with the highest levels of need were able to side-step their Council by going to the national Independent Living Fund (ILF) which created a wealth of best practice in person-centred home care. The development of Direct Payments as an alternative to Council provision was an attempt to mainstream some of the ILF principles. But years of financial cuts have reduced this provision, to just a history lesson.
Councils are in the invidious position of being told to pick up the pieces but with less money, and people using those services only have a time-limited protection within Council provision. The time will soon run out, as will the money. Government promises to make a lifetime cap on people’s own financial contributions to their care costs have been kicked into the long grass, put off for years to come. Meanwhile Councils look into bank accounts now and use the law to seize the value of people’s houses which can be sold later. It was becoming true that home care was for the poor and the rich, but not for people in the middle. However, with recent benefit changes, mostly around Housing Benefit (such as the weekly cap, increases in affordable rents, bedroom occupancy limits) the scope for poor people to survive on benefits with home care is increasingly hard to achieve.
So, the hardest test for devolution in Greater Manchester will very probably be to what extent a new local arrangement can mitigate against the worst of these cuts. To date, the system has been first to change the criteria, then to only fund those who meet the highest criteria, and to means-test all provision regardless of people needing modest savings to protect their wellbeing, such as saving to build a downstairs bathroom.
We saw in the devolved arrangements in Scotland how the promise of free social care for elderly people was rationed out in practice by creating long waiting lists for assessment. It is this type of practice which is seen by people as deceitful and it feeds distrust in politics and in what claims to be the democratic process.
We must have honest conversations with people
“Your home care assessment is for three hours support each day to help you with washing, dressing, eating, whatever. Your elderly parent can do some of this, and the Council can provide the staff or money for two hours a day of this. It isn’t ideal, and thousands are in the same boat as you and there is no spare money. But given this, what would you want us to provide first?”
You might say, start with anything involving heavy lifting. And then, give my parent each Tuesday off. Or whatever.
And the stark reality is, due to lack of funds, you can only go out twice a week, and it is only because the doctor has agreed to do home visits that these can include social trips as well as health appointments. But this is a more honest approach than creating new waiting lists to hide the numbers and pretending everything in home care is better than people know it is.