Martin Green: Service users must be at the heart of health and social care reform

Professor Martin Green writes that the pandemic has thrown the glaring weaknesses of the health and social care systems into the spotlight, and any future reforms must put the needs of service users first. 

The Covid-19 pandemic has changed every part of our lives and there is no organisation, or individual that has not felt some impact of this global health emergency. There have been a range of ways in which social care has been affected, and there are many lessons that must be learned from how governments, organisations and individuals responded.

At the start of the pandemic, there was a focus on the NHS and social care was ignored. It was clear that the scenario planning for a pandemic had almost entirely focused on the NHS, and there was little thought given to the fact that social care is supporting some of the most vulnerable people in society. This led to a range of actions, which had dire consequences for the people supported by social care. In any future discussion about how we respond to a pandemic the first lesson we need to learn is that we need to focus on people, rather than organisations, systems and processes.

At the beginning, there was a rush to empty hospitals to ensure that there would be enough capacity for those who might find themselves critically ill with Covid-19. This decision to move people out of hospitals into care homes and community facilities did not acknowledge the drastic impact there would be if Covid-19 got into services where very vulnerable people with many comorbidities were living. This led to many of our supply chains in social care being disrupted and I heard countless stories of care providers who had paid for commodities, which were not delivered and were redirected to the NHS. This left social care trying to fight the pandemic without the necessary equipment, with no comprehensive approach to testing of either residents who had been transferred into care, or staff, and the outcome of this was seen in over 35,000 deaths across care services. Added to this there were many people who had a range of non-Covid related health conditions, who did not receive treatment or support and this inevitably also led to some severe outcomes and in some cases fatal consequences.

At the start of the pandemic, we saw primary care withdrawing from social care services and many of the activities that were normally done by district nursing and other Allied Professions to medicine, were now being done by care home staff. There was also the added challenge of trying to deliver services to people with many health conditions and high level needs, at a time when a lot of staff were either absent because they had contracted Covid-19 or having to shield in line with government advice. This situation exposed to significant gaps in the data sets around social care, and the whole system was trying to plan without having the data that would tell them where the biggest challenges lay. This was another lesson that had to be learned the hard way, and despite all the rhetoric about integration, many of the organisations in government did not have an approach which understood the importance of social care or the interdependence with the NHS.

Data was another issue, the ONS figures on deaths in the community and particularly in care homes was being delivered several days out of date. This was at a time when 600 people a day were dying in the NHS and the data on deaths in care was not available in real time. I do not understand why in a digital age any Government statistical agency cannot deliver real-time data, which gives us a good understanding of what is going on. The ONS was not the only quango that did not bathe itself in glory during the start of the pandemic. Guidance that was delivered by Public Health England was slow to arrive and, in many cases, not fit for purpose. The evidence of this was that sometimes guidance for the social care sector was changing several times a day because the people who had written it did not understand who they were writing for. This is another example of one of many quangos, who are supposedly overseeing an integrated health and social care system, but all the staff and all the culture are rooted in health, and they do not understand how other parts of the system work.

One thing that became very apparent during this pandemic was the commitment, professionalism, and skill of the social care workforce, though it was sometime into the pandemic before this was acknowledged by key stakeholders, including the Government. Care staff were undertaking tasks which had previously been the domain of NHS staff and because the NHS had withdrawn, care staff stepped up and ensured continuity of care. As we move out of this pandemic, we need to acknowledge the contribution of social care staff, and we also need to reappraise what they can do and offer them the status and reward incumbent with a skilled role supporting people with very complex needs.

As the pandemic progressed the Government, the NHS, the media, and citizens began to get a better understanding that social care was on the frontline of the pandemic, and they brought in a range of initiatives that really helped. These included accelerating the enhanced healthcare in care homes programme, delivering free PPE, and also developing the infection-control fund, to mitigate the impact of the enormous extra cost burdens on the care sector. The infection-control fund was partly a response to the fact that of the extra £3.2 billion which the Government gave to local authorities at the start of the pandemic, only £0.5 billion reached the frontline of social care. This has really exposed a fault line in our system, where governments give money to local areas, but do not seem to have any control over how this is spent. At the time when the social care sector was being starved of money, there was a lot of extra resource being pumped into the NHS and this again reinforced the reality of a system that was supposed to be integrated but is very separate in terms of resource allocation and parity of esteem.

There have been many lessons learned and I hope that they will form the basis of the review of social care. I am however concerned, that the Government will only focus on the element of what citizens have to pay, and the reform agenda needs to be much broader than that. I believe we need to craft a new vision for social care and it needs to start with focusing on enabling people to live well. Our current system only supports people when they have had a crisis, and we need to have a vision for social care that down streams the approach so that every intervention is preventative and enables people to have the best life possible. There also needs to build in flexibility because people with long-term conditions should not be forced into a straitjacket of services that are available, rather services should be flexible enough to respond to their many and changing needs.

Any review of social care needs to have at its heart a clear workforce strategy and we need some clear skills and competency frameworks for social care, some national portable qualifications, and there needs to be a very clear career pathway, so that people understand how they can progress in their career. We need to have training resources and the pay and rewards structure needs to be commensurate with delivering a highly complex set of interventions, that support people to maximise their potential and have fulfilling lives.

The vision for social care also needs to include a root and branch review of the quangos surrounding health and social care. During this pandemic many of them showed themselves to be incapable of acting swiftly, and many had little or no knowledge of social care. I also want changes to the approach to regulation, working much more on an airline industry model. In the airline industry, there are in-depth analysis of critical incidents, and then the regulator identifies any systemic problems and cascades the learning as part of a sector improvement process to improve quality and safety to the whole of the industry. I believe this is how we need to approach the regulation of health and social care.

If we are going to meet the challenges of the future, we need integrated systems and I want to reclaim the term integration. All too often the focus of integration is the organisations, systems and processes that we currently have. This misses the point, the true success measure for integration is the experience of the person who uses this service and all the processes and organisations that enable this, should be background facilitators, not the focus of everybody's attention.

The Covid-19 pandemic has thrown up a lot of questions about whether or not our current system and the organisations and quangos that surround it are fit for purpose in the 21st-century. I hope the experience of this pandemic will be used as the platform for a new approach, and that we will all learn lessons from our experiences, and this will lead to building back a stronger and better system more focused on the needs and outcomes of service users.