It’s time to put the stick down.

Written by Richard Boddington, 15th September 2017

The blame game isn’t working. The apparent ‘divide and conquer’ tactics used by government to reduce delayed transfers of care is stifling the one thing that will solve the problem, namely much better collaboration between NHS and Council. I can understand the logic behind the ‘stick’ approach – having worked with the public sector for nearly two decades I understand that change is not something that happens quickly, or frequently even (unless we’re talking about internal reorganisations!). However, I cannot see how threats of reduced funding will achieve anything remotely constructive.

There are principally two organisations that bring about the changes needed to improve DTOC stats – namely the NHS and the local Council. Only by working together to collaborate more effectively will there be an answer. Threats of funding reductions will only exacerbate the tension between the two principles, potentially reward a game of finger pointing and blame, and certainly reduce the willingness of both parties to think beyond their own organisational remit and look at the best solutions for the wider care and health economy.

It is not possible to generalise on the issues any particular region faces – all have very local pressures that will lead to the increasing rates of DTOC, whether that is inefficiency in navigating through the variety of NHS services, through patients (and their families) resisting decisions, or the lack of available services via the council or wider community. Whilst the symptom may be similar, each cause will have its very own solution. This is one of the reasons why the stick approach will ultimately fail –because most know what needs fixing within their environment and their principle concern will always be to try and address the internal issues first. Much harder challenges, such as provider market issues or collaboration will end up on the ‘too hard, save for later’ pile. The finger pointing buys time, shifts focus, and makes the longer term aim for joined up health and social care harder to achieve.

So, if the stick approach is problematic, what about the carrot. Needless to say this has been tried. Significant funding is allocated to the Better Care Fund, but the program has a varied history and ultimately has not delivered the results intended. As Richard Vize points out (https://www.theguardian.com/healthcare-network/2017/feb/10/drive-health-social-care-together-mess-nao) , there are a multitude of reasons, but you cannot look far beyond three key issues; misaligned financial incentives, workforce problems and poor information sharing. These are not new, and are still not being addressed fully. To exemplify on just one of these points from my own experience, “Joint Teams” sitting next to each other but operating different systems, processes and not allowed to even talk about their data to the other would be funny if not so serious.

Integration and collaboration has worked, as have new models of care. But you will have to look very hard to find an example that is in any way sizeable or even potentially scalable to meet the needs of the entire sector. They do help point towards what is possible but are a long way from providing the ultimate solution.

The truth is the systems and processes in place restrict the change needed. Innovation is often too limited, and at worse can incentivise short term fixes that further compound the problem. Again, to exemplify, the current drive to renegotiate rates from an already aggregated and pressured provider market, whilst achieving some year savings, will lead to a further pressure on future year budgets and capacity.

It’s not all doom and gloom though. There are initiatives that may be standard to follow. Predominantly these innovations are driven by necessity (closer collaboration in Cornwall being a good example) or practicality (a number of London Borough’s) and more often than not the funding available supports the change, rather than prompting it. So maybe the lesson isn’t in how you force the change, but rather support it?

Scrap it all and start again is a flippant and trite comment… and ultimately not possible. But the next best thing may be to try and understand how we can encourage and incentivise real change in a better way because a few more years of the 'forced' short-term changes will only add even more tension to the relationship between NHS and Council that the future of the nation’s care and health relies upon.

Find out one way to make change happen.