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Why public health could be key to finding a sustainable social care solution

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A guest briefing from Andrew Cozens, independent social care and health specialist.

This autumn Budget once again made some temporary fixes for social care’s most acute pressures. But any long-term solution seems as distant as ever, with the promised green paper an apparently unreachable mirage.

At the sharp end councils and their partners are seriously debating whether moves towards integrated health and care organisations can reduce demand and deliver the savings needed to balance the books.

Given most plans have a strong focus on understanding need and responding to it better upstream, the further cuts in public health capacity, totalling £700m since 2014-15, seem at best perverse.

On the face of it, the NHS is the most stable partner locally, with the extra funding promised stretching out to 2023-24. But the headlines are misleading.

Many NHS organisations are in deficit with aggressive savings targets. Most will struggle to absorb the costs of pension revaluation, education and training, and capital requirements which fall outside this scope.

The current pattern of integration of health and social care is patchy and, with the exception of Greater Manchester’s devolved arrangements, rarely at any scale. Its precursors were principally either integrated commissioning models or delegated arrangements to health or care trusts.

The widest model – for learning disabilities and mental health services – has declined, with many councils withdrawing because of concerns about practice and budgetary controls.

The evidence of success is variable too. Most arrangements have seen improved user satisfaction with health and care support. Some can highlight changes in patterns of demand with a reduction in crises. Few can point to significant reduction in the overall costs though.

This time around the driver has been the NHS sustainability and transformation plans (STPs) on sub-regional footprints. Local government interests started out as peripheral but have latterly gained traction as new commissioning models have emerged with a stronger focus on places, prevention and whole system resilience.

The governance of new arrangements is a key concern in many places. Recent guidance suggests that health and wellbeing boards should maintain an overview of these developments, be clear about the benefits for their locality and help determine priorities.

In practice, governance stems from NHS England which develops, mandates and assures local arrangements, superimposing financial and performance expectations.

The best plans position demand for health and social care in the context of quality of life, addressing poverty and inequality, and drawing on the wider range of services and community assets in their area.

It is no coincidence that a public health perspective has identified the key underlying issues to address and that plans are linked to a clear and confident political vision. This approach may in the end prove more sustainable.

Andrew Cozens, independent social care and health specialist

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