Monday’s cabinet reshuffle has opened up some interesting possibilities. With Jeremy Hunt not only staying on as Secretary of State for Health, he has now widened his official remit / title to Secretary of State for Health and Social Care, with the current Department of Health being accordingly renamed the Department of Health and Social Care (DHSC).
Leaving aside that Hunt is not popular with health professionals (although I challenge anyone to name me any Secretary of State for Health who HAS been popular with health professionals!) and that in reality, social care has been a part of his remit for some time, this is, we hope more than just a change of title. We hope that it shows a recognition within the government that to reform healthcare in the UK, we must also reform social care.
At the same time as the NHS seems to be facing its worst winter crisis in a long time, if not its worst ever, many are calling for a cross party rethink on how we fund and deliver care in the country, and many are now calling for a cross-party Royal Commission to do this. Certainly, Hunt will be taking the lead on a new green paper to address health and social care reform in the coming months. So, reform of one kind or another would seem to be afoot.
Many fear that the ongoing reforms of the last two administrations are an attempt to ‘privatise’ the National Health Service (NHS) by stealth. These anxieties, from left wing media and health professional bodies, stem from an anxiety that subcontracting out services to ‘for profit’ companies risks diluting or even destroying the NHS ethos of care free at the point of delivery to all according to need rather than ability to pay. These voices argue that the profit motive leads to cut corners and compromises that do not benefit patients. More funding and more state sector intervention is the only hope of saving the NHS and its core ethos, they argue.
On the right, the concern is that a growing bill for providing services cannot be met, and a new, more cost-efficient health service is needed, with less bureaucracy. Market competition is far more efficient than state control, they argue, and so will lead to a more efficient service without compromising care.
Both are right and wrong, I would suggest. Right in much of their diagnoses, wrong in most their prescriptions.
Markets are great for products we buy and sell – they ensure that there is a price that reflect the need for the product and the cost of its production. Health, however, is not a product or a commodity – it is a fundamental of human existence. Healthcare is therefore not a product, it is an essential service that all of us will need to access to maintain our health at some point or other in our lives. More than that, the provision of health and social care is an act of social solidarity that says all human lives matter and that the quality of those lives matter. Ensuring people are cared for and treated well and with dignity is a core act of social solidarity.
The state has an important role in coordinating and distributing essential services and resources, responding to and identifying needs at a macro level through policy and infrastructure in a way that the private sector cannot. But central planning is a blunt instrument and does not easily allow for innovation and creativity. It can be inflexible, and can fail to respond to the difference in needs and circumstances as a very local level.
The German sociologist Tönnies pointed out that in pre-Enlightenment Europe mutual social solidarity was provided by the church, as a local, national and a supra national network and institution. Societies looked after those in need in their community through a variety of institutions and networks, many founded in the church. In many parts of this country, the church still fulfils that role.
Post Enlightenment, there was a move towards more secular networks and institutions to continue this, but also a shift from what Tönnies termed Gemeinschaft (community, mutuality, social responsibility, loyalty, friendship and love) towards Gesellschaft (a group of individuals bound together by utilitarian interests and necessity). The profit motive that is one of the big ties in Gesellschaft removed the sense of mutual care, responsibility and social solidarity. It puts career at the centre, and denies or minimises a sense of vocation, or calling to health or social care.
Socialist and free market systems are both guilty of promoting Gesellschaft at the expense of Gemeinschaft. The barren nature of Soviet era healthcare in Eastern Europe shows this at its most stark – universal, technically competent (for the most part) but reducing people to machines to be fixed and put back to work. It ignored the fact that people have complex hinterlands and responsibilities as well as needs. The free market approach to healthcare in some Western nations displays a similar, bleak utilitarianism that ignores the social and spiritual nature of human beings.
The NHS, amazingly, seems to hold these two ideas in tension – maintaining an ethos of service and social solidarity while operating a modern, professional pay and career structure. How else can we explain the number of staff working well over and above the hours for which they are paid just to keep services running, especially in the current crisis? The staff believe in the NHS, value it and through their time and effort, invest in it as a social institution.
This marrying of the vocational and the professional can probably be laid at the feet of such luminaries as Florence Nightingale who saw no contradiction between the two. And probably to many other social reformers of the 19th and 20th century as well, including the father of the NHS, Aneurin Bevan. While Bevan was an atheist, many of the other reformers of the 18th, 19th and early 20th centuries (such as Wilberforce, Fry, Barnardo, Shaftesbury, etc) were Christians – mostly evangelicals or non-conformists. However, even Bevan had his values shaped in a Welsh upbringing influenced by chapel and the Welsh revivals.
If we are going to see reform in the NHS, it must keep these two elements together – social solidarity and professionalism. While a pure profit motive will never do this, many are setting up Community Interest Companies (CICs) that hold the values of service and social solidarity alongside professionalism and a social entrepreneurship that is creating innovative responses to real needs.
In Manchester, where health and social care budgets are combined and are being commissioned jointly in a trial known as DevoManc, I have seen some real examples of this. One such CIC was started off by a medical student on an Oldham council estate who saw the lack of local GP services in her community. She challenged the local commissioning group about this, and they instead got her to set up a practice to address the needs she saw. The model of whole person care that the practice developed (drawn from a Christian world view) involved working with local community groups, churches and others to address the social as well as health needs of the people on the estate. It was so effective that the CIC she founded to run the practice is now managing nine practices across Greater Manchester, specialising in providing health in areas of social deprivation.
They have gone on to developed specialised community services such as Focused Care to help patients who have difficulty accessing services and complying with treatment. This service marries health and social services in an innovative, family focused approach to supporting patients with complex health and social needs.
This example shows how a private company can be moved, not by a profit motive, but by the ethos of care and compassion at the heart of the NHS’s founding principles. It also shows how small bodies can innovate in a way that larger organisations can sometimes struggle to emulate.
There are many other such innovations that should be part of the fresh thinking needed for health service reform. That many (though not all) of these are faith based should come as no surprise. The church has owned the ethos of social solidarity since it began two thousand years ago. Simply because it is the natural outworking of the gospel of Jesus Christ.
So, Mr Hunt, if you are listening as you survey your expanded DHSC kingdom, you would do well to come and talk to those out in the community who are already re-imagining health and social care, many of whom do so in service of another, much greater Kingdom.