Joint billing is a weak response to profound problems in both sectors
As Jeremy Hunt walked into Downing Street during the Cabinet reshuffle this month, it was widely assumed that he would move roles. When he emerged in the same job, but with a new title – secretary of state for health and social care – it took everyone by surprise. Despite speculation that he was asked to move, refused, and somehow emerged with an expanded portfolio, the reality is somewhat different.
The Department of Health has long held the policy lead for adult social care, and social care funding still remains a matter for local government, overseen by a renamed Ministry of Housing, Communities, and Local Government. As the editor of the Health Service Journal, Alistair McLellan, tweeted: ‘Profoundly irritated that DH now has misleading new name… simply because May ballsed up the reshuffle #nothinghaschanged.’
On one level, dismissing the name change as merely window dressing is tempting but probably not quite fair. What we call things matters, and having a renamed Department of Health and Social Care (DHSC) sends a helpful message that social care is important, raises its profile, and could even be an opportunity for the NHS to learn from social care (for example, around personalisation and assets-based approaches that build on what people and communities already do for themselves). It might have been an even stronger statement if we had had a Department of Social Care and Health (since social care is usually the sidekick) – but at least the new name feels like progress.
Moreover, the changes seem to imply, at least in principle, that a single senior minister is personally accountable for both services. Given the scale of the challenges facing adult social care, this might be a brave thing to do. Rightly or wrongly, Hunt has proved himself unafraid to take on a battle (for example, with junior doctors), invested in new models of care, and has shown a stubborn determination not to give up the health remit. These could be important qualities when it comes to the crisis in adult social care.
Words are not enough
However, simply reclassifying his role and department will not solve our underlying problems. Our health and social services were not designed with integration in mind, and they have different budgets, legal frameworks, geographical boundaries, IT systems, and cultures. There are fundamental differences between services that are national, universal, and largely free at the point of delivery and those that are local, targeted, and means tested. As a famous article on the five laws of integration puts it: 'You can’t integrate a square peg and a round hole.'
Against this background, having a single DHSC does nothing to change this situation. Many councils, as but one example, have had a directorate of social care and housing but with both services remaining almost entirely separate on the ground. Even in Northern Ireland, where we have had integrated health and social services since the early 1970s (and where the previous Department of Health, Social Services and Public Safety was renamed as the Department of Health in 2016), joint working continues to be problematic, and social care arguably remains a junior, sometimes marginalised, partner.
There could even be negative consequences. After the rebranding, it soon became apparent that the DHSC would take on responsibility for the forthcoming green paper on care and support for older people, which was previously the responsibility of the Cabinet Office. Whether this is because Hunt really wanted this hot potato, or simply because no one else did, is not yet clear. However, when Damian Green, then first secretary of state, announced the green paper he was clear that it would have to be cross sectoral and consider wider issues, ‘including the crucial role of housing and the interaction with other public services.’
Now there is a fear that a process led by the DHSC could be narrower and overly influenced by consideration of the implications for the NHS. As the Association of Directors of Adult Social Services said: ‘We hope the Secretary of State will see social care as crucial in its own right, and not just viewed through the prism of what it can do for health care. Social care is responsible for over 1.4 million jobs, and supports over 1 million of our most vulnerable adults. With a funding gap of over £2 billion, this will be one of the most essential tasks for the new Department to get to grips with in making sure that a long-term, sustainable funding solution is provided to address this.’
Above all, changing the name doesn’t feel like a sufficient response to the scale of our problems. Shortly after the reshuffle, senior doctors wrote to the prime minister to warn of patients 'dying in hospital corridors' and NHS Providers has talked about ‘a watershed moment’ whereby ‘we are now at the point where we cannot deliver the NHS constitutional standards without a long-term funding settlement.’ Despite its symbolic value, adding ‘and social care’ to the website, the signage, and a job title surely won’t be enough.
First published in the British Medical Journal: Health and social care: What’s in a name? BMJ 2018; 360 :k201
Professor of Health and Social Care and Head of School of Social Policy, University of Birmingham