Redesigning Health and Social Care

So the Spending Review is out and the time has come to take a razor to the public sector.  Osbourne’s abstract list of proposed cuts will, in the next few weeks, have to be worked up into planned actions.  How these will actually play out is anyone’s guess.  The BBC’s Mike Sergeant (link here) pointed out that “one part of public spending so often affects another. For instance: if incapacity benefit is cut, do we need to spend more on Jobseekers’ Allowance? If higher education spending goes down, does youth unemployment go up? If social housing is reduced, do we need to spend more looking after the homeless? If people pay more into their pensions, will they spend less in the shops (VAT)? [...] It’s not a zero sum game”.

The cuts will ask a lot of the private sector too.  How will they respond?  They need to generate the wealth required for the recovery by producing products and services of such quality and necessity that the population will be enticed to stop saving and start spending.  The state sector, now increasingly hollow will give the private sector contracts and they will provide the most effective, economic and efficient health and social care money can buy.

And the private sector will need to expand.  It will provide more local jobs to accommodate the armies of people shifted out of the public sector (490,000 workers) or off benefits into work.  The private sector will accommodate the family lives of single parents who will need to work to survive.  Those with disabilities who are now to be reassessed as able to work will enter the workforce needing accommodations for their disabilities. Education, now unaffordable to many, will still be needed making employers more responsible for their workers’ learning.  The Government’s support for apprenticeships is welcome here but the abolition of the Train to Gain programme is not.

On top of all of this, the private sector will have to pay a decent living wage.  If we apply Osbourne’s formula that it will always ‘pay to work’ rather than live on benefits, we need to take into account that benefits are to be capped at the average working family income.  Surely this means that salaries will need to be at least average if not better.

Let’s hope the private sector are up to it.  I’m not a cynic by nature. Maybe good things will come of this.  I recently had lunch with an old friend who was now working for a large international company providing a range of services – school dinners, construction, office reception to name a few.  She worked in the bit that ran prisons and she described an organisation committed to the rehabilitation of its prisoners and providing the kind of working conditions and development opportunities that enticed workers to leave the public sector and come to them.  I’m hoping that the ‘sober decade’ will give us a private sector that carefully balances self interest with a strong sense of what is good for our society as a whole.

I have been listening to George Osborne’s spending review coming in this lunchtime, holding my breath, waiting to hear whether we will all still have jobs to go to tomorrow, whether my children’s educational future hangs in the balance, and what kind of health and social care system there may be when all the full effects swing in.

But one of my biggest concerns for society, and one that cuts across all those individual personal concerns, is about the future of a critical society. One that will take the time to question what direction we are going in and why, and not always think the ultimate destination has to be the bottom line.

After the cuts will there be space and time in our society for people to take time to think? Will we still have students out there to study our courses here at the Open University, or will they be too busy making ends meet?

In the Faculty of Health and Social Care we produce courses which we hope will inspire each and every student to make their lasting contribution to society, in some way developed from what they learn with us – whether in their role caring for a sick relative, as a frontline member of the nursing staff, as community workers, social workers and volunteers, or maybe even as someone with some power to swing their own axes when future decisions have to be made.

But we rely on those students being able to fund themselves to study our courses in the first place, or on employers supporting them to do so. We also rely on a society and government that values lifelong learning in all its forms – and that includes the social sciences, humanities, philosophy and critical thinking, as well as business, economics and science.

In response to the Chancellor’s announcement, Labour’s Alan Johnson said “today we face the deepest cuts to public spending in living memory… today is the day abstract figures and spreadsheets turn into people’s futures.”

I still await, holding my breath, wondering exactly what those futures are going to look like, because I didn’t get a real sense from the figures and spreadsheets that the solution is yet in sight.

Which ever party got elected it was always clear that once the election was over there were going to be some tough decisions to make about public spending.

We are now waiting for the details of what the future holds but already there are worrying signs. My local Primary Care Trust has just announced a 20% reduction in the funding for mental health day services in the county. Will the axe fall evenly across all sectors or are some regarded as easier targets than others?

The election buzz is simultaneously sending out two messages – that public services are inefficient and need streamlining and that the NHS will be protected from cuts (here’s a tip for party leaders – when you give speeches about protecting the NHS don’t make cutting motions with your hands – it’s unnerving).

It is timely then that targets for health and social care services are back in the press again. This time The College of Emergency Medicines is arguing that the NHS target to treat people visiting accident and emergency units within four hours is compromising care and patient safety.

This is unnerving too – so how does target setting shake down at the frontline?  In the book ‘In Stitches’, Dr Nick Edwards, an Accident and Emergency Doctor explains that the four hour rule sparked a fair amount of ‘head banging’ that did lead the team to streamline processes in A&E.  There was some improvement in how they worked.  Targets do have some value.

But he also describes the little ‘fiddles’ necessary to meet targets.  If patients are moved out of A&E and into a corridor with curtained-off enclosures, they can be classed as in an admission ward – the 4 hour target is met.  Patients may be referred immediately and sometimes inappropriately to a specialist on a ward thus by passing A&E. Target met.

Edwards gives a specific example.  He is treating a patient with only 5 minutes left in the four hour window.  He has to decide whether to move her onto a ward without anaesthesia leaving her in a lot of pain for some time (but meeting the target) or spend 15 minutes treating her.  If he breaches the 4 hour rule, he argues that the managers will come down on him like a ‘ton of bricks’ and the hospital will receive financial penalties.  He decides to treat the patient, breaking the 4 hour rule and later they ‘massage’ the figures logging the time as 3 hours 59 minutes.

So, while ministerial lever pulling can appear to produce the goods from the organisational machine, the effects will be unpredictable and may only produce the illusion of goods delivered.  Nick Edwards reports targets improved what they did – this is important to acknowledge and is reassuring.  But he also highlights the stress, wasted time and energy spent skewing practice to meet the targets, making decisions to fit the targets and massaging figures to meet the targets.

I take an optimistic conclusion from this as well though.  Despite the warning of The College of Emergency Medicine, which I think should be heeded, we should have some faith in the humanity and care of the practitioners who do what it takes to look after people the best they can.

On the 10^th of March, David Askew a man with learning difficulties collapsed and died after years of abuse from youths.  Terrible news.  The BBC followed this up with this piece on Broadcasting House which you can hear here (it starts 7 minutes in but be quick because the podcast will be withdrawn soon) foregrounding the experience of one disabled man living with harassment, home invasion and violence. He ended up sleeping rough.  The Department of Health’s Co-Directors for Learning Disabilities describe such experiences as shocking but not unsurprising.

Tom Shakespeare, one of the leading thinkers and writers about disability, wrote a column in the Guardian where he describes his own struggles to recognise these acts for what they really are.  Referring to others like Askew, vulnerable and disabled, exploited, humiliated, and finally killed, he describes these acts as a very British problem and not something to be dismissed as bullying. See it for what it is: disability hate crime.

While watching the Channel Four documentary ‘Sticks and Stones’ with my kids (watch it here) my 7 year old daughter observed: ‘if you have a disability, you should have someone living with you all the time’.  Interesting idea this.  Care and support aside, having a disability may mean that you need a bodyguard simply to live a life free of threat.

Yesterday, the 8 March, marked International Women’s Day. For some, any mention of women’s rights or feminism sparks a sense of ‘gender fatigue’, or as one student once commented after a lecture about gender and inequality – ‘Stop banging on about women!’. Yet the very fact that International Women’s Day prepares energetically for its centenary in 2011, suggests that even after 100 years of campaigning and consciousness-raising, there is still some way to go.

So why am I banging on about it here?

Well, in preparing teaching materials recently, on ‘power’ in health and social care, I had to find suitable examples from sexual and reproductive health. I found examples exploring pregnancy, childbirth, the ‘cervical cancer vaccine’, and sexual relationships between residents in a residential care home for adults with learning disabilities. All our teaching materials then get sent out to ‘critical readers’ – experts in the field who can point out any omissions or inaccuracies. It is one of the strengths of OU teaching, and one of the reasons our courses are so well respected. And when I received comments back from critical readers, one had questioned why there was so much on ‘women and childbirth’.

I had two knee-jerk reactions to this. My first was – ok, I take your point, let’s ditch some women and childbirth stuff and bring in other examples. My second, took me the other way – and this was to think, well no, we live in a world in which women’s sexual health is much more medicalised than men’s. Women’s bodies are subjected to the ‘medical gaze’ much more than men’s, and women suffer a disproportionate burden of ill-health and early death.

In developed countries, childbirth was for many years the main cause of female mortality, so many welcomed the ‘medicalisation’ of childbirth and growth of medical interventions during pregnancy. However, some were concerned that medical needs rather than women’s needs seemed to be dictating progress. There has been concern that interventions are often used to manage labour according to hospital needs, rather than the needs of the baby and mother.

In developing countries, the same concern to get women to deliver in hospital has been driving policy and practice for years. Whilst this might improve outcomes for the women and babies who make it to the hospital, many thousands of those women will have been abused or raped before getting there, and in some countries, the abuse will continue in the hospital – simply because they are women.

Around the world, 1500 women die everyday as a result of complications during pregnancy or childbirth. Is this really something we can afford to stop banging on about?

From 2008 schoolgirls in the UK began receiving a vaccine to prevent them being infected with the Human Papilloma Virus (HPV). HPV is a virus which infects the skin and lining of organs such as the vagina, mouth and anus. The targeting of girls has been justified by portraying this public health campaign as a preventative programme for cervical cancer. However, whilst HPV can lead to cervical cancer in women, it is also implicated in some cancers of the anus and penis.

Anal cancer is about thirty-five times more common in gay men than the general population. So some suggest a more honest approach would be to make the vaccine available to girls and boys, as the vaccine could also have benefits in preventing penile and anal cancer amongst gay men.

Despite lobbying from pressure groups for such a move the Joint Committee for Vaccination and Immunisation concluded there would be no additional benefit in vaccinating boys. The decision was justified on the grounds that targeting girls would decrease the overall prevalence of HPV infection, and this would also benefit boys. This does not address the issue of boys who go on to have sex with other boys and men, neither does it address the issue of men taking responsibility for sexual health rather than implicating female bodies as the sole ‘reservoirs of infection’.

It might be concluded it would be a difficult political move to offer universal vaccination, as this would draw public attention to the fact that this is a vaccine against a sexually transmitted infection in the whole population, rather than a campaign against cervical cancer per se. It would also mean being open and honest about young people’s sexuality, and asking boys to take as much responsibility as girls. If we have a generation of young men growing up with the message that they need to take responsibility for their sexual health, then perhaps the male pill might not be such a pipe dream in the future!

The above quote by Pablo Neruda is the opening line of the latest government policy document on health inequalities. We learnt yesterday of some of the findings of Lord Marmot, author of Fair Society, Healthy Lives, that where you live determines not only how long you live but also the quality of your life. Those in poorer areas are likely to die 7 years earlier than those living in more affluent areas, and also that those who die earlier are likely to have health problems leading up to that earlier death.
When I heard these findings I thought, did we not hear that from the Black Report of 1980, and again almost 20 years later when the Acheson enquiry report came out? Has anything changed?
What the Marmot review has done that is different is acknowledge that mistakes had been made in the implementation of previous policies in that they were too narrowly focused and not long term enough, that communication was an issue in implementing a national strategy.
So are we entering a new era with this new, more pragmatic style report, or are the obstacles that need to be overcome to make the society we live in more equitable?
Last year the government missed its target to halve childhood poverty by 2010, and with 3 million children living in poverty, it does suggest that the health and social inequalities that such poverty brings are setting up generations of health inequalities for the future.
I think the Marmot Review is a real step in the right direction to addressing health and social inequalities, however the real obstacles not really tackled will be the cost of such initiatives, and perhaps more pertinent even, is the long term political commitment to making ours a more equitable society, so that in another 30 years the next generation is not dealing with the same dilemmas.
“We are not tinkers who merely patch and mend what is broken… we must be watchmen, guardians of the life and the health of our generation, so that stronger and more able generations may come after”

Dr Elizabeth Blackwell (1821-1910), The First Woman Doctor

David Cameron has become the latest in a long list of people to adopt the phrase ‘We can’t go on like this’. Through the past few decades it has been used in a variety of contexts to refer to political battles, immigration, the economy, war, the environment, and of course the growing strain on the health and social care services.

Yet Britain inevitably does continue to ‘go on like this’.

Cameron promises targeted health funding for those areas most in need. Labour retorts this is already happening. The Copenhagen Summit closed with no clear direction on global climate change; whilst evidence continues that the world’s climate is in some state of disarray!

Most recently I heard the phrase at my local Co-op, which I trudged through the snow to in the vain hope of getting a pint of milk. ‘We can’t go on like this!’ exclaimed the Manager as I entered, waving his hands around at the empty shelves.

Every year when we have snow, the country comes to a standstill, as we fail to cope with what other countries would see as a minor inconvenience. Today, as a dutiful parent, I faced a one and a half hour trek through snow and ice to get my kids to school. Accident and emergency departments across the country gear themselves up for a sharp increase in sprains and fractures as people, like me and my family, take to the un-safe streets to resume our normal lives.

On the trudge home I wondered why Britain is so apparently unable to cope with some very simple things; things like gritting our roads to allow deliveries through; like coping with a few more inches of snow each winter; like making our poorest areas healthier. I know Sweden never had all the answers for social welfare, but at least the snow never stops them trying. As a child in Sweden I remember skiing to school in the winter and my parents skiing to work. Now that would solve a whole range of problems in Britain – reduce accidents on the roads, improve fitness and get us all safely back to school and work…

Because really, we can’t go on like this.

I’m looking forward to seeing what Gerry Robinson has to say about dementia care in the UK. From the recent reports on the quality of care in residential homes it would seem that there are many factors which influence this. Funding is an important issue but so to are the skills, values and understanding of the staff who have to do this challenging work. The Open University course Adult Health, Social Care and Wellbeing that we are preparing for October 2010 looks at many of the issues which face practitioners when providing care for vulnerable clients. It will be interesting to see how many of the issues we have covered in this course are raised in these two BBC programmes.