"Where have we been, where are we going, and how do we get there?" Mark offers a plea from on the ground.
They say the best learning comes in time of adversity. This is an attempt to consider where we have been, and are hopefully going. I wonder whose needs are now the greatest, have our values and priorities changed, with lessons learned? These are reflections of my direct experiences, and appreciate others are far better placed and more articulate to comment. This is about offering insight and supporting change! It is clear we require change to historical cultures and top down approaches; it’s time to see actions and not more words.
Shifting resources upstream, with earlier intervention and prevention, are recommendations within the 2011 Christie Commission; the driver for health and social integration introduced in 2015. However, whilst there is no denying the theory and need for collaboration of resources, reflective of people and community needs; though sadly not demonstrating the required practice change with continued siloed approaches and hierarchical funding frameworks, reinforcing power and control within statutory settings, to the detriment of community engagement.
How has integration made a difference to the people they are meant to serve? The Scottish Government appear to hand budget responsibility to health boards despite resources being targeted for resources on the ground. This is a shirking of responsibility, further compounded with a disinterest in the quality and value provided from those resources. We can reference austerity policies over the past decade though there is a requirement to know the effective and efficient allocation of resources currently within our gift. If we don’t know, this is not good enough, and an area that can’t continue as a matter of course.
There is no doubt of the phenomenal efforts currently provided by those in health settings, and equally, social care- these areas can no longer be separated; social care must be recognised as an essential component, not a support role to NHS but of the same value, including those in non-statutory settings delivering valuable support to the most vulnerable and in the heart of communities. Not a medical model against a social model but one of community and holistic needs!
When we consider multiple reviews and inspections there is continuous reference to those Christie recommendations not being progressed, highlighted within Audit Scotland annual reports. In addition, the integration agenda requires meaningful engagement and involvement with the third and independent sectors. The lack of progress is a significant failing, with limited accountability being placed on the statutory sector. How do we establish how the public purse is being spent and reaching those most in need? Public sector should not be about multiple layers of management on significant salaries, and associated bureaucracy preventing resources being directed on the ground. Perhaps those niceties, not deemed essential, no longer continue?
That hierarchy of power and control continues playing out in front of us on a regular basis. For example, the Scottish Government will challenge the UK Government on protective equipment, who will respond with spin, numbers and everything they are doing; which is then repeated by the Scottish Government when challenged by health boards or local authorities. Then similar issues with third sector and care homes requesting resources from those statutory services; all the way to the bottom. Whilst all this toing and froing takes place, the staff and patients at greatest risk on the ground are not being heard, their needs not met or protected. This is where the actual measure should be on what actions are taking place, not defensiveness or passing the buck; we require honesty and transparent leadership.
This also brings in to view how those workers deemed ‘low skilled’ on the front line being the very ones keeping the country moving. How have we valued those people who are now essential workers? To consider catering staff, drivers, carers, home helps, cleaners, supermarket workers, lorry drivers, porters, refuse collectors and so forth of how valued they felt within respective organisations prior to the pandemic? To now witness Chief Executives and senior management being as engaged with those very staff; whilst recognition is much deserved, you wonder how those staff feel with this new found value?! It is a wake-up call!
What is clear, resources and people on the ground have never mattered as much; therefore, raises the question of the multiple layers of management within statutory institutions and ‘top down’ thinking. The priority on safeguarding systems, opposed to people, can’t return! If ever there was a time where operational needs trump strategic thinking, it’s not about national targets and outcomes but about people and their needs. The onus is on intervening at a community level where people’s needs are met preventing more acute and statutory involvement!! Proactive opposed to reactive; this is the spend to save agenda we talk about! Do those additional resources released, in the fight against the virus for community delivery, serve as an example of decisions being reached from the ground, getting to the heart of greatest need?
Despite relatively recent trauma informed learning, we have failed in addressing the adverse conditions experienced by the most marginalised and stigmatised groups. It appears our approaches reflect public opinion and it’s this that dictates a response from politicians in what is worthy or not? Are votes more important than people? Is this acceptable how society is willing to treat those requiring our greatest support? Will there be an increased level of humility and empathy given the vulnerability being experienced by us all, having little to no control of external factors?
In witnessing the rapid deployment of resources, such as moving people off the streets in to temporary accommodations, is a clear demonstration that solutions can be found, without delay, when there is a will. We have just chosen to ignore, as these unacceptable social conditions have been happening for decades, requiring a pandemic to see action. The NHS historically being risk averse and struggled with change, to now experiencing drastic culture shift in the most challenging of times.
Many have been calling for change for some time though public services being resistant; perhaps through the protectionism of budgets, and a historical culture of being untouchable and not accountable. Commissioning demonstrates double standards where 3rd sector organisations being put through the wringer disproportionately.
Maybe a zero-based budgeting approach is the way forward? Or perhaps considering self-directed support? This doesn’t include all vulnerable groups though is a time for listening to those people and communities in what they wish services and opportunities to look like?
Human rights has come into sharp focus, which does question how the most vulnerable having their basic rights respected and the quality of care on offer. We have chosen to be judge and jury with a hierarchy of the deserving and whose needs are important. A society who demonise, marginalise and stigmatise.
What does this new world look like? Will there be a relinquishing of power where those resources are embedded on the ground, with a strong commitment to scaling up what is working? We need to consider underlying issues and needs of society being affected with mental health, physical health, financial, trauma, and relationships where people can find purpose, meaning, hope and occupying time? Will we still operate within silos where people require manoeuvring the often complicated and unhelpful services? Will public policies get together to reflect multiple needs? How do we hear the voices of those most affected? Every policy must see the individual and protecting the rights of everyone without discrimination. To consider the Nelson Mandela quote ‘Stigma sometimes is more dangerous than the terminal disease itself. Because you can cure, you can fight, & live as long as possible with assistance of drugs, but a stigma, it destroys your self-confidence.’
Whilst more recently there has been a greater appreciation in the services provided by the third sector; it is important recognising this framework is far from a level playing field. For example, the larger ones having become an extension of those statutory services for some time. This may be a convenient arrangement for services though we must ensure any resources are meeting needs and providing value for money. In addition, the third sector interface model must be reviewed in how effective and representative they are of the sector in each locality? How does community planning consider those wider assets?
Will there be support for those smaller projects, with a level of financial security, where they can concentrate on providing the most effective service, opposed to constantly chasing pockets of funding; and all the effort this entails whilst feeling inadequate when these are unsuccessful, competing against national organisations who have dedicated resources to generate additional income. I wonder if funders would show courage through reducing the many barriers where the focus is on quality and not quantity, offering fresh ideas and perspectives!?
It has required a global pandemic highlighting the frailties within public health systems and appropriate resources being required at the ‘coal face’. If we want change, we should be scaling up what works through more courageous leadership. If there are clear gaps not being addressed, those projects offering solutions should be embraced, not dismissed!
Who is it deciding what is worthy or not? Do providers in receipt of steady funding really want change and to rock the boat? Or do local politicians want the change that may highlight inadequacies? All valid questions requiring further exploration!?
These suggestions are certainly not straightforward, requiring strong leadership by those with no hidden agendas or conflicts of interest, as there will naturally be a large degree of self-interest and maintaining the status quo, regardless of what must change and doing the right thing for the greater good!