The Contribution of the Bengoa Report to Health and Social Care
Derek Birrell, Professor in the School of Criminology, Politics and Social Policy at Ulster University and author discusses the interpretation of Professor Rafael Bengoa’s recommendations into an action plan for health reform.
The Bengoa report ‘Systems not Structures’ was established to report on the best configuration of health and social care services. The expert panel had identified a major disadvantage when it stated that adult social care was not to be the focus of the report and the Department would deal with this separately. This seemed misguided given that Northern Ireland has had structurally integrated health and social care since the seventies. The system is called Health and Social Care (HSC), not NHS Northern Ireland, unlike NHS England, NHS Scotland, and NHS Wales. The promotion of integration has become a major policy priority throughout the UK, supported by new legislation, new delivery systems, structures and funding. The Bengoa report stated that health and social care were closely related and social care provision directly affected hospital admissions. In practice the report went on to make extensive comments on the role of integrated health and social care, noting that it had not worked or been exploited as it might have been.
The Bengoa panel applied the two conceptual frameworks to their analysis. The first, the triple aim, is drawn from a threefold typology of: population health; experience or quality of care; and the per capita cost or value for money. The second framework is described as a local accountability care system. Within these frameworks the Bengoa report discusses a number of issues drawn from modernisation agendas and produces 15 recommendations, although these tend to be expressed as general principles and guidance rather than as precise recommendations for reconfiguration of services or governance or structures.
Some of the recommendations point in a radical direction of change, while others are not so clearly explained. Workforce development is seen as a key issue and a radical approach is taken advocating the necessity of breaking down traditional barriers to develop coordinated care, with the integration of health and social care permitting easier transferability of staff and skills. While supporting the transfer of provision to out of hospital care the report notes the financial implications and states that the system requires a 6 per cent budget increase each year even to stand still. Cooperation and user participation is also strongly advocated, with Northern Ireland starting from a low base, although there is some confusion in the report between user participation in decision making and self-management. The idea of local system accounting is discussed at length but the detailed implications for organisation and delivery remain vague. The Bengoa report is called ‘Systems, not Structures’ but arguably structures are crucial for implementing some of the recommendations on integration, co-production, local accountability, commissioning and delivery.
The Bengoa report was followed by a ministerial statement and a 10 year plan for health and wellbeing. Prominence was given to actions not included in the report, dealing with waiting lists and placing a social worker in each GP practice, a perhaps outdated idea, plus ideas on children’s care services, community pharmacies, and elective care centres. There appeared little understanding of Bengoa’s ideas on shared staff development, with only proposals on GP and nurse training, and virtually no mention of co-production or local accountability care system. It had been anticipated that there might be recommendations on the reconfiguration of hospitals but the report stated that the work was not about closing hospitals but about changing ways of meeting needs. The Department of Health set up a consultation on what was called criteria for reconfiguration of health and social services. This was based entirely on a set of seven criteria from the Bengoa report produced for assessing the sustainability of services. These criteria receive limited discussion in the report. An assessment of unsustainability does not necessarily imply reconfiguration and to put reconfiguration seems to be a misleading interpretation of Bengoa.
Derek Birrell has authored: ‘Transforming Adult Social Care’ [2013] Policy Press, with Professor Ann Marie Gray and is set to publish ‘The Integration of Health and Social Care in the UK’ Palgrave, with Professor Deirdre Heenan, in 2017.
