Effective Leadership, Management and Supervision in Health and Social Care

Richard Field,Keith Brown

• Publisher: Learning Matters
• Year: 2019
• ISBN:
  9781526468376
• Edition: 3
• Topic: Social Sciences
• Subtopic: Social Work
• Index: Social Sciences

This book offers a practical introduction to the areas of leadership, management and supervision for line managers, supervisors and senior practitioners working in health and social care settings. The authors explore different aspects of leadership and management, including personal effectiveness, supervision, strategic thinking, commissioning, planning and budgeting and leading successful teams.

This third edition also includes new chapters on leading services and care for older people, leading the workforce for health and social care services for older people and developing collaborative skills. There is also increased coverage of healthcare leadership and asset-based commissioning.

Chapter 1 Context

Keith Brown

Richard Field

Chapter outcomes

As a result of completing this chapter you will:

• Be aware of key features of the current health and social care context within which leadership, management and supervision are practised.
• Appreciate some of the significant pressures experienced by managers working within health and social care.
• Understand what, in our view, are the key challenges facing those leading and managing health and social care over the next few years.
• Understand how our sense of the environment, pressures and challenges has influenced the focus of this text.

Introduction

This chapter starts with a brief overview of the current context within which leadership and management in health and social care is practised and how this might shift over the next five years. A summary of key pressures and challenges facing leaders and managers is identified and implications are outlined. The chapter concludes with an explanation of the editors’ responses within this text.

Overview of the current and likely future context

The public sector in general – and health and social care in particular – are facing what is probably the most difficult time in their long history and it is easy to paint a dark picture of the future. Within the next five to ten years, difficult conversations need to be had, decisions made and actions taken, if we are to avoid the collapse of health and social care services as we know them.

However, another view is that this is a period of unparalleled opportunity, a time when we can really think about what good health and social care looks like and challenge long-held assumptions, traditions and practices. We believe we will look back at the period 2008 to 2020 and see this as a pivotal point in the history of health and social care – the time that an old, broken paradigm was abandoned and a new, better one emerged.

A journey is underway which will see immense change: a different deal between the state, individuals and communities, greater individual and community self-help, more equal relationships between practitioners, service users and patients, and a reduced and different role for the state and for those working in and alongside the helping professions.

This period is, and will remain, potentially difficult for those leading, featuring as it does considerable uncertainty and turbulence. Already we are seeing transformation at community and organisation level, or at least waves of change and new initiatives, some of which work immediately, some will work but only after considerable revision while others need to be abandoned. We are reassessing the value of what health and social care professionals have been doing for many years. Personal and professional beliefs and values are being challenged leading some managers to question whether they are still attracted to health and social care. We are seeing a shift in sources of power, status and reward.

The current context for health and social care features a significant number of forces that are driving this transformation, including the following.

Demand for services

The need for health and social care is increasing, particularly for the older population. The United Kingdom had a population of 65.6 million in 2016 (ONS, 2017) which is predicted to increase to 69.2 million in mid 2026. (ONS, 2017). In 2017, nearly 12 million or 18.2 per cent of the UK population were over the age of 65 (ONS, 2018), a percentage that is expected to rise to 20.7 per cent by 2027 (ONS, 2018). In 2016 there were 1.6 million aged 85+, a figure that is expected to double by 2041 (ONS, 2017). Life expectancy at the age of 65 currently stands at 85.9 and 83.4 for women and men, respectively (Age UK, 2019).

In England both sexes after the age of 65 can expect to be in good health for only 60 per cent of the rest of their lives (Age UK, 2019). Morbity increases with age with ‘the over 80 age group experiencing twice the morbidity rate of the 60–64 age group which is in turn twice that of the 20–24 age group’ (GOV.UK, 2017). Many diseases increase with age including back pain, neck pain and neurological diseases such as dementia and diabetic neuropathy.

The increasing number of elderly people is causing considerable financial pressure on health and social care. In health care terms alone, compared to the cost of looking after a 30-year-old, it costs three times more to look after a 75-year-old and five times more to look after an 80-year-old (NHS, 2017). Of 18.7 million hospital admissions in 2014/15 around 7.6 million were over the age of 65. This age group makes up 23 per cent of all attendances at accident and emergency departments (Age UK, 2019).

The impact on social care is significant but somewhat less visible due to the very high level of self care and informal care provided by family, friends and neighbours. Approximately 15 per cent of people over the age of 85 live in residential care homes, part of a wider care home residential population of 421,100 people aged 65+ (Age UK). Sheltered housing and owner-occupied retirement housing accommodates a further 5 per cent of the older population (Age UK). Given that 73 per cent of people living in care homes do so for less than three years, a very significant number of older people live independently in the community and until the very last stages of their lives (Age UK).

Resources

Increases in need and demand come at a time when the health and social care system is facing financial difficulty. In November 2017 the King’s Fund stated that total health spending in England alone would need to rise to £153 billion by 2022/23 to maintain standards of care and rising demand. However, at the same point total healthcare spending was expected to be £128.4 billion, a shortfall in excess of £20 billion. In the same joint statement, the authors concluded that ‘social care remains on the brink of crisis’, with an estimated funding gap of £2.5 billion in 2019/20.

The 2018 Budget brought some relief for health with the announcement of a further 3.4 per cent of real terms funding per annum meaning £20.5 billion extra money going into health by 2023/24. Sadly, this commitment does not extend to social care although there have been a number of relatively short-term cash injections for this sector (King’s Fund, 2018).

It is highly likely that the health and social care sector will continue to operate in a difficult and uncertain financial climate. While it may be the case that more money will be available, it is highly unlikely to be sufficient. Demands for greater economy and efficiency will continue, while at the same time the scope for this is reducing. A point will soon be reached where financial deficits will grow, taxes may have to increase, deep cuts may be made or more radical ways found to deliver the outcomes wanted by communities.

Changes to pensions, including the age at which payments start, will prove problematic for individuals who are physically or mentally unable to work in their later years and will, therefore, be forced to run down savings as they wait for pensionable age. As a result, the capacity to self-fund care later in life will reduce, particularly where the person is remaining in their own home. This may well lead to more significant health and social care needs arising earlier than would otherwise be the case, thus increasing demand on the state sector. The potential implications of ‘Brexit’, the financial health of the residential care market and pressure on provider costs due to rising staff costs pose significant problems for commissioners.

Legal, political and professional

Since 2010, there have been a number of key political and professional developments in health and social care, notably the Health and Social Care Act 2012 and the Care Act 2014, the former of which reorganised the health system, in particular introducing Clinical Commissioning Groups. The Care Act 2014 clarified responsibilities and standardised aspects of how social care takes place.

Primary care, which provides over 300 million patient consultations per annum (NHS England website), is currently experiencing significant change, including action to boost GP numbers, extending evening and weekend access, expansion in multidisciplinary care and the formation of Primary Care Networks or ‘hubs’.

There is a growing recognition of the need for greater joined-up working. The Next Steps on the NHS Five Year Forward View (NHS, 2017) reported progress in integration called for in the 2014 NHS Five Year Forward View. Early results from areas that have integrated GP, community health, mental health, hospitals, home care and care homes include slower growth in hospitalisations and less time spent in hospital, particularly among people over 75.

Over the last 30 years or so, much local authority direct service provision has reduced, and in many cases is now close to zero. Compulsory competitive tendering, outsourcing, the creation of social enterprises and various ‘arm’s length’ arrangements have been used to reduce internal provision. In health, there have been similar movements towards using the private sector but these are more modest and there remains significant internal provision. Commissioning, which should not be confused with procurement or outsourcing, is currently the main role played by public sector organisations with provision increasingly seen to be a private or voluntary sector matter. The capacity to deliver, therefore, increasingly rests with organisations that are subject both to commercial and public sector environmental influences. Commissioning organisations are increasingly taking a whole-system approach to delivering outcomes, collaborating with other statutory bodies, commercial and third-sector organisations together with communities and citizens.

Integration of health and social care has been encouraged and supported through the Better Care Fund, the formation of Primary Care Networks, Alliance Contracting and, in 2018, the bringing together of health and social portfolios at ministerial level. The voluntary and community sector which suffered significant reductions in state funding during the recession is now seen as a significant resource to the statutory sector and a way of bringing citizens into the care system as assets. The last few years has seen significant efforts to give patients greater involvement, freedom and flexibility in their treatment and care, examples of which include the choose and book system, personal health budgets in health and direct payments and personal budgets in social care. At the same time, patients in particular are being encouraged to take greater responsibility for their own health and well-being through self-management of conditions, which together with social prescribing are potentially important ways of producing better health and social care outcomes for patients and clients while at the same time reducing demands on the primary care system. Developments in commissioning are proceeding in the same direction, recognising that health and care outcomes can often be realised through a variety of means of which providing traditional services is only one. There is renewed interest in prevention and, more importantly well-being, nudging citizen behaviour such that the onset of conditions is avoided or at least delayed. Increasingly, health and social care organisations are seeing individuals and the communities in which they live as assets – initially as a way of replacing state-funded resources as, for example, through the use of volunteers. This approach is part of a more significant move towards asset-based commissioning where practitioners and service users collaborate as equal partners to co-identify the assets in a community, the outcomes desired and the chosen way of meeting these, through self-help, the use of community assets and the deployment of state resources.

There are a number of implications associated with these drivers – greater numbers of people living for longer with more advanced health and social care needs which, to a considerable extent, will be met in the community, delivered by the lowest possible paid members of staff or by volunteers. This poses a number of questions about the quality and consistency of care, for much of this will be done unobserved and unmonitored. There are currently 3.6 million people over the age of 65 who live alone, within which two million, are aged 75 and above (Age UK, 2016: 23). The level and range of risks to which these older, frail and often confused patients is exposed is considerable and increasing, with financial scamming added to physical, mental and emotional abuse along with high levels of malnutrition.

Indeed, current research undertaken by the National Centre for Post Qualifying Social Work and Professional Practice suggests that financial scamming of vulnerable citizens is far more widespread than previously thought and that its impact on the health and welfare of its victims is very significant (Olivier et al., 2016).

In order to manage the scale of the problems and issues, health and social care services will need to move away from ‘silo’ mentalities and work even more closely to meet the needs and protect the vulnerable. This will require clear leadership to challenge and change ways of working that put the interests of citizens at the forefront, not the agency.

Opportunities

It is easy to see the various drivers negatively, that they will forever harm our way of life, that we will never have it so good again, to coin a phrase. However, this view suggests that currently, everything we have by way of services or support is perfect, that the real needs of individuals are met and that all of this occurs in a cost-effective manner. The truth of the matter is that many of the services traditionally provided have not worked, or at least have not worked as well as they might. The largely deficit approach, whereby professionals determine needs on behalf of individuals or a group and then respond to these by designing, funding and running a service is myopic and needs to end. This approach successfully turns patients and service users into passive recipients that become increasingly dependent on provided services. A radical rethink is underway, with a growing realisation that individuals and communities have assets that they could contribute to achieving the outcomes that are important to them, with an associated shift for the role of the state in supporting individuals to engage in the commissioning process. This will bring hitherto un-thought-of resources into the commissioning process and allow state resources to be better utilised in helping individuals and the community achieve desired outcomes. Being active in contributing to achieving outcomes for self and others is of itself beneficial.

Key pressures

The current context exerts considerable pressure on the health and social care system and of course those that lead and manage health and social care organisations or services. In our work with individua...