Reforming Me: moving from listening, to hearing and believing

There are two particular words that will bring a sense of dread to those who have worked in health and social care for more than 10 years – they are ‘NHS Reforms’ – more of which later. However, in yesterday’s papers, there were other words that might also bring a sense of dread to many – front and centre of the FT Weekend were the words ‘Parents fear post-Brexit immigration system will spell au revoir for au pairs’. It was a clever headline, and one that I think which gave a slight nod to the somewhat cliched idea of the au pair having a relationship with the man of the house. What I didn’t know was just how many folk employ an au pair. It is estimated that over 45,000 families in the UK rely on au pairs for affordable childcare. I have to say, I’ve never ever thought about getting an au pair, childcare was the responsibility of one of the parents, grandparents, or whatever childcare setting you could afford to put your child into. Usually, in my day at least, it was a combination of all three approaches.

EU free movement ended this year. As such, au pairs who are designated ‘skilled workers’, now need to earn the minimum salary of £20,480 to qualify for a working visa in the UK. The consequence for families, (most of whom on average pay £100 a week for an au pair) is that they need to now pay about £180 a week. That is £180 a week plus board and lodging to provide around 25 hours of childcare a week. Currently the average cost of 25 hours in a nursery is around £131 a week, and there is no risk of the husband having an affair with the au pair either. What I also didn’t know was many of those 45,000 families who use au pairs are also nurses, doctors, policeman and other key workers. As I don’t think the Home Office are likely to change their minds over this, these changes are one more challenge for already hard-pressed key workers to address.

Many of these same people have been left exhausted, anxious and, in many cases, facing psychological harm going forward. What must they have felt if, like me in search of today’s news, they logged onto the BBC News website to see the words ‘Government plans to reverse Cameron NHS Reforms’? The headline refers to the Andrew Lansley reforms implemented in 2012 under David Cameron’s coalition government. There is nothing worse for health care folk to hear than the NHS is yet to be reformed once more.

The new proposals have been quietly socialised over the past 12 months through various ‘consultations’. These consultations have always seemed to me to have been carefully worded, so as to give rise to the outcomes the authors wanted to achieve. It was the ‘other’ Times that shone a light on what these reforms were all about: ‘Ministers to seize control of the NHS’. It sounded like a side story to the military coup in Myanmar and just as dreadful. One of the proposals is that the Secretary of State for Health would regain control and responsibility for the NHS rather than, as is the case now, NHS England.

Now that sounds like a great idea doesn’t it? The new reforms would make it possible for the Secretary of State to change NHS priorities more often than at present, and give more direct orders to the good folk at NHS England. We have seen (and felt) the consequences of such an approach in this government’s handling of the pandemic. Alongside this, Clinical Commissioning Groups (CCGs) are set to go. They currently control some £85 billion of health spending, but often indulge in some of the most bureaucratic approaches ever witnessed – well at least outside of a Handforth Parish Council meeting that is.  However, CCGs are GP-led, and taking their power to commission healthcare services for their patients away doesn’t seem a particular great way of keeping them on board.

If I’m sounding a little pessimistic, I don’t mean to be. There are many important changes in these reforms. Taking the decision making power away from local councils over whether to put fluoride in drinking water or not is one such example. This would greatly help improve child dental health. Tackling obesity in more direct ways is another. Obesity has proven to be a major contributor to the many of the 110,000 deaths from Covid the UK has seen. The creation of statutory Integrated Care Systems and doing away with the requirements for competitive tendering will be key in ensuring we are able to build upon the best of the innovative ways of working to have come out of the pandemic. Collaboration is key. What the pandemic has shown, in so many ways, is that when local health and social care organisations come together to find workable solutions to new problems, they will succeed in ways that up to now might have been thought impossible.

There is a however, in all of this though. A cautionary note that au pairs and families who employ them will be very aware of. The idea of an au pair is that they become part of the family. This can give rise to boundary confusions (and I’m not just talking about affairs with husbands). On one hand they will witness all our odd habits and behaviours, probably see our arguments and disagreements over who left the lights on or the toilet seat up yet again. On the other hand, they are a valued and welcome member of the household, who is entrusted to look after our precious children. But they are a paid employee, a stranger whose co-operation, loyalty and discretion we are essentially paying for.

Where the arrangement works well is where each party learns not to just listen to what the other has to say, but hears what is said, and most importantly, believes what is being said. We have seen much erosion of trust during the pandemic. A loss of trust in our political leaders, in the science, and the transparency of commercial decision-making to name just a few. If the proposed reforms are to succeed, then we need not only to rebuild trust in these areas, but find ways of building and maintaining trust across the new organisation forms. To do that we have to listen, hear and believe what others are saying, and in so doing create a shared vision and purpose.