Repeal of the reviled Health Act 2012 cannot be an end in itself. An alternative vision is needed for an integrated care system. We set out our ideas from a left of centre perspective.
We need proposals with the kind of support enjoyed by the 2000 Plan, taking time for genuine consultation, planning and mobilisation before implementation. A period of structural stability should be used to focus on behavioural and cultural changes.
The clinical professional bodies should decide how they can adapt their practices, training and professional development to meet the new challenges. They have also to confront some of the messages from the various enquiries which show that their role in ensuring high standards and enforcing best practice is inadequate. We also need a clear steer from clinical professionals about how to deal with the contentious issues around service reconfiguration and hospitals.
We have to clearly establish our support for an alternative to the regulated market not just because regulated markets are seen to be failing but also because our ideology is for an NHS based on social solidarity. The provision of care is a public service rooted in public service values.
There is little or no evidence to support marketisation as the main route to improving quality. Use of market forces reduces patients to the role of shoppers when the real need is to engage patients in their own care, engage communities in the wellbeing of their locality and making all key decisions within the system subject to proper public accountability and democratic control.
These are our ideas about principles – once these are established then thought can be applied to structures and funding.
A National Public Service
Improving health requires addressing the social determinants of poor health based on the principle that there is a role for an interventionist state, for redistribution of wealth and power, and a role not just in planning and commissioning but in delivery. We need a collective approach; a managed system.
We require national standards, national service frameworks, national outcomes frameworks and inspection and regulation on a national basis; and national terms and conditions to allow staff to move easily within the NHS. We already have national systems for collection of data and an obligation on all providers to supply that information.
But it’s a NATIONAL public service shaped by the common requirements placed upon it, not shaped by market forces. So far as makes sense, the service you get does not depend on your economic status or on where you live.
Whole Person Care
Many patients have multiple complex needs, few have a single episode of care, and we need a system which recognises this. Social care, physical and mental health, must work together in the patient’s interest, offering “integrated care”.
Patients should generally be able to agree care plans to meet all of their needs. A personal budget may be suitable for some, but clearly not for all. We need to ensure that patients have access to all data, GP, hospital and social care and that this record becomes a portal to a range of interactive personalised information.
Personal Social Care
Additional funding for social care is necessary to raise the quality and professionalize the workforce, with decent pay and conditions and a return to public provision where necessary: if not good integrated care will be impossible. In the longer term personal social care should be free since, as with healthcare, the risk of uninsurable and unpredictable high costs requires social protection. Integration will bring longer term savings, but the net additional cost has to be met through progressive taxes. A start can be made by meeting all costs above a certain limit and making care free for some, such as those who have disabilities.
Patient choice but not shopping
Patients should be offered informed choice about the treatment options open to them. They should be able to choose which NHS venue they attend and to select the appointment that best suits their needs. This is not choice as a market mechanism and there may be some limits in the interest of overall efficiency.
Enhancing the role for Public Health
Whole person care is about prevention as well as optimum care so we need to reinforce the value of a public health led approach to dealing with the social determinants of poor health. Public Health professionals should have a seat wherever key decisions are being taken.
Proactive Primary Care
Desirable changes to bring care closer to home and to place emphasis on early intervention and prevention require investment and major changes in primary care to make it far more pro-active.
There is evidence that the quality of primary care varies inappropriately and so a focus on improving quality is essential. There is potential in harnessing IT, in task-shifting and in involving patients in planning and self-care. These need supporting and coproducing.
The commissioning and management of primary care services should be undertaken locally and not be a remote national body.
Evidence shows community development in health is a key intervention that will benefit communities, particularly if “wrapped around” GP Practices.
The current design of primary care based around GP Practices may be inadequate to meet these challenges. Small businesses run for personal profit may not be the best vehicles for a strategic approach to improving quality and taking a proactive approach to health care for individuals and communities. Ensuring progress needs an appropriate structure and processes for overseeing quality and inspiring primary care.
Sharing the Power
Healthcare still relies too heavily on individual expertise and expensive professional input and patients and users want to play a much more active role in their care and treatment.
Embracing Community Development (CD) and Shared Decision Making (SDM)
Communities should be involved in the planning and commissioning of their services with a major say in how to improve the health of their locality.
We should make involvement in our individual care a reality by embracing shared decision-making and self-care; through pre- and post-graduate clinician training, making tools and information available and by changing the culture of the consultation and the relationship between patient and clinician.
Giving elected representatives powers over commissioning
In a market resources are allocated by market forces but in a public service allocation is based on judgement, supported by professional advice and sometimes even evidence. Those who exercise these judgments ought to be accountable to us; and they must be seen to be free from any influence by private (and public) providers.
There must be one single democratic body which oversees the whole of the strategic commissioning of services for a locality – usually a tier one local authority area, although they may delegate to more local bodies.
We need to harness data in two directions. Data on performance must be made available to users of the NHS in an intelligible form. This will drive improvement, partly through peer pressure and peer competition, but also by users driving change through informed criticism.
In addition, users need to be able to easily push data on their own experience into the NHS. As in so many other areas of service, this will also drive up standards.
Allowing earned local autonomy for NHS providers
The current model of Foundation Trusts as NHS providers brings some autonomy and a sense of local ownership, with freedom from top-down performance management, but too many FTs are remote from the NHS. To avoid further reorganisation we have to make the governance model work and give Governors a stronger role – for example with the ultimate say over the level of private income.
The other major type of provider is the GP Practices bound into the NHS by contracts but with considerable autonomy. We should look at other models perhaps with more directly employed GPs and encourage all practices to adopt what the best already do in terms of patient and public involvement through local groups.
Removing organisational barriers to integrated care
Organisational definitions which separate social care from health care and also separate mental health care from physical health are all unhelpful to the patient. We should introduce incentives for joint appointments, joint budgets, collocation, information sharing, and shared services across the NHS and local authorities. Initiatives such as “year of care” and “programme budgets” must be encouraged to incentivise joint working.
We already have a requirement for a strategic needs assessment and for a wellbeing strategy for each tier one local authority area, so an integrated plan for commissioning across all public services follows.
Encouraging development of integrated providers as a “local” NHS
The “market” approach is fragmenting provision and creating a hugely complex web of organisations linked by legal contracts, adding significantly to transaction costs. We should at least have a large scale trial with a fully integrated provider which covers delivery of all primary, secondary, mental health and social care, for a single County or City. This should make reconfiguration of local services easier and save a significant proportion of the overheads associated with the quasi market.
Using competition and private providers within a managed system
The NHS should be defined as a single national system set up on the basis of social solidarity and all relationships between commissions and NHS providers should be within the NHS and not the subject of legally enforceable contracts. While there are no contracts there can be no intervention through competition law.
Where a commissioner is unable to secure provision of the necessary service from an NHS provider to the required level of quality then they would be expected to look beyond the NHS and run some form of competitive process. The additional risks associated with using private providers should be taken into account.
Commissioners would be expected to test the quality and efficiency of all services on a regular basis to be able to demonstrate value for money.
Protecting from vested interests – separation of planning functions
The “commissioning” functions around needs assessment, the planning of services, the setting of required standards, ensuring continuity of provision, and the monitoring of performance and quality have to be done somewhere. These should be separated from provision to prevent undue influence by the dominant NHS acute providers and to prevent conflicts of interest. There has to be some independent strategic layer that allows resolutions of the wicked issues like reconfiguration where there will be winners and losers.
Making the Change Happen
Even under current legislation there are considerable powers of intervention and the ability to issue guidance or make regulations. The system is just a framework and everything depends on the approach of the political leadership and of those put in the key positions by the politicians.
New organisations within the current architecture can be made to work in different ways fostering cooperation and integration rather than overseeing competition. Greater accountability, openness and transparency can be directed. Licensing can work for patients rather than for organisations and regulation around quality and probity can replace regulation for competition.
Any approach to making changes must be evolutionary and would entail some system modifications such as:-
- Having a long term Plan for care built on a wide consensus.
- Restoring unambiguously the power of the SoS to direct and to intervene in any part of the NHS
- Convergence of health and social care through:-
- progressive introduction of free personal social care
- a single assessment process which is national and portable
- incentives to share staff, facilities and services between LAs and NHS bodies
- Using a licensing system to restrict unsuitable providers and enforce the requirement to supply all necessary monitoring information
- Move towards a single regulator/licensee for quality and governance
- Removing any suggestion of promoting competition or compulsory tendering of services and ensuring there is a sector specific set of rules covering the use of cooperation and competition.
- Moving responsibility for price setting to DH/NCB with flexible alternatives to a fixed national tariff price.
- Require HWBs to produce an integrated commissioning plan to support the local wellbeing strategy and to sign off commissioning plans.
- Giving Clinical Commissioning Groups a proper Board with majority of appointed NEDs; ensure all have sufficient scale to function independently
- Moving the commissioning of primary care service to local CCGs
- Ensure an independent and adequately funded Healthwatch.
- Encourage convergence of HWBB and CCGs into local commissioning authorities (as suggested by Health Committee).
- Bring back the Private Income Cap, agreed locally by governors and with an overall limit which can only be exceeded with approval from SoS.
- Allow FTs and commissioners to sign NHS Contracts, which are not legally enforceable and so outside scope of procurement competition law.
None of the above implies major structural reorganisation. The changes would adapt the current structures but move away from the market regulation architecture and towards a public service approach which gives space to address directly the cultural and behavioural issues that are central to genuine reform.
Dr Brian Fisher Chair Socialist Health Association
Richard Bourne Vice Chair Socialist Health Association