Francis set out an excellent analysis but sees solutions through fixing the current system – more regulation to address the comprehensive failure of regulation. It resonates with the mantra that more markets can address the fall out from the comprehensive failure of markets. By implication it accepts that with better regulation the force of markets and competition unleashed by the Health and Social Care Act will bring the changes over time (a very long time).
Our analysis for the SHA was that the 1948 model of the care system and the health/social care divide is fundamentally wrong and structural or regulatory fixes are no longer appropriate. The extreme end of the issues around caring for growing numbers of frail elderly were illustrated at Mid. Staffs. The NHS was never set up to deal with their long term complex mental, physical and social needs. The requirements have changed but the organisations, attitudes and behaviours meeting them have stood still.
Our view is more radical; bringing in whole person care, a label to summarise a system designed around the needs of people rather than organisations or vested interests; building on socialist principles. We need to bring together the disparate strands of mental health, public health, physical health, and social care. We must change the way clinicians, managers and other staff are trained and developed so they are comfortable with sharing decisions making and information with patients. Care has to be part of a comprehensive network of public service not with the NHS as a separate empire. We must have openness and accountability with shared decision making; regarding people and communities as assets so we are all part of the solution not the problem.
We know how large that shift will be and we also know it is constrained as a) there is no money b) there can be no more top-down reorganisations and c) we have to untangle the marketisation and reverse some of it within a market economy.
So some simple observations.
Faith. We have unleashed a further round of NHS bashing but our free at the point of need, mostly publicly provided, general taxation funded model is as good as any in the world and if we allow the Coalition to break it we will be sorry.
Time. We need fewer recommendations and more of a Plan. A Ten Year Plan built on the widest consensus and the best evidence, with a year for consultation and a year to plan and mobilise before we just launch into change.
Voice. Ten years ago analysts like Julian Le Grande dismissed the power of “voice” and opted for “markets and competition”. (Trust and targets and terror were also discounted.) Well the new technologies and social media have turbocharged voice, so voice is the new super power. We must give voice to patients through Shared Decision Making, voice to communities through Community Development and voice to us all through our democratic framework. We must free up the information at every level and open up all communications channels.
Staff. There are endless volumes and articles about how you can manage better than they did within Mid. Staffs. But advice is contradictory and evidence light. The only thing we appear to know for certain is that organisations which have a better relationship with their staff perform better. Staff engagement is the best predictor of good patient outcomes. We need enough staff, well managed and motivated and feeling valued.
Accountability. We have just learned that nobody is accountable; or rather everyone is a little bit accountable. The NHS is terrible at accountability. Cronyism and bullying are protected whilst whistleblowers are treated as criminals and innovation in the NHS is deviant behaviour. We can make a start by enforcing openness and transparency on all commissioners and all providers with no hiding behind Part 2 or commercial confidentiality. And we could do far more to make Foundation Trusts and Clinical Commissioning Groups open to accountability through genuine public and patient involvement.