Future options for the NHS

Notes from a Health Matters seminar at Kings College London  March 1^st 2013

Steve Iliffe from Health Matters with help from SHA organised the seminar with academics, senior health managers and clinicians

Near future:  In the run up to the 2015 general election, the NHS is likely to have:

• A large part of community services (and some hospital services) provided or managed by the private sector. Mental health services, of which 30% are currently provided by commercial or third sector organisations, are the shape of things to come.

• Clinical Commissioning Groups struggling with rising demand and expectations, and shrinking budgets, with limited powers. Some CCGs will manage these pressures better than others, perhaps changing general practice as they do so, but others will fail to develop services or balance budgets.

• Increased central efforts to manage (and micro-manage) the NHS, and promote service integration. Provider flux and unachievable targets will undermine these efforts, and top-down management will fail more often.

• More public engagement with the NHS agenda, through both official channels (Health Watch, the Health & Wellbeing Boards) and unofficial ones (campaigns to preserve existing NHS resources & services). The tension between bottom-up accountability and political accountability will increase tensions within the NHS.

• Further shrinkage of publicly-funded social care. Individuals managing their own social care by using the benefits system will be challenged even as political rhetoric emphasises personalisation and personal budgets.

• Instability in the hospital sector, particularly where there is PFI debt. This instability will also arise because of inability to respond to social and demographic changes (more very old, fewer carers), inherent inefficiencies in hospital organisation, plus declining staff engagement, motivation and confidence. The divide between DGHs and teaching hospitals will widen, and 50 or so Hospital Trusts will not achieve Foundation status.

• Persistent variability in the quality of general practice, with a low skill base and poor organisation being widespread.

• Growing interest in the importance of individual responsibility for health, and family and friends being seen as essential support for those in hospital.

Immediate problems:  The Health Matters seminar identified 10 problems that a Labour government elected in 2015 would need to address (but not necessarily solve) over a ten year period.

1. Funding constraints, prompting not only smarter working but also reclassification of PFI and other historic debt as “toxic” so that it can be managed differently.
2. Generic challenges (common to all health services in industrialised societies) including social and demographic changes, system obsolescence, unwarranted variability in service performance and outcomes, increasing expectations and intolerance of poor quality, and resistance to innovation. These trends suggest that general practice and DGHs are no longer workable, as currently organised.
3. The separation of mental health services from other services and their fragmentation by out-sourcing.
4. The variability of quality of care in general practice, its limited skill set and poor level of organisation, and the lack of NHS leverage over it.
5. The fragile means tested/privatised economy of social care, and the commonly poor working relationships between the largely commercialised care home sector and the NHS.
6. A historically weak political culture around the NHS, in which change is seen as a threat, and a deep democratic deficit, in which the public is excluded from NHS decision-making. There is a need for a mature political dialogue, but the mechanisms for it need to be established first.
7. Public health has been marginalised just as the social determinants of health and illness become clearer than ever.
8. NHS management has been re-organised too often, and has lost a great deal of experience and its collective memory. The decay of leadership means that the cadre of management needed not only to stabilise the NHS but also to promote organic growth within it, is weak.
9. Quality of care in the NHS is undermined by rapid and repeated organisational changes, a narrow focus on targets and the decay of leadership (amongst clinicians as well as managers). Perceptions of the quality of care manufactured by those hostile to the NHS.
10. Power in the NHS is dispersed across the health economy, without commensurate accountability across different centres of power, especially those in the commercial sector.

Future options:  An incoming Labour government in 2015 could centre its policy towards the NHS on a response to the generic challenges, from two angles.

First, a balanced economy of health care should contain incentives that promote prevention, reinforce holistic care, and reduce reliance on hospitals. This will probably require some combination of hospital and community services with lead commissioners and shared or programme budgets as possible funding mechanisms, but in most situations combination will not be achieved by merger. It is likely to require the abolition of the Quality & Outcomes Framework in general practice, and of Payment by Results.

Second, the key attributes of a service that meets needs can be defined in terms of:

• The forward application of expertise (the most experienced in the frontline, in hospitals and community services – including out-of-hours services).
• Training in the management of uncertainty at all levels of the NHS to reduce patient referral/hand-on and ‘buck passing’.
• Engagement of the public in NHS decision-making, and the NHS in community development, as a precondition for continued funding, with emphasis on increasing the power of ‘voice’ through use of social media.
• The promotion of generalism (a holistic approach) in community and hospital services.
• Making the maintenance of relational confidence between disciplines the primary task of NHS management.
• Establishing single budgets and shared financial accountability as the norm across community and hospital services, along with a single outcomes framework, and funding mechanisms aligned to desired outcomes.

In 2015 a Labour government could promote the development of local services spanning community and hospital practices, similar to Kaiser Permanente-type health maintenance organisations, but without driving their growth using market mechanisms. The exact mechanisms for governing these local services should be the subject of natural experiments (because we do not yet know the optimal mechanism), changes can occur slowly and the new services can evolve over time. Such changes could occur within existing legislation, once section 3 of the Health & Social Care Act has been repealed.

Engagement of the NHS with community development, the wider public involvement in the NHS that seems likely to occur, and the evolution of local integrated services will push the NHS towards becoming part of local as much as national government. This shift in accountability and governance will also be slow and incremental, with no system wide re-organisation by decree.