1. Introduction
With a general election less than 2 years away, what health policy options – and limits – would a Labour Government face? What should they prioritise? What could they afford?
This paper summarises views from a Socialist Health Association meeting in Bristol on 27 June 2013.
2. Context
There are three key points here. First, the financial context for the NHS. Described charitably by some as ‘flat cash’; in practice, this is failing to keep pace with the financial demands of an ageing population and medical technology, estimated at 3% annually. The £20bn national NHS efficiency target is likely to become £50bn by 2016/17. Together, these will require a greater focus on releasing value from the significant extra resources put into the NHS under 13 years of Labour.
Further focus will be needed on reducing variability, containing overall pay spend, and improving staff productivity. We will also rely more on shared decision decision-making with patients and community development to unlock financial resources, with a requirement for patients to be ‘fully-engaged’ in their own healthcare, as described by the Wanless Report.
Secondly, a unequivocal commitment by Labour to repeal of the Health and Social Care Act, sending a clear signal about a move away from markets and competition as the underpinning themes of national policy, and the explicit responsibility of the Health Secretary for NHS services.
Thirdly, increasing the power of patients’ voice in influencing how services develop. This covers patient views becoming more central within decision-making in the NHS, hitherto dominated by professionals. It also applies at the individual service level with even greater efforts required to promote shared care, patient /professional joint management plans and help certain patient groups become more expert in knowledge and care of their condition.
3. Major priorities for Labour
The core new idea for Labour policy should be the development of ‘whole person’ care, promoting integrated services to reflect the reality of individuals’’ needs, particularly in respect the most intensive users of NHS services – older people and people with long term conditions – who often requiring a mixture of physical and mental health services plus social care. Integrated working between health and social care can help mitigate the financial pressures faced by the NHS and social care, and address some of the wider determinants of health through work with other agencies (on the effects of poor housing for example).
The ‘big prize’ here, is about securing the resources to make social care free at the point of need. This will take time, and requires a funding formula to bring in extra resources, but the Coalition’s initial policy form the Dilnott report open the door to this possibility.
Also prominent should e restoring the NHS as a national organisation. The power of the Health Secretary to intervene in any part of the NHS should be restored, together with a resurrection of the Labour innovation of national standards for major clinical services (together with a national pay framework).
A key mechanism for implementing more integrated and ‘whole person’ care is delegating the NHS budget to local government, giving Health and Wellbeing Boards both real financial power and a strategic implementation role. It also offers scope to enhance democratic accountability for NHS services. CCGs would still have an important role, ranging from full delegation of funding to an advisory role. This would be underpinned by the NHS as preferred provider, only changed as a last resort when proven they are incapable of providing appropriate services. There are risks to allocating the majority of NHS funds to local authorities, though as in education some of these could be mitigated by clear national standards and rules around ring-fenced budgets.
The NHS needs more effective regulation and inspection, yet based on a commitment to integration not competition, and using more innovative methods such as peer review and national audits (linked to payments for best clinical practice, another successful Labour innovation) .
A key factor in maintaining standards, in the care industry particularly, is staff terms and conditions. Social care provides a lesson for the NHS about the impact of a ‘race to the bottom’ on pay and employment conditions. Specifically we recommend that Labour local authority groups should abide by the Unison Ethical Care charter and enforce it in subcontracting.
On specific areas, the approach of combining cross departmental budgets within the creation a time-limited agency, such the National Treatment Agency for substance misuse, is a useful way of directing focussed effort.
There also needs to be greater transparency about the funding formula, and a move away for the Coalition’s approach of favouring age exclusively as a weighting factor, at the expense of deprivation.
An underrated success of the last Labour government was improving safety and outcomes in major disease areas – stroke, heart disease, cancer and major trauma – through creating clcinal networks and centralising certain specialist care. The showpiece was acute stroke services in London, which reduced from 31 to 8, and transformed outcomes form the worse to the best in the country. There is scope for further improvement in this way – vascular and paediatric heart surgery for example, which means some services will change in order to improve treatment outcomes for patients. This can be controversial for local services, and so needs more open debate, and sharing of outcome information.
Labour should keep a focus on outcomes – weekend hospital mortality rates for example, whilst maintaining current commitments on waiting times. We must highlight the best outcomes and highest patient and staff satisfaction levels, as a benchmark for others to achieve and provide incentives and scrutiny. A modern system of rewards and appropriate sanctions would contrast with the laissez faire approach of the Coalition, who are relying on the media and general public to have the organisation and focus to campaign for improvements, or encourage a change of provider.
Public health policy should see a major departure from the Coalition’s discredited responsibility deal. A mixture of strong argument and high profile legislation, as with the public smoking ban, are needed to address the corrosive impact of junk food, the impact of cheap supermarket alcohol (and the link with pub closures), and promoting like skills ion food knowledge and cooking. Public bodies should take a lead, underpinned by appropriate measures in the national curriculum and local authorities to promote healthy lifestyles and nutrition.
Finally, staff wellbeing and moral in the health and social care must be a concern for Labour. This was not a priority for the Blair years and suffered despite the injection of significant new funding, and the Coalition’s reforms have also alienated staff. Motivation of staff has a proven relationship with positive patient experience, and this must continue to be a priority for policy-makers as well as senior managers running individual organisations.