Future options for the NHS

 This paper by Steve Iliffe & Richard Bourne, for the Health Matters seminar group is based on discussions about Future options for the NHS facilitated by Health Matters journal  and the Socialist Health Association in March and April 2013.

Near future:

In the run up to the 2015 general election, the NHS is likely to have a large part of its community health services (and some hospital services) provided or managed by the private sector. Mental health services, 30% of which  are currently provided by commercial or third sector organisations, may be the shape (although not necessarily the size) of things to come.

Clinical Commissioning Groups (CCGs) will be struggling to balance 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 new services or balance their budgets. There will be increased effort by NHS England to manage (and micro-manage) the health service, and promote service integration. The instability of NHS Trusts and unachievable targets will undermine these efforts, and top-down management will fail more often.

There will be more public engagement with the NHS, through both official channels (Healthwatch, the Health & Wellbeing Boards) and unofficial ones (campaigns to preserve existing NHS resources & services). The conflict between bottom-up accountability to vociferous local interests and central accountability to NHS England will increase tensions within the NHS.

Further shrinkage of publicly-funded social care will occur. Individuals trying to manage their own social care by using the benefits system will be challenged by benefits cuts and restrictions, even as political rhetoric emphasises ‘personalisation’ and ‘personal budgets’.

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

Variability in the quality of general practice will persist, despite the modernising forces within clinical commissioning and the ambitions of NHS England. The low skill base and poor organisation will remain widespread.

Public debate will express growing interest in the importance of individual responsibility for health, while family and friends will be seen as essential support for those in hospital, acting as advocates and also as direct providers of care.

 Immediate problems:

The Health Matters seminars identified ten problems that a Labour government elected in 2015 will need to address (but not necessarily solve), over a ten year period.

1.  Funding constraints should prompt both ‘smarter working’ (as advocated by NHS England) but also reclassification of PFI and other historic debt as “toxic”, so that they can be managed separately from NHS cash-flows, or renegotiated.
2. Generic challenges (common to all health services in industrialised societies) include social and demographic changes, system obsolescence, unwarranted variability in service performance and outcomes, increasing expectations and intolerance of poor quality, and resistance to innovation. The NHS is good at co-ordinated care for specific time-limited activities (maternity care, surgery, rehabilitation, palliative care) but less good when care coordination is needed for high volume, complex, long-term conditions. General practice and DGHs are no longer capable, as currently organised, to deal with these challenges. For example, there is a need to incentivise pro-active work, particularly in primary care, and a need to change incentives for hospitals to admit and discharge patients.
3. The separation of mental health services from other services and their fragmentation by out-sourcing adds to the challenges facing the NHS, rather than reducing them. Joined up care is needed in the NHS, and between the NHS and social care, and because patient experiences of care are so often poor,  it may make financial trade-offs possible and generate efficiency savings. Investment will be needed in the processes that are known to achieve collaborative working-such as shared budgets & professionals in services that are able to cross organisational boundaries.
4. The variability of quality of care in general practice, its limited skill set and poor level of organisation, make general practice a weak link in the NHS chain. The limited influence of the NHS over it cannot be allowed to persist. Although general practitioners (GPs) are in theory well positioned to provide coordinated care, the discipline is unable to do so under its present contract. A new GP contract is needed which will, for example, restore responsibilities for 24 hour care to general practice.
5. The fragile means tested/privatised economy of social care, and the sometimes weak working relationships between the largely commercial care home sector and the NHS, can result in variable quality of care for care home residents and avoidable costs for NHS hospitals. Free social care could be funded by an Estates (Death) tax, or through hypothecated compulsory social care insurance. Free social care could be introduced in stages. One early stage could involve drawing the care home sector further into the public domain, through an NHS franchise.  The different funding regimes in social care and the NHS are unhelpful, but providing social care for free will not in itself deliver more harmoniously functioning services.
6. A historically weak political culture exists 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, and then used systematically.
7. Public health has been marginalised just as the social determinants of health and illness become clearer than ever. Community development (to increase social capital) generates early benefits for health and wellbeing, so closer working between CCGs and Health & Wellbeing Boards should be promoted.
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. Recovery of memory is an urgent task, and debate is needed on how to achieve it.
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 poor quality of care are currently being manufactured by those hostile to the NHS. Their dominance can be undermined by adopting a person-centred approach to change. The debate about ‘integration’ of services is an opportunity to do this. ‘Integrated care’ is an unhelpful term because it starts from the perspective of existing services, not from the needs of people. It would be better framed as ‘joined up care’ or ‘whole person care’, or ‘co-ordinated care’. National Voices has a useful working definition of joined-up care which is very patient centred.
10. Power in the NHS is dispersed across the health economy, without commensurate accountability across different centres of power, as seems to have happened in mid-Staffordshire according to the Francis Report. This is especially the case in the commercial sector, as the Winterbourne View private hospital scandal demonstrated. Citizens have little influence over the health services available to them, professionals may be disempowered by local management, local services are also resistant to ‘command and control’ management from the centre, whilst the commercial sector hides its activities behind a screen of ‘business secrets’. Community development offers participatory accountability with effective involvement in planning, usually around geographic areas.

 Future options:

An incoming Labour government in 2015 could base 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, health promotion and a strategic role for public health, reinforce holistic care, and reduce reliance on hospitals. This will probably require some organisational combination of hospital and community services with lead commissioners and shared or programme budgets as possible funding mechanisms, but in most situations  these combination will not be best achieved by merger. This change is likely to require the abolition of the Quality & Outcomes Framework in general practice, and of Payment by Results in hospitals.

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

• The forward deployment 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 and other mechanisms.
• The promotion of generalism (a holistic approach) in community and hospital services.
• Making the maintenance of collaborative, trusting working relationships between disciplines the primary task of NHS management.
• Deepening relationships and encouraging effective and efficient working between local authorities and the NHS. The NHS can then evolve towards a situation in which local government Health & Wellbeing Boards sign off CCG plans, giving local government increasing responsibility for healthcare commissioning.
• Reducing the intellectual and practical gulf between services for mental and physical health.
• Establishing single budgets and shared financial accountability as the norm across community and hospital services, along with a single outcomes framework, communication systems for sharing of information between services, and funding mechanisms aligned to desired outcomes.

In 2015 a Labour government could begin to promote 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 (HASCA) 2012 has been repealed. Planning for the repeal of Section 3 of HASCA needs to start soon, including a realistic appraisal of what can be unravelled and what cannot. Legally watertight ways of avoiding the privatisation elements of EU law need to be finalised.

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

The Health Matters seminars included: Richard Bourne, Professor Peter Crome, Professor Ilana Crome, Dr Brian Fisher, Professor Claire Goodman, Professor Steve Iliffe, Professor Jill Manthorpe, Dr Linda Patterson, Martin Rathfelder, Professor Aubrey Sheiham.