One Person One Team One System

Labour Health Policy

These are the recommendations of the Independent Commission on Whole-Person Care commissioned by Andy Burnham to make recommendations about how we can integrate health and care services within existing resources, and without another reorganisation.

The final report, which can be downloaded here, sets out a blueprint for bringing our health and care services into the 21st Century.

The provision of care

1.1 A new government in 2015 must outline expectations and milestones for the growth of new forms of coordinated provision. Local flexibility in the development of new provider models must be encouraged by Government so that different integrated models of care can develop according to the needs of local populations – for example, Accountable Care Organisations, where there is local appetite to do so.

1.2            These changes must be enabled by the system. For example, Monitor and the NHS Trust Development Authority must encourage through their performance management the development of new outcome based models of care, rather than performance managing Trusts against their ability to develop positive balance sheets around the existing episodic model of care. Health and care regulators must allow new provider structures to form where this will benefit people using the services. They should place considerations of care firmly before those of competition – including the growth of new (and larger scale) models of primary care.

1.3   The person and their home should be at the centre of care – individualised, not institutionalised. We recommend active encouragement of technological innovation to support people and their carers for the 99% of time that they look after themselves, and the increased involvement of specialists in the community setting to begin to deinstitutionalise our basic concept of healthcare delivery.

1.4   We recommend the development of the role of NHS Choices to create a personalised health hub that will enable families and friends to support each other through ageing and ill health, even when far apart.

Getting the right people working in the right way

2.1 Supporting co-management and shared decision making should be the default operating model for all professionals and a commissioning requirement. This will require a system wide focus on skills covering the following topics: person-centred care; consumer engagement; self-care; health literacy; health information sources; safety and risk; risk communication; shared decision making; personalised care planning;  co-management support; health coaching; motivational interviewing; co-production; and multi-professional team-working.

2.2 Each person with complex needs should have a single identifiable individual who will act as their advocate in coordinating care to the wishes and best interests of that person. That individual advocate may be from statutory or voluntary sector.

2.3 Professional training bodies should be asked to incorporate these skills into their programmes and ensure they are assessed adequately and included in appraisal and revalidation procedures. All professional training courses across health and care should involve the people using those services, their carers and other lay people in teaching and assessment. Training in these competencies must also be required for existing health and care staff. Health  Education England (Care Education England – below) should be asked to produce a new workforce strategy that is aligned with the components of the House of Care model and supports personalised care planning.

2.4 Multidisciplinary working must be the norm. Professional training bodies must therefore place a far greater emphasis on multidisciplinary team working. The Royal Colleges, the General Medical Council, the Nursing and Midwifery Council, the Health and Care Professions Council and other standard-setting groups should be asked to ensure that  multidisciplinary team working are key components of training, with quality assured curricula and appropriate assessments. Training in these competencies must also be required for existing health and care staff.

2.5 The development of generalist training for doctors, nurses and other health professionals should be encouraged, balancing the current trend towards increasing specialisation.

2.6 We recommend a comparative review of the terms and conditions that apply to professionals working in health and social care, in order to identify and clarify any fundamental differences and examine their impact.

2.7 Quality improvement methods and training should be core to curricula for all staff and over time (within ten years) all CEOs and Clinical and Operational Directors should be expected to have advanced knowledge of these techniques and a record of implementation.

2.8 Health Education England should be transformed to become Care Education England, with its responsibilities broadened to include social care training. Its membership and governance must be revised accordingly. The Leadership Academy should become part of Care Education England, and its role and governance revised to drive the skills needed for whole-system leadership across health and care.

2.9 Local Education and Training Boards must be reformed locally to ensure a balance of professionals from social care, mental health, primary and community care and public health, as well as secondary care. They must also include service users and carers. Investment in education and training by LETBs must be aligned with the joint outcomes required of the health and care system as a whole, which will require engagement with local commissioners and health and wellbeing boards.

2.10 Improved assessments to identify appropriate support for carers must be a local priority. The provision of information for carers should form part of this support.

Information solutions

3.1       Information provision must be treated as a core health and care service. This must include active support for those who need it, including targeted interventions to help increase the knowledge and understanding of people with low health and care literacy. The effective provision of information must be reinforced through quality regulation for all health and care providers. Skills for information provision and support must for part of health and care staff’s mandatory (and on-going) training, and information prescriptions should become the norm.

3.2    We recommend the application of an Information Quality Mark to accredited providers of health and social care information and advice.

3.3    People must be given ownership of their own health and care records. The development and use of electronic health and care records should be governed by the creation of nationally defined standards: ‘meaningful use’ requirements. These should include a single set of national recording and where different mapped reporting standards for health and care data, and the adoption of these standards must be required by law for both software developers and health and care providers, reinforced through provider contracts.

3.4       The default assumption should be of implied consent for people’s information to be shared across health and care providers for their direct care. People should be able to ‘opt out’ of the automatic sharing of their information.

3.5    As part of this drive towards national interoperability, it must be a requirement for all organisations providing (health and social) care to use the NHS number.

3.6    There must be greater access to and promotion of the use of de-identified (weakly pseudonymised) data within a strongly controlled environment for health and care commissioning, audit, planning, case management, purchasing care pathways, individual budgets and invoice validation.

3.7       There must be greater access to and promotion of the use of end user irreversible psuedonymised data. This should not simply be restricted to the HSCIC and commissioners, but should include organisations who are using information as a means to provide better outcomes for people using health and care services. We recommend the simplification of the process to achieve the necessary controlled environment, which should ideally be controlled through regulation and a contract with liabilities and penalties.

3.8       Person-defined outcomes must be accurately measured and reported as part of the collection and use of information from people. The separate national outcomes frameworks for health, social care and public health ought to include  standardised generic measures that enable coordinated performance monitoring across health and social care of function and morbidity and not simply mortality.

Helping people stay as well and independent as they can

4.1 Provide an option for Sure Start Children’s Centres to be the hub for all children’s health and wellbeing services locally, with better integration of associated services. Consideration should be given for the transfer of funding and commissioning responsibility and accountability for Sure Start Children’s Centres from the global Local Authority financial allocation to the Public Health budget.

4.2 Preventative approaches aimed at improving older people’s health and wellbeing should be comprehensive across health and social care. All localities should offer older people preventative  checks to identify risks to health, independence and wellbeing and mobilize a response based on the priorities of the older person and their families. For example, a falls prevention strategy as part of a broader approach to improving older people’s health and wellbeing. Frailty should be actively sought by health and social care professionals.

4.3 Comprehensive Geriatric Assessment (CGA) must be used in the community, hospitals and care home settings.

4.4 Localities should create a multi-agency quality register (and plan) similar to the Swedish model, based on the needs and priorities of older people, identified through preventative health checks and the outcomes of comprehensive assessments.

4.5 We recommend that Public Health England be requested to create a number of practical Action on Obesity policies for central and local government, in collaboration with NICE and other stakeholders. We suggest two initial areas for consideration: (a) advertising and marketing of unhealthy food to all groups in society and (b) opportunities for acting on raw materials which are bad for health – e.g. trans-fats.

4.6 We recommend the creation of a national campaign to support the health of NHS and social care staff- supported by central and local government.

4.7 Planning and building regulations need to adapt to changing personal needs – for example, adaptability for ageing and disability – and address existing inflexibilities within the system.

4.8 Incentives should be created to encourage the development of progressive care facilities for older people. We recommend that Local Authorities receive an allocation of apartments within progressive care facilities for nomination rights.

Making the money work

5.1 We recommend the commissioning of an Independent National Conversation backed by all major political parties to define a consensus on the scope of services provided by, and the future funding of, health and social care as a single issue. This should report within 12 months of a new government being formed, to enable its agreed proposals to be enacted from 2020 onwards.

5.2 Health and wellbeing boards, or analogous local arrangements, should comprise the collective system leadership for services for people with multiple long term conditions, disability and frailty. They would be responsible for a collective commissioning plan informed by the whole budget (locality pound) for this cohort of the population. They will require development and have to demonstrate readiness to do this. As part of this development programme it will be necessary that health and wellbeing boards ensure representation from across the health and care economy – including providers and housing representatives. We recommend a statutory duty placed on commissioners (Local Authority and CCGs) to enact the collective commissioning plan.

5.3 We recommend the development of joint arrangements between NHS England (Care England), CCGs and health and wellbeing boards (around the geography of health and wellbeing boards) with the requirement of aligning primary care commissioning to local objectives.

5.4 There should be permissive legislation to enable health and care economies who wish to formalise a single budget, with amended accountability arrangements to match, to do so. We see Care England as the approval authority for such arrangements.

5.5 We recommend that an annualised capitation tariff be introduced for all of the care needs of people with long term conditions and complex needs. Over time, we recommend the development of broader population based capitated payment mechanisms covering larger groups of people – for example, capitated payments for all of an older person’s care needs in a particular geography. Payments must be linked to the outcomes that matter to those people using the services.

5.6 We recommend aligning GP incentives and Clinical excellence awards with locally agreed system objectives.

5.7 We recommend that the central outcomes defined within this process are person-defined, developed by and for service user – not the system. In seeking to measure person-defined outcomes, we believe that person reported outcome measures must be viewed on the same level as clinical and system measures.

Wider system changes needed

6.1            Over the lifetime of the parliament from 2015, £10 billion should be identified from within allocated resources to strengthen community health and social care services. This should be routed through Care England, as part of the mandate, and made available to health and wellbeing boards.

6.2       In the medium term, there should be a single central government department   responsible for health and social care policy with devolved local responsibility for implementation.

6.3   We recommend that NHS England be revised to become Care England. Care England would need to demonstrate that its structure and functioning reflected the needs of the majority of people using the health and care system. We believe that this would require a substantial rebalancing of professional input to increase that of primary care, mental health, social care, community care and allied professionals, alongside the creation of whole system strategic plans geared towards people with multiple conditions. Care England’s mandate should include the requirement to demonstrate fitness for purpose for the delivery of whole person care. This would include the introduction of Non-Executive Board members from local government. Care England would formally be the strategic lead behind which Monitor, the NHS Trust Development Authority and other statutory bodies should align.

6.4   Disease specific clinical networks should be reviewed to ensure alignment with the principles of whole person care. The continuation of clinical senates is of questionable value for whole person care and should be abolished.

6.5  Responsibilities for national tariff creation and pricing for the NHS should reside in the same organisation.

6.6    We recommend that the benefits are considered of a single regulator covering issues of both care and economics, whilst recognising that is not feasible at present. We believe that the Office for Fair Trading’s role in reviewing competition decisions should be removed.

6.7        We recommend that section 75 regulations be abolished, and replaced with new regulations which support the development of whole person care.

6.8    We recommend ensuring that a greater proportion of R&D funding focuses on whole person care, implementation of existing research and reducing variations in clinical and safety performance. As part of a refocus of publicly funded research to implementation, we also recommend a redesign of Academic Science networks to be multidisciplinary bodies, run as true balanced partnerships between NHS, social care and academic bodies but independently managed.

6.9    We recommend the establishment of a complex care research centre from within existing resources, and to seek to do so as part of a multinational effort with others who are also in pursuit of the same objective (such as Ontario and Scotland).