Our Care System – Issues for Incoming Labour Government


There is a growing sense that our NHS is performing less well that it should, many attributing this to the stewardship of the Coalition.  The public cares about waiting times and access and about fairness – they both hate a post code lottery whilst supporting local freedoms.  They support the basic free at the point of need model but place totally unreasonable expectation on what exactly can be provided for free, ignoring the implicit rationing that has always existed.  Was ever thus.

By and large they don’t care about structures insofar as anyone understands them.  But there is a significant and growing belief that it does matter whether services are provided by the public sector or privatised.

The big message from Labour will be negative.  Our NHS has been damaged by the Coalition’s pointless and expensive redisorganisation and quality is being risked by the obsession with privatisation and the fragmentation that brings.

The attack line should be supplemented by the message that Labour has a vison for a 21st century care system that will bring stability and ensure improvement, restoring waiting time guarantees and reducing unfairness, with a total rejection of greater privatisation and any other route to charges, fees and two tier services.  The promise of “integration” and a whole person care system will be announced and if it is brave Labour will also commit to do this by bringing social care into a NHS type system.  Once more an end to top down management and devolution to the front line and to local decision makers will be announced.  But this is a more complex message to get over than just “don’t trust the Tories”.

So what should happen if Labour is elected?

An incoming Labour administration should remove any uncertainty by reaffirming the fundamental principles underpinning the NHS; universal, comprehensive, and funded from general taxation with a Secretary of State (SoS) who is both politically and legally accountable with the appropriate powers.  It must add to those principles that the care system should be an important contributor to raising wellbeing and reducing inequality.

It should point out that whilst far from perfect the NHS is probably the best most cost effective system in the world.  It should affirm its intention to move to a system for personal social care on the same principles for the same reasons which brought our NHS into being.  It should stress than prevention is better than cure and boost support and resources for public health.  It should signal the end of the acute hospital domination of the NHS and champion community and primary care.

To do this will be require eliminating barriers across mental, physical and social care and the barriers both between multiple providing organisations and within organisations. The barriers introduced by the split between commissioners and providers will be reduced and eliminated over time.  Planning will have to be re-invented.  Adding up to biggest change since 1948, requiring a new deal with those who work in the services but taking a generation to implement.

Policy will be based on reversing the presumption that competition and markets are the key mechanisms for reform and asserting instead the importance and value of a care system firmly rooted within the public sector and exemplifying the values of cooperation and collaboration.  Genuine accountability for major decisions, the allocation of resources and setting priorities will be introduced for the first time.  The recognition of the patients and public as assets will be recognised with shared decision making and community development established as central to policy.  Developing how our “voice” can become more powerful than the vested interests and the elites.

Policy on structures will be to make the minimum necessary changes and to avoid any major top down reorganisation.  The top down (bullying) culture and its implicit lack of accountability will be replaced by a permissive regime where entitlement is clearly defined within a national system whilst key decisions about how delivery is organised locally will be devolved and made open, transparent and democratically accountable.  There should be only the necessary minimum of prescriptive guidance and regulation and a limit on the scale and scope of any top down initiatives and programmes.  Shifting the balance of power, once a vague promise, should become reality.

There are tough questions to answer.

How can the transition to a much better integrated system be achieved without a reorganisation and without the benefit of significant real terms growth in funding?  What can be developed to bring genuine accountability and involvement and ensure patients and communities are viewed as assets?  How must the roles of professionals and others in the workforce change?  How can “free” health be merged with “means tested” social care?  How can essential relationships and local leadership be fostered?  How does funding flow and who decides on funding priorities?  How are failing services dealt with?

Labour could start by setting out its broad vision in something like a Green Paper before the election and start serious discussions with patients groups, local authorities, Royal Colleges and Trade Unions.  Testing out its broad ideas with those that would have to implement them is a good idea!  Saying changes will take time and not making short term headline grabbing promises.

We all know that Labour has repeatedly pledged that it will repeal the H&SC Act, but that may need to be done in two bites. A Day One Bill should do the necessary minimum followed by a major bill which repeals the H&SC Act and consolidates the rest of the key primary legislation. But other changes can be introduced and driven forward without any need to legislate.

In the Day One Bill the essential change is to restore the power of the SoS to issue directions and to give NHS England similar power.  The law is changed so that NHS Contracts are the only basis for arrangements between commissioners and providers of NHS services, removing all external enforcement of competitive tendering and removing the inhibitors to mergers, alliances, service sharing and any form of cooperation or collaboration. The legislation around use of special administration would be repealed.

A Day One Bill could also extend the scope and powers vested in Health and Wellbeing Boards; enhance governance within Clinical Commissioning Groups and make then responsible for primary care; give Healthwatch independent resources; strengthen the role of public health within local authorities. This could all be drafted up now.

Having established some stability there could then be a year to work towards a 10 year plan for care – a plan with the widest possible support as with the 2000 Plan.

Immediate steps could be taken to improve staff morale by protecting terms and conditions and by not constantly denigrating them.  Quality problems that arise can be dealt with by an open and honest approach and making sure they don’t happen again instead of using them as an excuse to attack the whole NHS.

There may also have to be a Day One Bill for social care. Attention would have to be focused on how to end the poor quality being delivered by poorly trained, poorly paid staff often of minimum wage, zero hours contracts; starting a journey that ends with a professionalised social care workforce with training, development and working integrated with NHS staff.  The implementation of the Care Act changes have to be well managed by Local Authorities and extra funding for this may be necessary.  Very soon too, the basic issue of chronic underfunding has to be addressed.

The central problem will be the money; crucially initially money for social care. The argument about the extent to which public expenditure should rise as a %GDP to pay for a modern care system needs to be developed.  There will almost certainly be pressure for a one off injection of funds to meet the NHS “crisis” and the social care “crisis”.  More funding could be could be badged as an investment in the transition from an inefficient fragmented system to the whole person care integrated alternative which would bring savings over time; arguing that only once the new system has been defined can any assessment be made of the necessary level of annual funding.  Worth a try.

Stability in funding is important and there needs to be a long term settlement. Funding based on weighted capitation methods should progressively replace payment by results (volume).  Market mechanisms like payment by results will need replacing by better methods.  Funding flows to cover health and social care together should be introduced, flowing through HWBs, building on established models like Better Care Fund but without all the top down approvals and oversights bureaucracy.

So we have from day one new top team bringing stability, energy and support to the NHS whilst driving changes by consent and through enabling changes to be determined locally rather than imposed from the top.  There would be a year of engagement and consultation on a long term settlement for a care system.  There will be a Day One Bill to set the tone and to sweep away the inhibitors to sensible change.  And in time a 10 year plan and a major consolidation bill.

There has to be some structural change, for example to deal with the confusion of who does what to whom as between Department of Health, NHS England, Monitor, The Trust Development Authority and a lot of other quangos.  But sorting that out is not the same as major told down reorganisation of the whole system as traditionally imposed.

It is perfectly possible to use the current architecture differently with different leaders and still to make a huge shift in the way our care system works.  In the end culture trumps systems and improvement depends more on developing relationships than on structures. How the funds flow and who makes the decisions is important too!