Equality, efficiency and quality


I recently attended the HSJ Commissioning Summit to discuss where the Labour Party are up to with our plans for NHS commissioning. I thought it would be useful to summarise the main points from my speech and the themes from the discussion that followed.

Debbie Abrahams

As part of our policy development process there have been a number of independent policy reviews. The inquiry into whole person care chaired by Sir John Oldham in particular has informed the party’s direction on commissioning.

Listening to many of you and having worked in the NHS myself, I know that the scale of the service and financial challenges we are facing now is unprecedented. One in four trusts are predicting a deficit in 2014-15, up from 10 per cent for last year. In July hospital accident and emergency departments missed their four hour wait targets for 52 weeks running, with 1 million people waiting over four hours in the last 12 months. After years of falling waiting lists for elective care under Labour, they’re now at their highest level in six years. In the last year there have been a half a million avoidable admissions of over 65-year-olds.  And the timely access to GP services is now an issue in many areas, coupled with recruitment to GP training posts being at its lowest level since 2007. The crisis in the NHS is being matched by the crisis in social care. For example, with £3.7bn of cuts 85 per cent of local authorities are now only able to provide care for people with substantial needs or above.

And we know this is going to get worse, not better. We are an ageing society – in 2012 there were 3 million people over 80-years-old; by 2037 there will be 6.1 million. We are all living longer, which is great, but we also know that people on low incomes – and there are now more people in work living in poverty than there are in unemployed and retired households combined – do not live as long as people on higher incomes. In my own constituency, there is an 11 year difference in life expectancy for those people from affluent backgrounds compared to those on the lowest income.

And as my friend Frank Dobson said: “Inequality in health is the worst inequality of all. There is no more serious inequality than knowing that you will die sooner because you’re badly off.” But we also know that socioeconomic status will determine “healthy life expectancy” too – how long we will live in “good” health. The most recent data shows a difference of 19.3 years for men and 20.1 years for women for the most to the least advantaged. And of course, this impacts on the NHS and social care. In terms of activity levels across the life course, the under 5-year-olds and over 65s are the greatest “service users”, with over 65s using two-thirds of emergency bed days. People with long term conditions account for 70 per cent of NHS spending.

Whole person care

For the last 20 months or so Andy Burnham has argued that to meet the challenges we face, we need an integrated health and social care system that focuses on the whole person – their complete physical, mental and social needs – whether that’s a child with complex needs, a working age adult with disabilities or an older person.

The Oldham report described the experience of “Mrs P” – she’s 85 and has chronic obstructive pulmonary disease, high blood pressure and diabetes. In a good month she will see 10 different professionals. Most days are spent waiting for someone to come and carry out some care for her, with the value of the intervention not lasting long. Last year she was admitted to hospital via A&E five times. There are many “Mrs (and Mr) Ps” up and down the country who are currently having to live like this. This is not a criticism of health and social care workers. This reflects the hospital centric system we have at the moment, which has been exacerbated by the Health and Social Care Act 2012, with its focus on competition and a costly, top-down reorganisation.

This year’s Care Act was also a huge disappointment. The so called “cap on care charges” is disgracefully disingenuous, with the £72,000 cap not covering accommodation costs and being based on a standard local authority rate. It has been estimated that nine out of 10 people won’t even reach the cap before they die.

If Labour wins

Under a Labour Government in 2015 the Health and Social Care Act will be repealed in the first Queen’s speech. We will set out how we will deliver an integrated health and care system fit for the 21st century, working with existing structures to deliver our vision for whole person care: a single service delivered around the needs of the person not organisations – truly personalised care. This is not just about integrating care pathways; this is about joining up the whole system. And we will show the commitment that we have always shown to the NHS. We will establish and invest £2.5bn extra a year with a “time to care fund”, raised from clamping down on tax avoidance, a mansion tax on properties over £2m and a levy on tobacco company profits. Part of these reforms with reorganisation must involve overhauling how finite resources are allocated to commissioners, as well as different approaches to commissioning and remunerating health and social care providers.

We’re consulting on the best model on how health and wellbeing boards can work with clinical commissioning groups, with the active engagement of patients, the public, clinicians, and other health and care workers, to undertake the planning and procuring of the health and social care needs of their local population with a single health and care budget. And on how GPs, community services, acute and mental health trusts can work together with social care providers to deliver the health and care services that are needed. Whatever the model, decisions will always be made in partnership with clinicians – clinical leadership will still be vital – and based on clinical evidence, but there will be democratic accountability too.

We recognise the concerns some CCGs have about this and understand that some HWBs are more equipped to undertake this role than others. But to repeat a well used phrase: “there will be no top-down reorganisation”; this will be an evolutionary process, not a big bang.

We want to do this with you, not to you! In partnership with all stakeholders, we will develop criteria to assess HWB competence. The commissioning role will only be undertaken by a HWB when they are assessed as competent.

We also understand the differences of the health and care systems: culturally, organisationally and of course, financially. However, we believe a single budget and an integrated commissioning process will enable much greater efficiencies, but opportunities too. f we are to deliver high quality, personalised care that addresses the pervasive inverse care law, we need to have not only the tools to identify inequalities in access to services as well as inequalities in health outcomes, but the financial incentives to secure the service changes needed to address them. As such we need to revise provider payment models for secondary care. Although payment by result is not universal, its focus has been on rewarding activity that has introduced “gaming” into the system with some negative, unintended consequences, including supplier induced demand. A “year of care” budget is being developed to reward personalised care, and care wherever possible, in the home.

It needs to be stressed that this is different from a personal health budget. We have serious concerns that although many people have positive experiences of these budgets for social care and for health, they could become a forerunner of a health insurance payment model. Personalisation should not be equated to the personal health budget. Personally, I hope it will also recognise and reflect complexity, quality and whole system performance, in addressing equity issues and collaboration across the system, for example.

I also believe the time is right to rethink how we reward our family doctors; if about 30 per cent of a GP’s income is performance related through the quality and outcomes framework, this may influence their focus and may also have unintended consequences. Similar to secondary care, I hope we would look at for example, how we might incorporate access, equity and patient behaviour dimensions. We must shift our health and care system to enable prevention and wellbeing.

On specialist commissioning, although we supported the principles of a national process when the Health Bill was going through the House, there is real concern in how this is being discharged. For example, the updating of national service level agreements done by the clinical reference groups, and what further changes may be forced through as a result of last year’s overspending of £376m. We will be watching this closely as we prepare our detailed plans over the coming weeks and months.

We recognise there is still a lot we have to do and in a context of quality, intervention, productivity and prevention, a decimated public health information system with so many analysts, as predicted has hived off to do generic council data analysis, and has a poor record in contracting/procurement.

However, there is also much we have learned from the evaluation of world class commissioning such as the value placed on a competency based approach; the need to align payment models with commissioning objectives; and to link any assurance model with commissioning activity and not demonstrating commissioning activity.

The NHS is facing a battle for its survival. The Coalition Government has put in place legislation to enable, not just the privatisation of health services, but the development of an Americanised insurance based health system. Suffice to say we reject this. In the process of delivering our vision for whole person care, we must look to transform our NHS and care system into an efficient, equitable and high quality system fit for the 21st century. How we allocate resources, commission services and pay our providers is key to this.

his article, by Debbie Abrahams MP, first appeared in the Health Service Journal