The Stevens Five Year Forward Look for the NHS has had a generally favourable reaction for what it contained and some scepticism about what it didn’t. We should welcome the clear signal that more funding is needed and support for the position that care funding has to rise faster than inflation just to maintain services; although “savings” of £22bn by 2020 are simply not credible. There is little about the need to deal with huge issues around social care in order to make change in the NHS possible; but this is a plan for the NHS not a plan for a care system – the biggest issue of all.
Stevens clearly does not support a key role for Local Government and since he heads the NHS that is hardly surprising, but the time has come to bring the NHS properly into the public sector not leave it as a separate empire without democratic accountability.
We should see local authorities as the local planners for the care system bringing the whole of the public sector together to ensure resources are allocated to gain the greatest benefits, reducing inequality and confronting head on the determinants of poor health. The mantra of “no reorganisation” means we don’t invent new structures; we use what we have more appropriately. Local authorities already plan and commission far better than the NHS and they can work across boundaries better and they are the only sensible place to hold the “single pot” or single budget. We do not need elected commissioners or new elected health boards (they did not work in Scotland) – we use what we have and make it work better.
Using existing democratic structures to make the key decisions about priorities and resource allocation is the only way to overcome the vested interest in the health system. We don’t want to “take the politics out of healthcare” we want it front and centre.
Local authorities led on huge socially transformative measures like slum clearance, safer water, sewerage and they are able to show leadership even when faced with unpopular choices. The NHS is hopeless at this scale of change and NHS and we don’t appear to have any strategic bodies in health at all. NHS leadership always backs down at the first sign that anything is unpopular; and often the public has no idea of who makes the decisions anyway. Using local authorities is the only way we have to ensure decisions are made openly and with accountability clear.
Then there is the elephant – the Lansley legacy. Stevens appears to accept that we retain the regulated market with multiple providers from all sectors competing for services through competitive tendering, all joined through legally enforceable contracts. The purchaser/provider split is kept.
Here is the major disagreement and the fundamental argument. All the evidence is that the market structures add to administration costs, commissioning (we have had 4 goes so far) does not work and that competition amongst providers has no benefits in terms of quality. It is also clear to many that there is a major opportunity cost as providers focus on sustaining income as much as improving care. We must support making the NHS a public service not a market and we should aspire to seeing social care provision brought back from private providers who led the race to the bottom with zero hours contracts, 15 minute visits and untrained staff.
Whatever structures are to be used to plan the allocation of care resources they must not subject to competition law and compulsory competitive tendering. But this is not what we have now under the S75 regulations or in local authorities. Of course there will be the use of formal procurement for some services, although rarely for clinical care. There will continue to be the use of some providers in the private and third sectors – where the NHS (or social care) is unable to provide what is required. Existing contracts, however stupid, cannot just be torn up.
But we can, and must, remove the competition architecture and remove the threats from competition law, EU procurement regulations and even TTIP. We must go back to a care system based around social solidarity and cooperation within a public service. (The Clive Effort Bill actually shows how this can be done).
Similarly we cannot go on funding healthcare providers through quasi market mechanisms like payment by results; that is just a recipe for instability and diverts management attention away from the key issues around care provision.
Apart from the most basic issue of how we pay for care that gives us three big areas to campaign around.
We have to deal head on with the unacceptable state of social care – we need to move to ensure care is free for those with greatest needs, we need a proper workforce and we need additional funding.
We need to win the argument for the major role for the public sector and thus for local authorities (made harder by some local authorities!! and some Councillors!!!)
We have to get rid of the competition architecture and move to preferred provider and a care system based on cooperation between all parts not competition.
We may also have to damp down expectations. We know structural reorganisations don’t work but we need structural change. We need a programme for evolutionary change over many years; but we don’t have the managerial capacity or capabilities to manage one.
We know enough to doubt the claims about easy savings, like saving £10bn from removing the market or £2.5bn by eliminating errors or £zillion from better procurement; but we do need realistic levels of savings to complement increased investment.
We can stop privatisation and increase the level of public provision over time but we can never have (never have had) a fully publicly provided system.
So even if, as appears more likely now, we get the money we need a ten year plan for change to get us to a genuine public service care system. We need that sort of time to recruit, train, develop and reward properly then deploy the workforce we need and we need the managers to make that workforce effective and efficient.
We need the confidence in our goals, and the patience and determination to deliver change against what inevitably will be a chorus of opposition from all sides (there always is).