Labour must be convincing about the NHS

Labour Party Public Health

Anyone who was at Labour Party Conference this year could not fail to have been impressed by the shared enthusiasm and sense of endeavour linked to the issue of the NHS.  Harry Smith’s speech about the progress we have made moved some of those in the audience to tears.  Everyone was fired up with enthusiasm to make the NHS our big election issue. Fringe meetings about the NHS were full to bursting.

It is great to see the Labour Party united around an issue where the Tories are distrusted and we can make the running. So does that mean there is nothing more to say in an essay like this about the NHS?  Unfortunately that is not the case.

There are several issues related to Health and Social Care which need much more thought and clear decisions.  I believe that if we do not resolve them we shall achieve the worst outcome of all – that is raising peoples’ hopes but not being able to deliver.  That is what the Alex Salmonds ,Nigel Farages and Nick Cleggs of this world do, and I do not want to be in their company.

I would recommend you read two documents, even if you haven’t got time, as most of us don’t, to read more widely. They are:

These are not political documents, but they set out fairly clearly the challenges the NHS faces.

The Challenges facing the NHS

Most experts agree what the challenges facing the NHS are, even if they may not always agree about the best way to deal with them. They are:

  • The costs of the NHS have risen in real terms every year since it was founded in 1948. The average growth of funding each year has been about 5%, although that has not been a steady    Since the election of the Coalition in 2010  funds have increased annually by less than inflation. Even Margaret Thatcher continued the annual increases.
  • The pressure on resources is particularly acute because of the ageing population and the increase in the demand for long-term care not necessarily in hospital.
  • New treatments and drugs are expensive but the widespread use of the internet and rising expectations has made people more aware of these even if they do not fully understand whether they are effective or not..
  • The way we live now has increased the incidence of what are known as “lifestyle” diseases such as cancer, heart conditions, and diabetes which are exacerbated by smoking, unhealthy eating , too much sugar and lack of exercise.
  • The development of new highly expensive and sophisticated treatments has resulted in the concentration of specialist hospitals onto fewer sites, with the resulting long distances for patients and ambulances to travel. As a result there is more effort to either prevent illness or treat it as far as possible within the community.
  • Treating more conditions and illnesses in the community means more pressure on GPs. There is currently a shortage in many areas.  An opinion poll commissioned by the Royal College of GPs found that half of the 1001 adults interviewed thought waiting times were a “National Disgrace”.
  • Measures to improve health, rather than simply treat disease, will require more spending on public health, and probably direct intervention to regulate the content of food and drink. This will not be popular.
  • Mental health must be fully integrated into the mainstream NHS and given greater status. One of the depressing facts of recent years is how Mental health has suffered a greater proportion of cuts, a fact admitted by the Lib Dem Minister, Norman LambP. who wrote in May 2014:

In my time as Mental Health minister, I have written here several times about the unacceptable disparity between mental health and physical health in our health system.  For far too long, physical health has been prioritised over mental health.

Perhaps the most stark difference is in terms of what happens when you suffer a mental health crisis. If you break your arm or suffer a stroke, you know that you will be taken to A&E, where you will get access to the expertise you need.

It’s very different in mental health. You may end up in a police cell or you may get sent a long way away from home to get a bed in a mental health unit. This would never be tolerated in physical health so why should it be acceptable in mental health?(Norman Lamb)

  • Similarly the need to reorganise the NHS and transfer more resources to the community will result in the closure of some units, and the transfer of services away from others which will be very unpopular. Most M.P.s and councillors find such decisions difficult to deal with.
  • There is near unanimity on the need to combine health and social care to move towards a “whole person service”. What is less clear is how this should be done while preserving effective management and public accountability. The Clinical Commissioning Groups (CCGs) are led by clinicians, and are not accountable to the wider public although they spend public money.  The Local Authority Health and Wellbeing Board (HWB) exercises a general “oversight” and the CCGs are subject to the Overview and Scrutiny Committees.  Nevertheless there is a feeling in some quarters that there is an accountability “gap”.  The old Primary Care Trusts (PCTs) had a majority of non-executive directors over the clinicians.  In the CCGs the clinicians make the decisions, and lay members (who are a minority) provide “assurance”.(Which means make sure things are done properly and there is no conflict of interest.)  It should be added that there is concern in some quarters that if commissioning is transferred to Local Authorities through their HWBs, they will not have the knowledge and expertise to commission effectively. There are some unresolved issues here.
  • There is a strong feeling that Scrutiny of the NHS by Overview and Scrutiny Committees and Healthwatch needs to be strengthened. Public and Patient Engagement also leaves much to be desired. Practice does vary.
  • The NHS and social care are often portrayed as complex bureaucracies around which vulnerable people and their families have to navigate. There is an overall desire to simplify this, and remove “perverse incentives” where some treatments are paid for and some are not.
  • There remains the problem of funding and the fairest way to do it.
  • There is also the issue of democratic accountability. This is also unclear. As I observed above the issue of commissioning remains problematic.

Labour’s Proposals

I am taking these proposals from the 2014 Report to the National Policy Forum which were agreed at Conference this year. I shall group them and explain what they appear to be. The final part of this contribution will consider strengths and weaknesses and suggest a way forward.

  1. Repealing the Act

The main thrust  of Labour’s proposals is repeal of the 2012 Health and Social Care Act which obliges NHS bodies to put services out to tender, and allows private providers to mount legal challenges if they are not considered, thereby wasting money and time. It should be remembered, however, that independent providers, many of them charities or social enterprises and working on a small scale, play a valuable role in the NHS particularly regarding mental health.  Repealing the Act would restore the position of the NHS as the “preferred provider” but allow use of the charities and social enterprises to continue.  This will be popular throughout the party and many parts of the NHS where there has been needless reorganisation

  1. The Integration of Health and Social Care

The Party proposes the strengthening of Health and Wellbeing Boards to enable public health, housing and social care to work better with health, but does not make it clear where ultimate accountability lies. There are many “loose ends” here since some specialist services are commissioned nationally by NHS England and the HWB may not have the expertise to do this. It is also unclear whether integration will mean joint planning or actual working together at a grassroots level.  There have been examples of this in the past.

  1. Scrutiny and involvement

The proposals also recognise the problems for service change and wants to give communities “more ownership of the consultation process” by giving it to the Health and Wellbeing Board rather than allowing the Commissioners who are proposing the changes to do it as at present. The HWB will have a duty to “secure real public engagement”.  This is a very welcome change, but leaves open who will actually make the decision in the end. There is a promise too to strengthen Healthwatch and ensure proper accountability of local services. Again this begs many questions which I shall address below.

  1. Public Health The section on Public Health recognises how important it is and the need to try and implement some of the proposals of the Marmot Report of 2010.

This was a very influential report pointing out that the causes of health inequality were multi-faceted, and could not be addressed simply through remedial action alone such as encouraging healthier lifestyles, but had to deal with a range of issues including housing and education. This is an approach many Public Health Departments are now adopting. The section is disappointingly short, and does not deal with resources.  Public Health funding comes under the Local Authority budget.

There is no mention in the document of direct intervention to control the amount of sugar, for example, in drinks or food, or to regulate salt content. Andy Burnham has spoken about the need for this on various occasions.

  1. Mental Health

The Labour Party proposes to rewrite the NHS Constitution to give mental illness the same level of priority as physical illness and to ensure that mental health specialists work with GPs and nurses.  Again funding will be crucial.  The mental health budget has been under-resourced in the past.

  1. The Health and Social Care Workforce

There is a very welcome section drawing attention to the undervaluing of carers both in their pay and the training they receive. Hopefully raising the minimum wage and tackling zero hours contracts will go some way to addressing this.  Baroness Kingsmill is currently carrying out a review on how to better understand and tackle exploitation in the care sector.

  1. Funding

This is the big issue.  Everyone agrees that integrating health and social care will cost money, particularly if social care, or parts of it, are made free as NHS treatment is.  The Kings Fund Report estimates £3 billion per year for simply making care for those with the most severe needs free. In addition the programme to treat and care for more people in the community, rather than in hospital, as outlined in “The Call to Action” is going to cost money.  £5 billion has been estimated. Any “transformation” of a service costs additional money until it is embedded, since you cannot withdraw one service until the replacement is working effectively.   Andy Burnham proposed at Conference that an additional £2.5 billion could be raised by a Mansion Tax , a crackdown on tax loopholes and a tax on tobacco companies.  At the same time ending privatisation and reorganisation could save money within the NHS. The NHS is already facing the Nicholson Challenge to reduce costs by 4% a year over five years, aiming for a target of 20% by 2015.  It was not made clear where further efficiencies would come from.  At least, however, Labour is grappling with the funding issue.  I shall pursue this further below.

A Way Forward

I am very pleased that the Labour Party has announced a clear commitment to restoring the NHS, and laid out some clear ideas about how these can be achieved.  Things could not have gone on the way they were.  A Spanish waitress in Manchester saw the pin in my lapel saying “Proud of the NHS” and implored me to make sure it did not go the way of the Spanish Health Service.  I gave her the pin.  Support for the NHS is widespread and there is a fear that another five years of the Tories would end up with the end of the NHS as we know it.  But this alone is not enough for the Labour Party to both win and ensure a sustainable future for the NHS.  The principles set out need to be sharpened, and where they are vague, clarified.

I think there are four areas, all interconnected, where there needs to be further work.  They are:

  • Funding
  • Integrating Health and Social Care
  • Public Health
  • Commissioning and accountability.

These may appear unconnected, but in fact they all fit together into a coherent philosophy of the NHS, which I shall explain below.

Any discussion about the NHS must have clear philosophy about what it is and the principles behind it.  We all know that Nigel Lawson once described it as the”nearest thing we have to a national religion”(Lawson,N. (1992).  The view from No 11: Memoirs of a Tory Radical. London: Bantam Press.). I think it is more that we live in a society where commercial and market values have been allowed to dominate, and the public are sickening of them and realising their limitations.  The NHS expresses values of community and solidarity, of all of us having mutual obligations which challenge an individualistic, market-dominated view of the world. There are several ways of looking at the NHS.  It could be regarded simply as “health insurance”.  A publicly funded health system could simply be the government paying the bills and providers administering the treatment.  It could even be a system where only the less well-off have their bills paid, something which I expect some Conservative M.P.s have thought of even if they do not admit it.  This is more or less what is emerging in America, after much huffing and puffing. This is not an approach many socialists favour.  They would see the NHS rather as all of us taking responsibility for each other.  Socialists, and the Socialist Health Association in particular, have always stressed the importance of public health, since many of the factors which make us ill are outside our own personal control. Socialists are also interested in reducing inequalities in health, which have been starkly pointed out from the Black Report in 1979 onwards.  This was the first of a series of reports to point out that despite the advances made in the thirty years of the NHS since 1948, and the overall raising of standards, health inequalities persisted. Most experts, from Professor Tom McKeown onwards, (McKeown T, Record RG. Reasons for the decline of mortality in England and Wales during the nineteenth century. Popul Stud. 1962;16:94–122.) believe these inequalities can only be reduced through programmes of public health.

Thus a socialist approach to the NHS sees it as a collectivist enterprise with the aim of ensuring a fair distribution of health obtained through mutual effort. It also seems to work.  That is why socialists like it and many Conservatives don’t.  A collective publicly funded enterprise must be accountable to the community it serves, and this is an issue which must be resolved.  Before we try, remember the first line of the NHS Constitution The NHS belongs to the people….. The NHS is founded on a common set of principles and values that bind together the communities and people it serves – patients and public – and the staff who work for it.

I will now consider the four issues I identified:

Funding

Raising £2.5 billion from Tax evaders, owners of large houses, hedge funds and Tobacco companies is desirable.  These groups either do not pay enough tax or contribute to bad health.  But is it a sustainable source of funding for the NHS?  The Mansion Tax will reduce the price of housing, particularly in London, which is desirable, but it may provide   diminishing returns if this happens. Similarly a windfall tax on tobacco companies; if we can reduce smoking this will also diminish.  All Governments promise to crack down on tax evasion, but often find it harder than they think.

It seems obvious to me that if we want to implement the changes which are needed additional funding will be needed. The proper integration of health and social care, and removing perverse incentives, will cost money. So will providing better facilities in the community to reduce hospital admissions. Ways will have to be found for the majority of us to contribute.  Kate Barker, in her report for the King’s Fund, has identified some of them.  Older people use a disproportionate share of the NHS’ resources. There is a strong case that those who continue to work after retirement age should contribute National Insurance, albeit at a reduced rate. Similarly some benefits which all pensioners currently receive, such as winter fuel allowance and free TV allowances for the over 75s, could be means tested. (I would not include free bus passes. There are good social and environmental arguments for these.  Many older people can no longer drive through no fault of their own, and the passes  reduce car use and subsequent pollution.) These two between them could raise £2 billion per year.

I am not intending to debate all the schemes that have been suggested here, merely to point out that simply relying on a small group of rich and unpopular people to provide the additional funding needed may not prove sustainable in the long run. In any case if the NHS belongs to all of us, we all have to pay for it, but in a fair and equitable way.

Integrating Health and Social Care

Most informed opinion is agreed on the need to do this.  The standard of care in the community needs to be improved, both because it is inadequate at present, and also because it is causing blockages in hospitals because elderly and vulnerable people cannot be discharged. When they are, without proper social care they may soon be readmitted.  The Government has already assigned £3.8 billion to the Better Care Fund to form a pooled budget with Social Care Departments to “ensure a transformation in integrated health and social care.”

The aim is to prevent so many people being admitted to hospital and to ensure better discharge arrangements. This money has to be paid by Clinical Commissioning groups (CCGs) ,without any overall increase in their budgets. In most cases taken it has been taken from the money paid to hospitals. This is one of the reasons for the present financial crisis with many hospital trusts.

As I mentioned above there is a difference of opinion as to whether overall commissioning should be done by the Local Authority, or the CCG and Local Authority working together under the auspices of the Health and Wellbeing Board (HWB).  Whatever the outcome, and I favour the second option, what is important is working together on the ground.  There are examples of this.  There have been good examples of inter-agency working, or “whole systems” working as Professor Hudson prefers to call it. He analysed a joint project involving Sedgefield Primary Care Trust, Sedgefield Borough Council and Durham County Council.  These three partners established five locality-based teams across the borough, each consisting of social workers, district nurses and housing officers.  Hudson noted that it had the effect of producing faster responses, since people talked directly to each other rather than going through lengthy procedures.  Unfortunately this scheme is no longer working because of reorganisation in the PCT, Local Government and housing, but it is a practical example of what integration means.

Integration is not so much about governance arrangements, but ensuring people work together at a grass roots level.

Public Health

Socialists have all stressed the importance of public health, both to prevent us becoming sick and in reducing health inequalities. There seem to be three issues here, the organisation of local government, what happens on the ground, and ensuring what we eat and drink is healthy.

There are many facets of local government which influence public health, including planning and parks and recreation.  When at the Labour Party Conference I went jogging in the morning (partly to counter the other unhealthy effects of conference living) and was impressed by the people-friendly way that Salford Quays (where the hotel was) had been designed.  It was possible to walk, jog or cycle in a healthy environment round the basin, without worrying about pollution or traffic.  One of the reasons people are reluctant to walk or cycle is because they think it is dangerous.  Proper town planning is important.  So is the provision of parks, playgrounds and Leisure Centres which are accessible and affordable.  Public Health is currently funded through local government, budgets which are under severe pressure.  If we really think it important that budget must be both increased and protected.  The role of the Health and Wellbeing Board has to be strengthened to ensure all local authority departments play their part in protecting and promoting public health.

Much of what public health does is try to promote healthy lifestyles.  People do not like the idea of the “nanny state” and in any case it does not usually work.  Working people and those on low incomes do not take kindly to being lectured about what they should and should not do by those who are better off than themselves.  I have been impressed by the many community projects which I have encountered, which mobilise local people to organise to promote good health themselves, whether through support groups, fitness clubs or simply growing healthy food in allotments.  Healthworks in Easington is a good example.

Finally the content of  what we eat and drink is being recognised as increasingly important in the promotion of good health.  Diseases such as diabetes are linked to obesity, and could be a major expense for the NHS in the future, apart from causing misery to those who suffer from them. Food and drink is now clearly labelled as to what it contains, and fast food shops such as MacDonalds now display the calorie value of their food. It is unusual to praise McDonalds in a publication such as this, but that is a considerable advance to what is sold in many takeaways, where we know neither the calorie value nor what is actually in the food served!

My own experience, however, suggests that those at risk, particularly the young, take little notice of these labels and become addicted to harmful substances such as excessive sugar at an early age. Labelling may influence the “worried well”, but if we are seriously to improve public health direct action will have to be taken to control the salt and sugar content in food and drink.  This will mean a confrontation with the food and drink industry, but we managed it with tobacco.

Commissioning and Accountability

I think I have made it clear I am not happy with the idea of all Health and Social Care Commissioning being done by the Health and Wellbeing Boards.  I do not think at present they have either the appetite or expertise to do it.  Labour is already proposing significant new responsibilities for them, managing the integration of health and social care and also ensuring a much wider remit for public health across all local authority departments. That does not mean that I am happy with CCGs, which spend a considerable amount of public money (about 60% of the total NHS budget), which is about £65 billion per year.  Accountability arrangements are poor.  There are not enough lay members to ensure the proper functioning of remuneration or audit committees,(most CCGs only have two or three lay members.).A Local Authority Member appointment to  provide a better link with the local authority would be a good idea.

But I do not think arrangements for commissioning or governance are what the public is really bothered about. What is important is how they are involved in the body they own, the NHS.  Can they influence it? Before trying to answer that, we need to think what public involvement should be about.

I have had some experience of organising public involvement for the NHS.  The present arrangements can attract enthusiasts with tunnel vision, who are only concerned about a particular clinical pathway or NHS institution, often something which has touched their family.  Others feel they must defend an institution in their town, regardless of whether it is performing well or is even necessary.  Many of them dwell on past experience, and do not understand current clinical practice.  Having said all this I still think public engagement is very important the NHS.

Now if we go into a supermarket we do not expect to be asked to join a committee.  We simply want efficient service.  So why does it matter with the NHS?  Well firstly because we own it, and it has a very close relationship with us.  If the NHS is to thrive it must cultivate a good relationship with the people it serves.  There are big changes happening in the NHS and they need to be explained to the public.  The traditional model of NHS consultation was to come along with a reorganisation plan (which had usually been wrongly described through leaks in the press beforehand) and ask the public if they liked it or not.  Not surprisingly the answer was “No” and many months, if not years, of difficult argument would follow.  There have been various examples where new projects have had to be shelved because of local distrust and disagreement.

Public engagement is a “two way street”.  Clinicians and managers must explain their ideas to the public at an earlier stage than they do now so the reasons for changes are properly understood.  Although they cannot advise on clinical matters, and it would be wrong if they did, patients can contribute to discussions of treatment pathways and on how local services can be organised. To be fair, the NHS is getting better at this.  Rather than simply presenting a “fait accompli” to the public, problems and choices are now more openly discussed.  If we want the public to contribute more financially to the NHS, as it appears they will have to do, then they need to be confident the money is being properly spent and their views respected. But it should be remembered that patient and public engagement is not easy, and time and resources have to be devoted to it. It should not be farmed out to other organisations.  People in the NHS must appreciate public engagement is part of their responsibilities.  Healthwatch has a scrutiny role, and there are risks if NHS bodies rely too much on it to provide public engagement.

Conclusion

Those of us who care about the NHS must be heartened by the fact that the Labour Party has united behind making it a priority election issue. Nevertheless there are some unresolved issues, and both the Party and the NHS must be prepared to debate them openly.  I hope this essay is a useful contribution.

I said the four points I discussed in the previous section were interlinked. They all represent different aspects of the fact that the NHS is something which is there for all of us, to which we all contribute, and to which we all have obligations.  The funding has to be fair, so we all contribute our share, health and social care are about “whole person care” which will affect all of us, public health is about how we organise our society in a healthy way, and engagement is how we interact with a service which we own and cares for us.

The NHS is something very precious, part of what it means to be a good society.  That why it is so important Labour wins next time and ensures its continuation.