The key challenges for care are:-

• the level of funding is inadequate
• not enough is done on primary prevention, social determinants of health and inequalities compared to remedial care
• waits are too long especially for diagnostics
• the outcomes from the system are not good enough
• the variation in outcomes is unacceptably large
• our experience of care is often poor in both health and social care
•  provision of care is not joined up around the needs of individuals
• not enough is achieved in terms of reducing inequalities
• care is still in silos (acute, primary, social, mental health etc)
• focus on the individual, little concern with populations or community
• poor accountability

Root causes of key issues are:-

The level of funding is inadequate

• magic solutions do not work
• needs investment to enable changes
• needs higher level of revenue funding in both social care and health
• inefficiencies through fragmentation

Not enough is done on primary prevention compared to remedial care

• Clinical culture focued on interventions
• No tradition of focus on population health and poor evidence base
• We are an individualist society and getting more so.

Waits are too long especially for diagnostics

• Poor management of the workflow
• Inadequate investment in people, systems and admin

The outcomes from the system are not good enough

• Inadequate useful data to clinicians which is then used to encourage better practice
• Inadequate inspiration by leaders and the system
• Inadequate peer competition
• General practice not interventionist enough
• Inadequate funding in some areas
• The UK population has poor health literacy and knowledge

The variation in outcomes is unacceptably large

• General practice is poorly managed and poorly organised
• Lack of effective role for Royal Colleges in publishing and enforcing standards
• Lack of commitment to collect/publish high quality comparative data

Our experience of care is often poor

• Chronic underfunding of social care and resulting poor quality of workforce
• Little shared decision-making or for self-care
• Inadequate respect as a patient
• Admin across the NHS for non-urgent care is poor
• Clinicians are not interested or familiar in responding to patient experience

Provision of care is not joined up around the needs of individuals.

• Although the NHS is a single system, silos around power bases remain
• Inadequate records, poorly coordinated records and patients don’t yet have access to their information
• Little research and guidelines
• Differentiated provider bodies and royal colleges
• Separation of a means tested social care system
• GPs as small businesses
• Fragmentation caused by H&SC Act
• NHS separate from rest of public services

Mental and physical health are split, intellectually and functionally

• A Cartesian system
• A historic divide
• Different nurse training in the two sets of hospitals
• Few liaison psychiatrists, even fewer in paediatrics
• Difficulty in doing diagnostics in mental hospitals
• Difficult responding to recurrent problems with no diagnosis

A frightened and bullied and multiply inspected NHS

• Stressful work and defensive attitudes
• A hero culture, little support for clinicians
• A legalistic approach to failure
• The simplest response to failure is to inspect rather than find causes and holistic responses
• Little trust across the system
• Little experience or trust in formative processes outside general practice.

Poor accountability

• NHS has never had any democratic accountability
• Hostility of professions to Shared Decision Making and Community Development
• Cultural divide between health as bureaucracy and social care as democratic accountability
• Public distrust of elected representatives
• poor quality of some elected representatives; lack of training and development.

Some REMEDIES

Increase Resources in Health and Social Care

• £2bn into transformation fund
• settle pay disputes
• increase funding into social care
• invest in development of councillors, governors, senior managers in care system
• invest in community development and PPI
• take strategic control over capital spending and asset management
• remove role of competition authorities
• stop competition in the NHS
• new funding scheme – to channel most funding through LAs based on weighted capitation set up a transformation fund
• Challenge Treasury on the drive to austerity
• centralise major property management (eg PFIs)
• renegotiate PFIs
• Begin reverse PFI for redundant land, working Has to lease it out and gain substantial profits

Primary prevention, the social determinants, reducing inequalities

• Boost Public health (how?)
• Promote community development
• Introduce in training for all community staff and all clinicians
• Assurance and inspection regimes insist that this is a vital focus
• HWBs to become the commissioners
• Harness the Social Value Act
• A Living Wage

More focus on communities

• Community development throughout primary care
• A stronger PH focus
• A clear evidence base
• Community reps on Boards and on all key commissioner committees

Waiting

• Use modelling
• Improve management
• More staff
• Online booking and customer management systems
• Invest in diagnostics

Outcomes and variation

• Improve role of Royal Colleges in publishing and enforcing standards
• collect/publish high quality comparative data
• peer competition
• NICE to focus more on multimorbidity
• Invest in diagnostics
• Restart the National Service Framework approach
• Performance manage primary care, with a more formative approach than now.

Poor Experience of care

• Patient experience outcomes as part of performance measurement
• Training for all clinicians in promoting shared decision-making and self-care through techniques such as motivational interviewing
• Making available and in all clinicians’ consciousness techniques that encourage SDM/SC, such as record access, decision aids, patient agenda setting, group appointments
• Reduce waits through more staff, far more use of IT, more diagnostics, modelling, buddying poor performers with better ones, comparing performance publically.
• Improve admin through shared electronic records, tripadvisor feedback, more staff.

• plan to bring social care staff into A4C
• consult on new workforce planning system
• support staff through systems such as Schwartz rounds

Siloed care

• remove role of competition authorities
• remove payment by results payment and replace with a range of options that could be trialled, based on success in other countries
• rebuild and invest in partnership structures (like SPF)
• repeal HASCA
• social care free at the point of use, eventually, starting with palliative care.
• Commissioning through HWBs, then through LAs – will need significant boost to existing HWBs.
• Community development supported to integrate statutory services from the ground up

Mental and physical health are split

• Nurses to have physical health training
• More liaison psychiatrists, including in paediatrics
• ??

A frightened workforce

• Formative assessments
• Dismantle much of the inspection regime
• Support staff through Schwartz rounds and similar interventions
• Either make all hospitals FTs or get rid of the FT concept (my preference) while keeping the PPI aspects
• Remove failure regimes
• No competition in the system except for peer competition
• NSFs
• Social care staff into A4C

Poor accountability

• Assume participatory and representative democracy
• move to a rights based approach to entitlement
• community development throughout primary care
• lay people in all key committees in commissioning organisations
• improve the FT-type structures and include in all commissioning organisations
• remove competition and marketization in the NHS, thus almost removing the corporate influence
• democratically accountable commissioners