The current National Health and Care System has shown the fact that a system can run on the basis of an ethic of altruism and public service, not profit.
The hospitals have always held primacy in our system, and reorganisations have tried to rebalance the system in favour of community health and primary care.
Public Health has been weakened by the 2012 Act and enjoyed more prominence during the period of Primary Care Trusts when it was integrated with Primary Care. This situation needs to be restored
Health and Care need to be integrated regionally and the paper argues for Combined Authorities to be given overall control.
No, the title was not a typo. There is more to healthcare than the NHS which we all know and love. Health Care includes Public Health, Social Care, Pharmacy and Dentistry, and they all need to work together. The present crisis has shown this. This is something which many experts in the field have acknowledged for years; doing something about it has proved elusive and difficult. This present crisis has shown not only the heroic dedication and commitment of the staff, but also the gaps and problems which need to be rectified, so perhaps this is the time to try and do it.
In this paper I have tried to set out some sort of roadmap of the problems we need to tackle. That is why I have called the objective a National Health System, rather than the current NHS, but have preserved the iconic brand which is known all over the world. I once met mountaineers in a foreign land who praised the NHS.
I am not an academic. I have taught about how the Health System works, but more practically I have been a councillor, worked for the NHS, served on a Clinical Commissioning Group and now Health Education England. I wrote a book about how the NHS should be organised with Sunderland University, and I will draw on bits of that in this paper, but my knowledge comes mainly from my practical experience. (“What Sort of NHS do We Want?”, Searching Finance, 2012)
How we arrived at the present position
There is much ignorance amongst the public as to how the NHS actually works. It is certainly very fragmented, but still able to respond as a national system, which has been shown by the present crisis. Many fondly think there was a “golden age” back in the 1950’s when the NHS was first established. Aneurin Bevan boasted of a national system where the “sound of a bedpan dropped in Tredegar would reverberate around the Palace of Westminster”.
We all know establishing the NHS was a political struggle and what emerged was a messy compromise. The immediate problem was sorting out hospitals which needed investment after the war. I can remember seeing pictures of my Grandmother, who was a hospital almoner, lining up the nurses to go out with the collection tins. Hospitals seem to have dominated ever since although they deal with a minority of the people who use the system. There are more patient contacts with GPs, carers, Public Health programmes , and Social Workers. Local Government had played an important role in health before 1948, and Directors of Public Health were important people. Much of what we would now call primary care was still run by local authorities up until the major reorganisation of 1974. Strong central control was the way things worked in 1948, a legacy of the war – the NCB, British Railways, The National Grid and even the New Towns. The new NHS was no different.
Initially Governments thought that a strong NHS would improve health and once the backlog of bad health had been dealt with, costs would reduce. This of course did not happen, so managing the NHS became a constant struggle between improving the service and keeping a lid on costs. In 1974 all health services came under Regional Health Authorities and this remained until the next major reorganisations at the end of Thatcher’s period in power. This was when the concept of the “market” was introduced into the NHS.
At that time the model of the big top-down organisation was being challenged both in the public and private sphere. Although big organisations were still centrally controlled from the top, they wanted more flexibility locally to restructure and adapt to changing conditions at the bottom. Even the army now operates like this. The idea was that those who planned a service would commission it from who could provide it best. Commissioning meant what the service was going to be had to be evaluated and planned. The NHS had to think exactly want it wanted and the best, and most cost-effective way, of achieving it. This does not necessarily mean using the private sector. Other NHS and not for profit organisations are often involved. But it was never a free-for-all. The NHS was still in charge. Resulting from the Thatcher reforms there was a privatisation of many ancillary services such as cleaning, maintenance and catering. For clinical services there was still a preference to commission NHS and not for profit organisations. One consequence of these changes was that local authorities outsourced much of their social care provision, mainly for economic reasons.
The Labour Governments after 1997 modified the model, introducing both Foundation Hospitals and Primary Care Trusts. In my opinion the PCTs were a very progressive reform, and one for which the Blair Governments, Frank Dobson and Alan Milburn received very little credit. They brought together Public and Community Health and allowed a high degree of local government involvement since they covered the same areas as local authorities and usually had councillors on their boards. Under the Blair Government resources were diverted to PCTS, and also prioritised deprived areas such as Easington in County Durham. There was a real push to reduce health inequalities. In my experience the PCTs also put a considerable amount of resource and effort into engaging with the public. In some ways this was a “golden age” for engagement, compared to the much less robust arrangements which replaced them.
The Black Report in 1979 pointed out that despite large investment in the NHS, health inequalities persisted. Professor Townsend, one of the main authors, mentioned Easington in a later report and visited Peterlee to explain his ideas. The dominance of the Hospitals in the system had led to a neglect of both social care and the promotion of health in the community. To reduce inequalities meant placing far more emphasis on how people lived, the conditions in which they lived and looking after them in the community when they were frail or unwell. Successive reports re-emphasised what the Black Report had said.
The Primary Care Trusts were an attempt to redress the power balance with the hospitals. More resources were given to community and public health, which were now integrated. GPs had a major role. The PCTs were coterminous (horrible NHS word) with local authorities, and the Director of Public Health was now appointed jointly between the local authority and the PCT. Cooperation was much easier. Many PCTs had councillors on their boards. The PCTs now had more power to negotiate with the hospitals to get better deals, and work with them. At this stage commissioning was mainly for other public sector and voluntary organisations. The NHS was the “preferred provider”. The PCTs made considerable progress in improving public health, such as the reduction of smoking and teenage pregnancies, and set up many community initiatives.
In my opinion the PCTs were a very progressive reform, and one for which the Blair Governments, Frank Dobson and Alan Milburn received very little credit. They brought together Public and Community Health and allowed a high degree of local government involvement since they covered the same areas as local authorities and usually had councillors on their boards. Under the Blair Government resources were diverted to PCTs, and deprived areas were prioritised. There was a real push to reduce health inequalities. In my experience the PCTs also put a considerable amount of resource and effort into engaging with the public. In some ways this was a “golden age” for engagement, compared to the much less robust arrangements which replaced them.
I think I should make a few remarks about commissioning. Many on the left regard it as synonymous with privatisation. This simply is not so. As explained above the NHS is not monolithic and contains many different sections and specialities. Some of commissioning is straightforward – estimating the number of routine, predictable operations required in a year, like hip replacements. Then it is about negotiating the best deal with a provider. But some is more complex, such as public and community health which requires constructing alliances between different organisations. Using a private provider is not a necessary part of this at all.
All this was changed by the infamous Social Care Act of 2012 which established the Clinical Commissioning Groups. It compelled contracts to be put out for public tender, so private providers could apply, and often threatened to sue if they thought they had not been fairly considered.
Councillors were not allowed to be involved, and their only oversight was through Scrutiny Committees. Public Health was handed back to local authorities. A strong national agency, Public Health England was created to exercise many of the responsibilities which PCTs had previously done including disaster planning and campaigns to reduce smoking and other habits deemed to be harmful to health. I will say more about the consequences of that later.
The CCGs were a result of lobbying by a minority of GPs who wanted to commission directly without the NHS bureaucracy and pressure from private providers who wanted a bigger slice of the action. The Government thought they could use them to reduce costs. The whole enterprise was ill thought out and very disruptive. It is a useful lesson in the sort of “creative destruction” advocated by the likes of Dominic Cummings. The idea being that somehow once the bureaucratic shackles of the NHS and local government had been thrown off, GPs would somehow emerge as the heroes of the NHS and challenge the dominance of the Trusts. I can remember attending seminars before the new act was implemented where it was even advocated that two GPs could form a commissioning group. How they would work out the necessary plans and calculations was not thought about. I can remember a seminar about the changes entitled “Breaking Though”.
In reality it was only a minority of GPs who wanted to run the NHS. Most of them simply wanted to get on with their jobs which were demanding enough. Much of the pressure came from private providers, aided and abetted by members of the government anxious to reduce costs and eliminate, as they saw it, unnecessary bureaucracy. Andrew Lansley, in many other ways a fairly level-headed man, seemed carried away by it all, and David Cameron and Nick Clegg did not really understand it. The only contribution by the Liberals was to ensure lay representation on the new CCGs. The reorganisation was described by one critic as “visible from space” and disrupted the NHS for several years. Patterns of cooperation between agencies, carefully established over time were either disrupted or had to be carried on “under the radar” in the new competitive model. A new bureaucracy had to be established from the PCT staff to perform commissioning.
One hospital (Hinchinbrooke) was taken over by a private company which could not cope and had to hand it back to the NHS. Many private providers attempted to run the new 111 services, but now most of them are organised by Ambulance Trusts.
The idea behind the 2012 Act was that there would be a free market. The CCGs would commission the most efficient service, public or private. Collaboration, whether between hospitals and other parts of the NHS was not, in theory, allowed. Private providers could take the NHS to court if they thought the NHS had an unfair advantage. In practice, however, the national NHS kept a firm grip on things. There is always the need in the NHS to pool risk. If there is an outbreak or crisis in one area the whole system has to pitch in.
The 2012 Act led to an extremely costly and disruptive reorganisation. Many health professionals soon realised that it did not work. In reality the bureaucracy expanded, and much energy had to be expended negotiating between different parts of the NHS. The majority view was that if the NHS was going to cope, two things were necessary. Firstly, more resources needed to be directed to promoting good health, and thus reducing those diseases which were caused, or exacerbated, by a bad lifestyle, such as diabetes. Secondly an ageing population meant more people would need care in the community, rather than treatment in hospital. If they did not receive this care, then they would end up in hospital, as so called “bed blockers”. Hopefully if policies to address these objectives could be put into place it would reduce unnecessary hospital admissions.
Local health professionals have tried to negotiate arrangements for CCGs, Hospitals and Local Authorities to work together. These were originally called Strategic Transformation Partnerships, abut have now morphed into Integrated Care Systems.
Simon Stevens, Chief Executive of the NHS, said in the Five Year Forward View
“The government will not impose how the NHS and local government deliver this. The ways local areas integrate will be different, and some parts of the country are already demonstrating different approaches, which reflect models the government supports, including: Accountable Care Organisations such as the one being formed in Northumberland, to create a single partnership responsible for meeting all health and social care needs; devolution deals with places such as Greater Manchester which is joining up health and social care across a large urban area; and Lead Commissioners such as the NHS in North East Lincolnshire which is spending all health and social care funding under a single local plan.”(Implementing the five Year Forward View 2017)
More detailed plans for ICSs have been set out last year
The NHS Long-Term Plan set the ambition that every part of the country should be an integrated care system by 2021. It encourages all organisations in each health and care system to join forces, so they are better able to improve the health of their populations and offer well-coordinated efficient services to those who need them.(The NHS, Designing Integrated Care Systems in England 2019)
It is important to notice the word “Systems”. These ideas rely on different organisations working together. They do not pool budgets, and have no one accountable management, just committees who liaise.
The trouble is all this is against the 2012 Act. Manchester eventually commissioned other NHS organisations to deliver its community health services, but was threatened with court cases from private providers. All that would have wasted a considerable amount of public money.
The Conservative election manifesto recognised the system was not working in 2017 and proposed changes to the rules. All this has since been forgotten about with the dominance of Brexit but will eventually have to be addressed.
Some on the left see the ICS’ as some sort of conspiracy, implying that there is a secret plan to fragment the NHS and then sell off parts of it. Simon Stevens is often portrayed as being some sort of ogre who is using his American experience to somehow smuggle American health companies into this country. Remember that health is largely organised on state lines in America, and the insurers who pay for much of it want single organisations whom they can work with. I think the reality is somewhat different. Many think Simon Stevens is a shrewd operator who managed to secure additional funding for the NHS.
Ever since I have been involved with the NHS there have been efforts to join up health and social care at a community level, and to challenge the dominance of the hospital Trusts. In the early 2000’s the former Sedgefield Borough Council worked with their Primary Care Trust and Durham County Council to effectively integrate services by putting social workers, district nurses and housing officers in the same room, and Easington PCT considered integrated care initiatives. The Sedgefield initiative worked at a grassroots level because it did not involve redesigning systems. As soon as you tried to set up a new structure people retreated into their bunkers.
It is much easier to set up an integrated system in theory than in practice. One senior insider I spoke to recently said that negotiations to set up an integrated care system locally were not getting very far because of vested interests. Different organisations have different hierarchies and systems of accountability. They are also keen to hang onto their budgets. It looks like a solution will only be reached if the NHS imposes it, and they do not have much spare energy for that at the moment.
I remember the days before local government was reorganised in Northumberland and Durham, and District and County Councils were merged into the present unitary ones. The Government asked councils to work out ways of working together. There were interminable liaison meetings between the different councils which got precisely nowhere, each one wanting to preserve its own interests. Eventually the Government imposed a solution.
Insiders also tell me there is very little interest from councils in the new arrangements. Although in practice working relationships between the local authority and the NHS in most areas are good, some councillors appear to prefer the scrutiny role than actually being responsible for the service.
So overall I think the problem is not so much a conspiracy to carve up the NHS as some on the left seem to think, but rather getting our fragmented system to work together for the benefit of all of us.
Where we are now
Most people on the left believe in a publicly run health service, free at the point of use. They also value the dedication of the staff and think they should be better rewarded.
Socialists also dislike privatisation. There is a difference between having to use the private sector if nothing else is available and the obligation to put services out to tender regardless of whether they are functioning properly as happens now. Efforts to integrate services are also hampered if parts are privately owned, as private providers may not disclose their information and not cooperate. (I remember my efforts on the CCG to get Capita to produce its accounts to the Audit Committee for a service they provided.)
Privatisation often results in poor staff conditions and pay. I think nearly all Labour Party members would wish a future Labour Government to repeal the 2012 act and restore the NHS as the preferred provider.
That is the easy part. Now we get to the difficult issues of how we organise an integrated service in the future and ensure it is accountable. Let me stress now that I do not want another major reorganisation. Our NHS staff do not deserve that. Rather we must think about how what we have now can be made to work better.
I have not said much about Social Care, either personal, which is delivered at home, or residential in care homes. It is widely accepted that the situation is at crisis point. The paper by Professor Paul Corrigan is an excellent starting point. A recent briefing by the Nuffield Trust emphasised the dimensions of it. (Nuffield Trust, Election Briefing Nov 2019.) Here are a few statistics:
We believe the scale of the workforce challenge has so far been underestimated: our new calculations show that just providing a basic package of care of one hour per day to older people with high needs would require approximately 50,000 additional home care workers now. To provide up to two hours would need around 90,000 extra workers. ( Then there is the question of where they would come from if Brexit is implemented)
A decade of austerity has seen government funding for local authorities halve in real terms between 2010–11 and 2017–18,* which has led to councils tightening the eligibility criteria for care. It is known that there were 20,000 fewer older people receiving long-term social care services in 2017/18 than in 2015/16, but this is likely to understate the problem – estimates of unmet need go as high as 1.5 million.
Constraints on public sector finances in recent years have meant that fees paid by councils to the organisations that provide home and residential care have been cut repeatedly. The predominant approach used for buying services from providers incentivises organisations to provide a bare minimum of services and nothing more. Some 75% of councils report that these organisations have either closed or handed back contracts in the last 6 months, creating enormous disruption and discontinuity for those receiving care.
The problems of Care Homes have been highlighted by the current pandemic. There are roughly 11,300 care homes in the UK who look after 410,000 residents. Most of their income comes from fees paid by residents or their families, with a minority provided by local authorities. In practice the private fees subsidise the public ones which are often insufficient to cover the costs of the residents. Sally Copley of the Alzheimers Society says “The whole system hasn’t been working properly for some time”. Many staff are on zero hours contracts and staff shortages are endemic as Professor Corrigan pointed out. Staff are paid far less than they are worth and do not receive adequate training nor professional recognition.
We all have formative experiences which make us socialists. One of mine was in a care home where a member of my family was a resident. I knew two married members of staff well. Both were dedicated to their work and the residents. They were always cheerful. I can remember them saying with great enthusiasm how they had saved up enough to take their young family to Great Yarmouth for a week in the summer. Their work deserved far more reward than that. I though “something has to be done about this”.
A proper care system would assess people on the basis of clinical need, not ability to pay. At the moment there is continuing health care, provided by the NHS, which is free, for those thought to have health issues, but domiciliary and residential care largely has to be paid for by the clients or their families except for the minority who benefit from a stringent means test. Dementia is not classified as a medical condition. Many people feel this system is unfair. A senior commissioner I spoke to said she would rather commission “care” which would be provided by professionals trained by the NHS, rather than try and distinguish between continuing health care and social care.
At the last election the Labour Party promised free personal care for those over 65, as in Scotland. As the Nuffield Report points out this does not include assistance with cleaning and general supervision.
One of the best assessments of the cost of integrating health and social care was done by Kate Barker and associates for the Kings Fund in 2014. They looked carefully at what social care involves, and how it could be paid for. There are different levels of social care, and they conclude that the same principles should apply as to the NHS. Afflictions can strike anyone, rich or poor, so care funding should come from the public purse. The costs of care and treatment should be publicly funded, although this might not include the actual “hotel charges” for residential care. The authors suggest various ways to raise the extra funding, such as means testing free TV licences, and requiring those (usually better off) who continue to work after the retirement age to pay national insurance. There would of course be a need for those on higher incomes to pay more tax, possibly after the age of 40, and the Government should consider a wealth tax which in reality for most would be a tax on your home. There are various avoidance schemes and tax loopholes for the wealthy which could be closed.
There would probably be agreement amongst socialists that health and social care should be integrated and paid for out of taxation, but it is no good thinking only the rich would have to pay. Everyone would have to pay something.
Finally, there is the issue of Public Health. Transferring it to local government has not been a success. The budget, supposedly ring fenced, has been diverted to other local government departments because of the squeeze on local authority finance, and last year some of the poorest authorities took a very big hit. Durham lost almost 40% of its public health funding. Yet even in its diminished state, The Centre for Health Economics at York has estimated that expenditure on Public Health is four times more effective in promoting health than that spent on the NHS. Simple common sense tells us that keeping people healthy is better than curing them once they are ill.
Several distinguished epidemiologists, including Professor Allyson Pollock at Newcastle, have argued that the marginalisation of Public Health locally has severely reduced the country’s ability to deal with the coronavirus epidemic. Back in PCT days Public Health had the resources and plans to deal with disasters, often pooling risk with others. Now that has been transferred to Public Health England, leaving local authority public health departments to deal mainly with schemes to keep people fit. Worthy enough, but nothing like the resources they used to have. A regional public health response might have led to better testing and efforts to contain the virus. The Government’s response has been “one size fits all”. Restoration of the importance of Public Health and its reintegration with the NHS should be a major aim of policy.
Our policy objectives will be ambitious. We might need a five year, or even ten year forward view to coin a phrase.
We seek an integrated National Health System, encompassing the National Health Service, Social Care, Public Health, with links to Pharmacy, which has a role in primary care, and Dentistry, which is not a totally public service although the NHS controls the training. But we do not want a major reorganisation again. Our dedicated health and care staff do not deserve that. What we want to do is give the present system more resources and steer it in the right direction. Repealing the 2012 Act would be a priority.
We must ensure that particularly in social care staff are paid a decent wage and given proper access to training. The present system which relies on the minimum wage and zero-hour contracts must end.
The first thing we know is that all this will cost more than it does now, although integration may produce some savings. A future Labour Government has to be honest about this. It is no good promising a few rich people will pay, as the public simply will not believe it. It is a good principle that everyone should contribute to something which is part of national solidarity, so all feel that it is theirs, but contributions have to be proportionate to the ability to pay. A proper revaluation of properties, which is akin to a wealth tax, would raise money through the community charge to make a substantial contribution to social care. An increase in National Insurance, earmarked for the NHS should be considered, provided that it became more progressive.
Then we come to the whole issue of Governance. Despite showing little enthusiasm, local government needs to be involved in the whole strategic planning of the NHS. But they must not see it as simply concerning their own territory, so to speak. The present structure of Foundation Trusts should stay, but Public Health and Commissioning Services should be reintegrated into Primary Care Trusts, in my opinion one of the most successful NHS organisations in its long history of restructuring. The PCTs would have oversight of Pharmacy and Dentistry. Many of the responsibilities transferred to Public Health England should be restored to the PCTs. Their boards should contain both professional and local government representation.
There is a need for a regional dimension in all this. When the Northumbria Trust reorganised its A&E provision to build a super emergency only hospital at Cramlington it did not consider the effect on major hospitals in Newcastle like the RVI. Patients in Hexham, for example would find it easier to go there than to Cramlington. This is just one example of where a regional perspective would have been useful.
Local authorities’ power over social care providers need to be strengthened. At present there is a real mixture of providers, commercial companies, charities, cooperatives and individuals who provide personal care as a small business. There is a strong argument for integrating the private sector, which is virtually bankrupt anyway, into area trusts responsible to local authorities. Standards and remuneration need to be strengthened.
Trying to merge different organisations would be very difficult and disruptive. The result could be some unwieldy bureaucracy which would be difficult to manage and slow to react to changing needs and priorities. Accountability should be pushed upwards. We need to have some sort of accountable umbrella which ensures that hospital trusts, PCTs (coterminous with local authorities) and Social Care, which is regulated by local authorities, all work together. There will always be oversight from NHS England, NHS Improvement, and the Care Quality Commission, but these bodies are mainly regulatory. There needs to be a more local system of Governance and Oversight.
Nationally the country is moving to a system of Combined Authorities which at present oversee economic development and transport. Manchester has also had community health added to its powers. A combined authority does not take powers away from local authorities.It has power and oversight over services provided by other organisations. Its membership is delegated from existing councils, with a mayor if that is agreed. It would seem logical for a combined authority to exercise oversight over the Foundation Trusts, PCTs and Local Authority Care in its area and produce a plan to ensure they work together. The CCGs now cooperate to cover larger areas in any case. That way we preserve flexibility within the system without adding another layer of bureaucracy,and move towards the integrated National Health System we want.
I want to end by stating that as socialists we owe a great deal to the NHS and Care Services. They are an example, much admired elsewhere, of how a publicly run system can be successful, and that duty and altruism more important motivators of human conduct as making a profit. It is our duty to ensure it is funded and run properly.
David Taylor-Gooby, author on the NHS and member of the Socialist Health Association