Draft response from Doctors in Unite to Institute of Public Policy Research discussion document “Reforming Health and Social Care”, published September 2023
Summary
IPPR has been a major “left of centre” think tank since 1988. In the main, especially during the Blair – Brown years it espoused social market solutions and proposed policies within a framework of the use of commercial disciplines in our public services and the internal market in the NHS. The Economist described it as providing the ideological backbone to Blairism ( May 2019). It attracts significant financial support from a wide range of of corporate bodies including those with an active interest in health care. In September 2023 it published “Reforming Health and Social Care” which took a broad look at how a future left of centre government might wish to address the challenges of the NHS.
The starting point of the document seems to be be that society:-
1) Cannot bear the present burden of ill health in terms of lost productivity, tax revenues and output
2) Cannot afford a linear expansion in our health and social care needs and the budget needed to address it. We therefore need shift the priority to prevention and managing chronic illness effectively recognising the growing prevalence of mental health problems.
Central to delivering this agenda is
the need to increase (including retaining) and retrain the workforce
improved digital and physical infrastructure that is in line with this new agenda and that is bench-marked against other international health care systems.
the wider improvement agenda must unlock innovation and enhance professional capacity and autonomy. This should include more frontline involvement in service design
Better ways needs to be found to capture both the patient experience as well as measuring their outcomes. The use of Citizens’ Assembly’s could be explored.
Particular strengths of IPPR discussion document
1) Recognition of the economic benefits of increasing healthy life expectancy and preventing ill health, rather than simply reacting to illness. Implicit in this is to complement the traditional medical model of care with a social care dimension.
2) Recognition that many of the policy levers for prevention of ill health lie outside the remit of health and social care services. As well as government, the private sector must engage with this wider model of promoting productive, well-being.
3) The need to plan services with a view to assessing long term outcomes not simply measuring inputs and surrogate outputs.
4) Over recent decades primary and community care has faced relative decline compared to the hospital sector. This has to change and it needs to be actively monitored.
Primary care needs to be built on improved access ( including more IT consultations), continuity and long term relationships. It should be shaped around multi-disciplinary community hub and spoke models through which the hub is an active enabler and facilitator of service provision.
5) The recognition of the potential benefit of public health expertise being based in neighbourhood hubs. This should be linked to identifying need, stratifying risk and promoting well-being within the population .
6) GPs should be offered an NHS salaried primary care consultant role without compulsion and without abolition of the partnership system.
7) The recognition of the vital importance of continuity of care especially for those individuals and with conditions that require such an approach.
8) Social care must be recognised as fundamental for a strategy for prevention of ill health and promotion of independence. It too must embrace the access, prevention and early intervention agenda with a greater alignment of services with need. There should be an expectation for and the right to “care at home”.
There needs to be a more valued and professionalised workforce linked to the establishment of a Royal College of Social Care.
9) The proposals for tax funded free social care provision but this would be expensive in the face of other competing social care priorities.
10) The abolition of the purchaser/provider split and market based target setting. Trusts should be brought back under unitary ( ICS) NHS control and funding pathways should not produce perverse incentives that militate against preventive and community provision.
11) The recognition that good pay and conditions are essential for workforce retention and optimisation
In proposing this approach there needs to be a long term predictable level of resources of an initial catch up increase of NHS expenditure of 4.3% followed by annual increases of 3.5% over the next four year. In social care there would need to be two years of catch-up funding ( 9.6% and 8.3%) followed by increase of about 3.4%. However if free personal social care was to be provided, this would require significantly more initial spending. A catch-up capital expenditure plan is also needed.
DIU welcomes and endorses large sections of the discussion document, whilst having concerns:
- That there is no call for increasing resources beyond 3.6% in health and 5.6% in social care should that prove necessary.
- That the need for the NHS to be not only free at the time of use and comprehensive but also to be publicly provided (not just publicly financed) has not been acknowledged.
- That the costs of offering GPs a salaried option have not been considered nor the underling principles of NHS employment ( e.g. professorially led, clinically independent, patients advocacy – though it does say that the contract should be attractive).
- That the benefits of reducing inequality have been given insufficient weight.
- That any community care capacity fund needs to be recurrent not short term.
- That the reintroduction of nursing bursaries, and debt forgiveness for medical students have not been mentioned.
- Social care will continue to be provided through the present balance of private / public provision. However there is recognition of the risk of “profiteering” and “financial hedging” by corporate elements. Small is good but the problems of scale in many areas is not acknowledged.
- That the the Royal College of Social Care also have quasi-trade union functions. There are already trade unions operating in the social care sector.
- Does not seem to be enough emphasis to early years provision.
- While the document does acknowledge the need for more resources for the NHS and social care it is not clear what happens if we do not have an economic growth “dividend”.
- In view the present massive hospital waiting lists, there is no transformation plan that would deal with this while moving towards a community / prevention agenda.
- There is little in the document on how the various regulators and professional bodies move from a tick box / compliance agenda to one of high standards based on professional autonomy.
DIU recognises that i ts own policy discussion paper from May 2022 , which includes significant overlap with the IPPR document, provides a fuller and more comprehensive strategy for the NHS and social care.