National Policy Forum Consultation Document
Issued as a discussion document by the Labour Party March 2002
I’m delighted that you are taking part in the Labour Party’s policy consultation process and I hope you find this document thought-provoking and informative.
This is one of five documents produced this year as part of our Partnership in Power process. Partnership in Power is about how we engage in the key policy debates that are crucial to our country’s future. Whether on the issue of the future of the health service, Britain’s role in the world, raising industrial productivity, reshaping our welfare system to create opportunity for all, or improving the level of political engagement – in all these areas your contribution is crucial to our long-term policy development.
The purpose of this document is to explore the key issues around the subject and the challenges Labour in government will have to tackle. These documents are not intended to be comprehensive – either in their coverage of what we have done as a government, nor in all the many issues that could be raised in each area.
Instead the document is intended to provide a platform from which to consult with the British people. Your contributions and thoughts are extremely welcome – there is summary of the consultation questions at the back of each document. Submission will form part of the process that will help shape Labour’s next election manifesto, and I can assure you they can and do have a big impact on the way we develop our policy.
Thank you again for your interest – and please do take the time to let us know your views on these important matters.
With best wishes,
Charles Clarke MP
Chair of the Labour Party
The economic and social strength of a nation relies on the health and well being of its people. Better health services are only one part of improving the nation’s health. Our aim has to be to both provide high quality health services and improve health outcomes across all communities.
For the British people the NHS is the most important Organisation in the country. There remains overwhelming support for an NHS providing health care based upon need rather than ability to pay. Health care is not just another commodity to be bought and sold in a market. Our need for health care is, by its very nature, unpredictable and can be extremely expensive. People realise therefore that health care is best provided through collective action. Rather than asking people to take the risk of providing for their own care it is surely right that we provide for it collectively through general taxation, pooling resources and spreading the risk across the population as a whole.
The NHS is not just a structure. It is a set of values that go beyond the provision of health care. More than any other institution the NHS expresses our core belief that we can do more when we all work together rather than just for ourselves. This must provide the basis for everything we do in developing health policy.
Our vision is of a health service designed around the need of the patient. To do this requires significant extra public investment in health; the growth of capacity – more doctors, nurses, and other NHS staff, modern hospitals; and reforms to the supply side – decentralisation, a stronger relationship between health and social care, a clear focus on tackling health inequalities and more choice for patients.
In the 2000 spending review, the Labour government announced record increases in NHS funding, and in the 2001 pre-budget report we said that it will be right to devote a significantly higher share of national income to the National Health Service. Labour believes that the right way to fund the NHS is through the current system of funding through taxation. (See annex A for why the current funding system is both fair and efficient).
As we commit extra resources to expand capacity and NHS-funded care, we are also committed to major reforms in the way in which care is delivered. The health reform programme applies the Prime Minister’s four key principles of public service reform. They are high national standards; devolving power to the frontline; greater flexibility for public staff; and promoting choice. These are the big challenges ahead. In meeting them our overriding principle is and will remain what is best for patients.
Over the next few years the NHS will start to look and feel like a better service as the reforms already introduced take hold. For example, NHS Direct is transforming access to the health service. There is so much more still to do. Rebuilding the health service for the 21s’ century is among the greatest challenges for our generation.
High quality public services are a key pillar of a fair and prosperous society. Tackling long-term under-investment is the first step to achieving that. Record and sustained increases in investment have been allocated up to 2003/04 and substantial extra resources will be required beyond that.
As the Wanless interim report makes clear, the UK has under-invested in health over a number of decades. It is mainly the size of this under-funding, rather than the method of health funding that explains the difference in the performance of the NHS versus other European countries. Other European countries have been spending more public funds on health, regardless of whether they are tax-financed like the NHS, Denmark or Sweden or social insurance funded like in Germany.
Health expenditure per capita and as a percentage of GDP (1998):
|Country||Per capita||% of GDP|
Source: OECD Health Data 2001
- Per capita expenditure is expressed in US$ economy-wide purchasing power parities
- EU-15 Health spending per capita is population weighted. Health spending as a percentage of GDP is income weighted.
This spending backlog means the NHS – and the country as a whole – lacks capacity. It has insufficient doctors and nurses, few hospitals and insufficient modern equipment and treatment. We all know that the NHS has lacked investment and reform. It is this we are seeking to put right.
On investment, the NHS is today the fastest growing health service of any major country in Europe. Given the Tories’ policy to reduce spending as a proportion of GDP, they want to see more private forms of funding like in the United States (for example more use of charges for clinical services and greater use of private medical insurance). This means that access to health care would increasingly be based on people’s ability to pay. This will make the NHS one of the main issues up to and including the next General Election in the UK.
For the past 50 years, the NHS has provided largely comprehensive services, overwhelmingly free at the point of use. By so doing, it has provided good health care for all citizens, unlike for example the United States where over 40 million people have no health insurance. As health costs rise, now more than ever we should say unequivocally that the right way forward for Britain is an NHS provided according to need, not ability to pay.
On reform, the Labour Government produced the NHS Plan in July 2000 in consultation with patients and NHS staff as our strategy for the next 10 years. This forms the framework for the development of policy and practice for the reform of the NHS.
By the time of the next election, there wi11 be 20,000 extra nurses, 7,500 more consultants and 2,000 extra GPs. Waiting times will be down for hospital operations to a maximum of six months by 2005 compared to 18 months now. People will have to wait no more than 48 hours to see a GP and local people will have more say in the policies that affect them. Services will have greatly improved in our priority areas of cancer, cardiac and mental health services, alongside care of the elderly.
The new Primary Care Trusts (PCTS) will mean that GPs will be working in teams alongside nurses, pharmacists, dentists, therapists, opticians, midwives and social care staff. The GP surgery will be the place where appointments for outpatients and operations are pre-booked to suit the patient. More information will be provided to allow patients to exercise greater choice. A new range of intermediate care services will help people resume independent living more quickly.
Power and resources will be devolved to local health services. Primary Care Trusts will control 75 per cent of the total NHS budget. Both PCTs and Trusts will be subject to rigorous performance assessment and the NHS Modernisation Agency will be on hand to support those organisations that need it most and to spread good practice throughout the system. Local health services that are doing well will have more rewards such as team bonuses and more freedom to deliver their services. Those that are performing badly will be given more support, help and where necessary intervention. In a small minority of cases new management will be brought in to turn the service round.
Good managers see things through the patient’s eyes – asking their views on what is convenient, what works well and what could be improved. They find a better way of doing things, making treatment and care easier and quicker for patients. Where this has been done, it has resulted in improved services for patients, improved productivity, and in many cases it has released resources to spend on other areas of health care.
People will have the reassurance that the NHS is adopting high standards and striving continuously to improve the quality of its care. There will be strengthened and streamlined independent inspection of organisations providing NHS care. So these are the health challenges we face as a country and the steps we have already put in place to meet them. We believe, because of these measures and the record investment we are making, that the NHS is now on the road to recovery. But we must now consider how we can build on this progress which again will require hard decisions and determined action. Throughout, our wider policy agenda will mean that the underlying causes of ill health continue to be addressed. In order to improve health, tackle inequalities and transform health care we need to fulfil four objectives.
1. Reducing Inequalities and creating a healthy Britain
Better health services are, of course, only one part of improving the nation’s health. We all know that the most dramatic progress in our health in the past has been because of social advances along side new medical treatment. Improving the health of everyone and the worst off in particular is a matter for the whole of Government. The crusade to tackle child poverty – which has already seen a million children lifted out of poverty – and the record numbers in employment will have a significant longterm beneficial impact on the population’s health.
So there has been progress in our first term. We set demanding targets for tackling some of the major killer diseases. More screening services, greater prescribing of cholesterol-reducing drugs, new smoking cessation services and programmes like Sure Start have contributed to a better focus on health improvement. The life expectancy gap between rich and poor has narrowed for the first time in decades. But still boys born to low income households die seven years earlier than for high income for girls the gap is six years. The life expectancy gap between Manchester and Kingston is seven years. There are many indicators of health outcomes readily available, although in some cases with a time lag of a few years, for example life expectancy, infant mortality, survival rates and measures of morbidity. What e/se can we do to shift the focus still further from the nation’s health service to the health of the nation? How can we ensure we don’t lose sight of this fundamental objective?
Poor health has complex causes. The worst health problems will not be tackled without dealing with their fundamental causes. This means tackling disadvantage in all its various forms – poverty, educational attainment, unemployment, environmental, crime and disorder, domestic violence, discrimination and social exclusion. How can we step-up the cross-governmental focus on health inequalities? What more could local government and other organisations do to tackle health inequalities?
In creating a healthier Britain, however, Government can only do so much. Many causes of ill health are based on lifestyle choices. People make their own choices about how to live their lives but Government needs to make sure they have the information they need and that real opportunities to lead a healthy life are available to all and not just some. What role should Government Play in providing people with information and opportunities to lead a healthy life? How can Government encourage people to take responsibility for developing a healthier lifestyle?
This is particularly important for children’s health. If a mother smokes the child is much more likely to have a low birth weight and suffer a range of further health complications throughout life. In this Parliament the Labour Government will pass an Act banning tobacco advertising but we need to take measures to reduce smoking further. The NHS smoking cessation services are the best in the world. Neo-natal and primary care services both play an important role at this stage of a baby’s life. We need to explore how working with other early years services can better support this important service. Is there anything further that the Government should do to reduce smoking? Is there any way in which we can improve neo-natal and early years services?
Health inequalities continue to manifest themselves through childhood and whilst we have made a start with changes to education we need to look much more thoroughly at increasing the way in which schools can improve the health of children and parents. We are already implementing the policy of placing free fruit in primary schools, but we need to do more to tackle food poverty and poor diet. Other organisations have a role to play too, for example housing associations and small businesses. Our policy of reducing child poverty will have an important and positive impact on the way in which health inequalities are bequeathed from generation to generation. How can schools play a bigger role in helping children and parents develop healthy habits? How can we ensure that reductions in child poverty have an impact upon health improvements? Is there a role for employers to promote healthy lifestyles among their employees? How could this be encouraged?
Good healthcare is an imperative for improved productivity and national economic success. Sickness is a major cost for business, not to mention the personal costs associated with ill health. The CBI estimates that temporary sickness absence costs business over. £10 billion each year. In the past “occupational health” has tended to have a heavy health and safety bent to it. To reduce ill health caused by work activity we need to ensure that businesses continue to provide a healthy and safe working environment. How can we improve occupational health care services for both employees within the NHS and more generally to employers? How can we ensure that occupational health provision is provided for all employees irrespective of the size of the employer?
Increased drug use and binge drinking by some young people and adults are having a detrimental effect upon their health. It is important that health education is not seen as being against people ‘having a good time’. However given the impact on health throughout life, we do need to get messages across about these issues. It is also the case that England has higher rates of single parenthood and teenage pregnancy than other European countries. How can we make any impact on these aspects of young people’s behaviours that cause health problems in later life?
We have a huge programme of work underway to meet the longer-term challenge of improving mental health. Mental health promotion can contribute to improving the general health of people living with mental health problems and challenges discrimination. Promoting mental health in schools can play an important role in reducing inequalities, by reaching vulnerable or at risk children. We know that half of young people diagnosed with a serious mental illness will attempt suicide and one in ten will succeed. It is a tragedy that these people’s needs have not been met when they are at their most vulnerable. What systems can we put in place to reach out to people, particularly young people, to break down taboos and encourage people to seek help at an early stage?
2. Reform of health services
But, of course, a high-quality NHS is also vitally important to improving the health of the nation. We can achieve the best by making the NHS more responsive to NHS patients. That is our overriding objective. This means pursuing traditional NHS values – health care that is free, delivered according to need – and also developing new ways of delivering those services so that patients and their families have a better experience of the NHS.
High national standards
The National Health Service was set up to provide good health care across the nation. But patients do worry about a “lottery” in care where access to health care or a new treatment is determined by where you live. This lottery is not just wrong but also dents public confidence in the whole NHS. When we came to office in 1997 there was an absence of national standards, no means of implementing them, of spreading good practice or eliminating bad practice. That has now changed with National Service Frameworks for the major conditions like cancer, heart disease, mental health services and care of the elderly and the National Institute of Clinical Excellence laying down clear standards on which treatment and drugs work best. This is all part of our drive to raise standards of care for patients. We also need to ensure that there are national standards for primary care services. We will start with a clear standard for access to your GP but need to ensure that access to health visitors and other primary care staff is also available across the country. The Commission for Health Improvement – the new health inspectorate – is being given greater independence and more powers to ensure these standards are applied right across the NHS, including the ability to ensure struggling hospitals are put on ‘special measures’.
Where an NHS service is failing local people we want to see it improve. Special measures could include external help through the Modernisation Agency or in extreme problem cases bringing in – or franchising – the best people to help turn it around. In most cases this will be top managers from within the NHS. However, we should not close our minds to the involvement of people from elsewhere in the public sector, the voluntary sector, charities, universities, the private sector or local government if they have the expertise necessary to improve the local NHS. Drawing on appropriate management expertise to improve an NHS hospital is not privatisation. Franchising does not involve selling off or handing over the ownership of a single NHS asset to the private sector. These hospitals will remain in the NHS. But both NHS patients and NHS staff will have the benefit of better management. What more can we do to overcome persistent problems? What are the barriers to change? How best can we overcome them?
Devolution of power and resources
For 50 years Whitehall has attempted to run the NHS on a day-to-day basis. Since the NHS employs over a million people and treats almost a million patients each and every day this has proved impossible. The 2001 manifesto committed the Labour Government to decentralise decision making to local Primary Care Trusts by giving them control of 75 per cent – £40 billion – of the NHS budget. This is a good start. But now that for the first time there are not just common standards but also an independent inspectorate in place to guarantee them across the country, further decentralisation is possible.
Devolution is a key step in ensuring that the NHS becomes more accountable to the people it serves and is able to respond quickly and effectively to problems and local needs. For the first time, all NHS trusts and Primary Care Trusts now have to ask patients and carers for their views on the services they receive and these views will be published as Patient Prospectuses. We want to see the local NHS providing services that meet national standards but also focus on the needs in local communities. In primary care what could PCTs do to give individual GP practices better incentives to develop services for patients? In secondary care, what resources should staff have control over? How can we improve the accountability structure of PCTS and Trusts so that both patients and public have a bigger say on their local health services? What further incentives are needed in the NHS to improve services?
We are already working with the best NHS hospitals to see if a new form of NHS Organisation could be established. These would be fully within the health service, still firmly within the public sector but with greater freedom to innovate. Providing greater freedom to improve services – whether in local government or the NHS – can act as a powerful incentive to ratchet-up performance. We need to explore whether the idea mooted by the Co-operative movement of a different kind of Organisation such as “mutuals” or public interest companies within the NHS to give to the staff and the community greater input into their local health services. Whatever the structure of these organisations, every hospital and PCT will remain in the NHS, inspected as part of the NHS, providing services to NHS standards and NHS principles. What are the potential benefits and disadvantages of such approach? Could a similar structure work for PCTS?
Not everything can be nor should be devolved from the centre to the local level. The Government will ensure the integrity of the whole system by setting standards, allocating resources, securing integrated information systems, ensuring a national framework of pay, and staff training. But there are obvious tensions between decentralising power and national standards. How can we ensure we get the right balance?
Local people need to be fully involved in determining the shape and delivery of health services in local communities. There will be a number of mechanisms to help patients and the public get involved, through PALS, Patient Forums, and The Commission for Patient and Public Involvement. Scrutiny by local authorities will be key to improving standards and strengthening the partnership between the NHS and local government. But structures alone are not enough to achieve genuine and meaningful engagement with communities. We need to ensure that local people have the knowledge, information and confidence to participate and really make a difference. Currently, non-executive directors of NHS Trusts are drawn from a fairly narrow social background. How can we support local people from a wide range of backgrounds, in becoming involved in shaping and running health services? What other mechanisms should be in place to ensure that local communities have a say in determining local health services?
Increased flexibility for staff
NHS staff are our greatest asset. To create a modern health service, we will have to make the best use of the skills and potential of all its staff. That’s not always happened in the past when the NHS had a very rigid and hierarchical way of working. If we are to deliver fast and responsive services to patients, we will have to support staff in finding more flexible ways of working, involving teams from different professions. This new approach will reform the old demarcations that in the past have held back staff and slowed down care. But this is difficult. If we empower nurses to take on a wider range of clinical tasks, doctors will also have to be flexible. If nurses are to take on more responsibility they too have to give up other tasks to health care assistants. The same transition is true with all other health care professionals including midwives, radiologists, pharmacists as they develop new professional roles. Breaking down barriers will ultimately enhance the quality of care patients receive but in doing so we must ensure we do not lose the caring element so important to the patient’s well-being. Are we right to pursue changes in skill mix in order to deliver better services to patients? How do we ensure that staff in the health service are supported to work in a flexible way? What sort of changes in pay and conditions are needed to support greater flexibility?
People compare the experience of using the NHS with the quality of service they receive from many high street organisations where services are generally tailored, responsive, and flexible. A modern NHS has to offer services that are fast and convenient for those using them. Over the next few years, patients will be able to choose the date of their hospital operation rather than having it chosen for them. Patients faced with a last minute cancellation of their operation will be able to choose an alternative hospital for their treatment. Heart patients who have waited six months for their surgery will choose between waiting longer locally or travelling further to be treated quickly in another public or private hospital. How can the Government best further its existing policy of patient empowerment through choice?
Most patients of course want a simple choice: the choice of a good local surgery and a good local hospital. And that is why – unlike the failed internal market experiment – we have put in place the levers needed to raise standards everywhere. In the vast majority of cases, the local provider will be a good quality NHS-provider. However, a system where the only choice people can exercise is to opt out of the NHS and get treated privately is undesirable and, more importantly, unsustainable in the long run. How can we promote choice in the NHS?
To introduce more consumer choice into the NHS requires more capacity. The NHS is expanding fast but we need every bit of extra capacity we can get. So we are using the PFI to build new hospitals and making greater use of spare private sector capacity to treat more NHS patients. This is no blank cheque. We use the private sector only to support public services and where we can get good value for taxpayers and better standards of care for patients. But if we can get the private sector working for the NHS we should do so. This greater diversity in supply of services will help NHS patients. The fundamental point is that the NHS pays for the treatment, not the patient. NHS standards of care and inspection regimes apply. The patient remains an NHS patient. Do you think this will lead to a more responsive NHS? Do you agree that patients will benefit from this approach?
Some health services will serve large populations spanning local authority boundaries and health strategies may have significant regional variations. We need to develop relationships with both local government and emerging regional government structures, to ensure that issues influencing public health and social care are fully considered. How can we make sure that scrutiny of the NHS helps to strengthen the partnership between health and local government, and takes account of emerging structures for regional government?
In order to exercise choice, patients will have to have information available about services and this information will have to be provided in a way that makes sense to GPs and to patients. Only with this information will patients be able to make the choice that ‘best suits their needs’. Patients will have access to their medical records and letters regarding their care will be copied to them. What information should the health service produce that will assist patients in making choices? How can we use IT to help patients understand and make choices available to them?
3. Capacity and investment
After decades of under-investment the NHS has problems with both the numbers of trained staff and the standards of buildings and equipment. We are urgently increasing capacity in both.
The biggest problem for patients is delays for diagnosis and treatment. At the moment there are not enough staff to ensure that the public can receive treatment without waiting. There are 90 distinct professions working in the NHS. The delivery of high quality patient care relies on teamwork. Given the years it takes to train a doctor, a radiographer or a nurse, decisions taken before 1 mean t at now we face a shortage of staff which can only be overcome by training more staff. We have increased the number of medical places for doctors by up to 40 per cent from 1997 the biggest increase for a generation. But this will take time to come on-stream. But while we wait for these new staff to qualify, we will ensure greater flexibility in the use of staff skills and recruit, where appropriate, from abroad. The NHS will not actively recruit from developing countries without the agreement of their governments in order not to undermine their efforts to provide local healthcare.
Labour in Government wants to see better pay for NHS staff. New contracts for GPs and hospital consultants, alongside a new fairer system of pay for other NHS staff, are currently being negotiated. If these negotiations go well staff stand to gain and so will the patients through a better use of staff skills.
However, staff recruitment is not only about pay. Many NHS staff cite working conditions as the major factor in their decision to join, remain in or return to the NHS. We will only achieve our targets for staff recruitment by demonstrating that the NHS is a flexible employer that can fit around the needs of its staff. Nurses will come back into the profession if they can fit their lives around their times of work. This is an issue for all medical and other staff. Effective recruitment requires fair terms and conditions for all NHS staff, improved childcare, and career development opportunities. How can we attract more staff to come back to the NHS and staff from other countries to come to work in the NHS?
But recruiting and training new staff will only succeed in helping us build a first class health service if we retain those dedicated and highly skilled staff we already have. This means we must tackle the problems which can force people out of the NHS. London and parts of the South have some of the highest vacancy rates in the country and this is in part due to expensive property prices. We have been working hard to improve this situation. Already around 100,000 healthcare workers in those areas where the cost of living is highest are benefiting from the introduction of the new Cost of Living Supplements of up to £l,000. Should we consider paying NHS staff more in areas of the country where the cost of living is higher? Or would it be fairer to pay all staff the same?
The need to provide the opportunity for staff to purchase their own homes is a significant factor in the retention of staff. The new Starter Homes Initiative will help key public sector workers get a foot on the property ladder in those areas where the cost of living and property prices are high. We need to look at a range of options, including rented accommodation, to suit NHS staff of difference ages and different circumstances. Further improvements to childcare facilities and support are also vital, including more nurseries in NHS clinics and hospitals and local childcare coordinators for staff. Effective training and career development is essential in any strategy for retaining staff. It is important that training and development takes place for all staff and that there are real opportunities for staff to develop their career throughout the NHS. That is why we are creating an NHS University to develop the skills and potential of all the one million staff of the NHS.
What more can be done to develop the careers of support staff? What role should the new University of the NHS play? What more could we do to help ease NHS staffing shortages? What responsibility should there be on NHS staff to improve staff retention and job satisfaction?
We also need to involve staff fully in the development of that health service. How can we ensure that all NHS employers are modem employers and involve their staff in the development of policy?
Modern hospitals and facilities
It will take many years to overcome the decades of under-investment in hospital building. At the moment we are engaged in the biggest hospital building programme ever. Since 1997 we have given the go-ahead for 68 new hospitals. To deliver this unprecedented expansion in the NHS building programme, the Government has adopted new and innovative ways of funding them.
In the past NHS building projects were at the mercy of how much public capital the government could afford to spend on projects each year. Funding was often stopped or reduced after the project was started. Between 1980 and 1997 only seven conventionally funded major schemes were completed. Whilst other models will develop over time and whilst the Labour government is doubling net public sector investment, the main new method of funding schemes is through the Private Finance Initiative. PFI schemes are about creative partnerships between the public sector and the private sector, bringing the strengths of each to bear on the needs of the health service. We are also developing ways in which, within the framework of PFI management, support staff can remain part of the NHS team. We do not want a two tier workforce to develop within the NHS. How can the NHS combine the best of public and private resources and expertise to expand and modernise hospital equipment and systems, including bed numbers? How do we make sure that all capital investment programmes continue to deliver an overall increase in capacity and that we are getting value for money from all capital expenditure within the NHS?
Over the next few years the main problem for the NHS will be one of capacity. That is why we are building new hospitals and modernising primary care facilities. It is vital that we are in a position to ensure that every possible operation for NHS patients is carried out in order to reduce the times that they wait. To increase the capacity open to the NHS, we need also to make full use of suppliers of private health care to ensure that no NHS patient has to wait longer than they should providing of course that patients get high standards of care and taxpayers get good value for money. How can we best work with the private sector to use their spare capacity for NHS patients to be treated on the basis of need and not on the basis of the amount they can pay?
Improved information systems must be a major feature of the changing health service over the next ten years if we are to improve the patient’s experience. The UK health service has a poor record on the use of IT – the result of many years of serious underinvestment. Given the starting point, the challenge of putting in place the necessary technology systems should not be underestimated. That said, Labour is determined to ensure that all IT infrastructures support integrated clinical services and provides more information to the public about their treatment. Over the next few years, we will start to see more electronic booking of appointments for patient treatment and more electronic prescribing of medicines giving patients faster access to care. Electronic health records will avoid patients having to constantly repeat their medical history. What are the priorities for IT in the NHS?
The genetics revolution is already underway. Potentially, genetic medicine and stem cell research could lead to new drugs and therapies, new means of preventing ill health and new ways of treating illness. In time we should be able to assess the risk an individual has of developing a disease including our country’s biggest killers cancer and coronary heart disease as well as other debilitating diseases.
The potential is immense. How best can the NHS prepare for the genetics revolution?
4. Social care
Our vision of social services is of care and support designed around the needs of the user, rooted in the values of community. Expanding staff numbers and investing in frontline services are the pre-conditions for improvements in social care. But investment alone will not deliver. Reform in social services is as vital as reform in any other area of our public services. And the four main principles that underpin the public sector reform programme apply also to social services. The old barriers, which divided health from social care, and separated public from private provision, must now be overcome. The poor performers must receive direct support to do better. The ‘big improvers’ must spread the lessons of improvement. The best performers must have new freedoms to be better still.
In social services investment is growing too. Growth in social care budgets is up to 3.7 per cent in real terms next year compared to growth of 0.1 per cent a year prior to Labour coming to office. But we have not solved every funding problem. Both the NHS and social services must be able to cope with the pressures and demands they face otherwise there is a risk that the whole system will not be able to function effectively. Social services need to be funded appropriately to play its role in this partnership. However, effective partnership is not just a question of extra investment but through pooled budgets and other forms of joint working breaking down the barriers that result in bed blocking and poorly coordinated care for elderly people.
Social workers and social care staff carry out excellent and invaluable work on a day to day basis and we need more of them. One of the most important factors deterring people from joining the social care sector is the negative image that surrounds the profession. Despite playing a critical role within every community, people have very little knowledge or understanding of what social workers and social care staff actually do. We want people to realise that social workers and social care staff help some of the most vulnerable in society including children, older people, people with mental health problems, physical or learning disabilities and the homeless. We have already embarked on the first ever national advertising campaign but what more can we do to encourage more people to become social workers or care sector workers?
A great deal of social care is carried out by family and friends. The Government must support these carers. How can we ensure that everywhere in the country social services and local health services work closely together? How can we support families, carers and neighbours in their work as carers?
People have the right to know that they will get certain minimum standards wherever they live. There is excellence in our social services. Our ambition must be to make it available to all. Of course local services should be attuned to the needs of different local communities. That is why we have locally run social services. But right now, as the recently published performance indicators show, the variation in performance across social care is just too great. For example, the wide variation in delayed discharges or “bed blocking” should concern us as it means people are being kept in hospital when they should be at home.
We need to make performance information more accessible to service users and the public at large. Just as we have recently done for hospitals this year, in future each council will receive a star rating for its overall social services performance. We have already established the Social Care Institute of Excellence (SCIE) in England and Wales to work with key stakeholders to establish a knowledge base of what works in social care and to translate this knowledge into guidelines. How can we get greater consistency throughout the country?
The aim of National Service Frameworks (NSFs) is to drive up standards and to address unacceptable variations in the NHS and social services – established NSFs include Older People, Mental Health and Coronary Heart Disease. Next will be the Children’s NSF which will develop standards to help ensure children and young people are able to access the right services at the right time and importantly that they can take an active part in making decisions about their care. Do we need to set standards and national frameworks at the centre for social care?
The way we organise care can turn into a maze for too many of its users. There is, above all, confusion and uncertainty about where the responsibilities of health and social care begin and end. We must tackle this. In future, we need to encourage faster take up of the legal powers, which are now available, for health and social care to pool their budgets and work more closely in partnership. This year, the first of up to fifteen Care Trusts will come on stream, bringing together in a single Organisation health and social services for older people or for people with mental health needs. How else can we break through bureaucratic boundaries in order to focus on the needs of service users?
People with care needs, particularly older people, want to remain living independently at home for as long as possible. We, as a Government, are committed to helping them do so. This calls for imaginative solutions. We need to work together not just to shore up existing provision in care homes but to develop new services in people’s own homes: intensive home care packages; new more active intermediate care where the emphasis is firmly on rehabilitation and independence. We need a multiplicity of providers – not just good local authority provision and private provision but including other organisations such as the voluntary sector and housing associations. There should be no ideological barriers getting in the way of the best care for vulnerable people. How can we provide more choice for users by promoting greater diversity in provision? How can we strike the right balance between supporting more people to live independently at home – which we are doing – and ensuring a sufficient supply of residential care and nursing home places for people who need them?
Direct payments give choice, control and flexibility to people who need social services. People in England aged 65 or over can already apply for direct payments from their local authority to fund non-residential care services, such as home helps, laundry services and other support. As stated in our 2001 manifesto, we are now looking to extend this choice available to older people, people with disabilities and their carers. In future, these people will be able to decide which services they want with the choice of having cash to purchase services currently given to them directly by local councils. This will place the users of a service in charge of the direction of those services. How can we further empower older people and other social care users? What will this mean for the organisation and delivery of social services?
Our action on long term care – investing in intermediate care, improving standards of care and fair access to services – will generate more important benefits of health and independence for older people. We are making nearly £1 billion available to improve health and social services for older people. This will pay for 5,000 more beds, enable 50,000 more old people to live independently at home and extend respite care to 75,000 more carers. Nursing care assessed and delivered by a registered nurse is now free for everyone in nursing homes. The NHS Plan’s proposals to develop new services for older people represents a better targeting of resources. Making personal care free for everyone would carry high and increasing costs without in itself improving services. What further services do we need to see developed to improve care for older people? /s it right that our number one priority should be promoting the independence of older people, giving them more choice and options about where and how their care needs can best be met?
Questions for discussion
1. Creating a healthy Britain and reducing inequalities
Creating a healthier nation by tackling health inequalities, dealing with fundamental causes of ill health, encouraging people to lead healthy lifestyles, and action to reduce smoking.
1. What else can we do to shift the focus still further from the nation’s health service to the health of the nation?
2. How can we step-up the cross-governmental focus on health inequalities? What more could local government and other organisations do to tackle health inequalities?
3. How can Government encourage people to take responsibility for developing a healthier lifestyle?
4. Is there anything further that the Government should do to reduce smoking?
5. How can schools and employers be encouraged to play a bigger role in helping children and adults develop healthy habits?
6. How can we make any impact on the aspects of young people’s behaviours that cause health problems in later life? How can we improve mental health services for all but particularly younger people?
2. Reform of health services
A more responsive NHS with clear national standards, common independent inspection, devolved power and more freedom for locally run services, greater flexibility for staff, and more choice for patients.
7. What more can we do to overcome persistent problems in local health services? What are the barriers to change? How best can we overcome them?
8. How can we improve the accountability structure of PCTS and Trusts so that both patients and public have a bigger say on their local health services? What further incentives are needed in the NHS to improve services?
9. What are the potential benefits and disadvantages of looking at different kinds of NHS organisations?
10. How can we ensure we get the right balance between decentralising power and national standards?
11. How can we support local people from a wide range of backgrounds, in becoming involved in shaping and running health services?
12. How do we ensure that staff in the health service are supported to work in a flexible way?
13. How can we promote choice to benefit patients in the NHS?
14. What information should the health service produce that will assist patients in making choices?
3. Capacity and investment
Long term investment to increase NHS capacity. Better pay and improved working conditions to recruit and retain NHS staff. Modern hospitals and IT systems for patients.
15. How can we attract more staff to come back to the NHS and staff from other countries to come to work in the NHS?
16. Should we consider paying NHS staff more in areas of the country where the cost of living is higher?
17. How can we ensure that the health service is a modem employer and involves its staff in the development of policy?
18. What more could we do to help ease NHS staffing shortages?
19. How can the NHS combine the best of public and private resources and expertise to expand and modernise hospital equipment and systems, including bed numbers? How do we make sure that we are getting value for money from all capital expenditure within the NHS?
20. How can we best work with the private sector to use their spare capacity for NHS patients to be treated on the basis of need and not on the basis of the amount they can pay?
21. What are the priorities for IT in the NHS?
22. How best can the NHS prepare for the genetics revolution?
4. Social care
Investing in social services, more social and care workers, more support for carers, empowering older people and people with disabilities with direct payments, support for independent living.
23. What more can we do to encourage more people to become social workers or care sector workers?
24. How can we ensure that everywhere in the country social services and local health services work closely together? How can we support families, carers and neighbours in their work as carers?
25. How can we get greater consistency throughout the country?
26. Do we need to set standards and national frameworks at the centre for social care? How else can we break through bureaucratic boundaries in order to focus on the needs of service users?
27. How can we provide more choice for users by promoting greater diversity in provision? How can we strike the right balance between supporting more people to live independently at home – which we are doing – and ensuring a sufficient supply of residential care and nursing home places for people who need them?
28. How can we further empower older people and other social care users? What will this mean for the Organisation and delivery of social services?
29. What major challenges, not already identified, do you feel will be facing health policy in five years time? How should we respond?
Appendix 1 – National Funding
Historically one of the cornerstones of the NHS in Britain has been the way that we have paid for our public health services through general taxation. There is now a vital national debate on different ways of funding the health service and it is important that over the period of the policy making process, the Labour Party plays a full role in this debate.
In these discussions there will be many comparisons with the way in which other health services are funded. It is always important, when making these comparisons, to not only look at the way in which the health service is funded, but the amount of funding. There are four main options for funding health care. Here we judge them against efficiency and equity. In analysing these options, it is evident that funding through general taxation, the current system, is both the fairest and most efficient system for the UK
Efficiency. This is highly efficient from a macro economic perspective. It involves low administrative costs. Because it draws income from such a wide base, it helps to minimise distortions in particular sectors of the economy.
Equitable: Funding health care through general taxation ensures universal access to services irrespective of ability to pay. Access is based upon clinical need. A 1999 study found that funding of health care through general taxation in the UK to be progressive overall.
Health activity. By not charging for services at the point of delivery it does not prevent access to early diagnosis and encourages the public to take up issues such as immunisation
Efficiency: Systems that rely on private medical insurance tend to exhibit poor cost control and the commissioning of health care services is very fragmented. For example pharmaceutical prices are on average 75 per cent higher in the US than the UK. In the US administrative costs are up to 15 per cent higher than in Canada because of the cost of insurance processing.
Equity: In some countries (e.g. the US) private insurance is relied on by a majority of the population as their sole means of cover. In other countries, private insurance is largely taken out by higher income groups. In both cases there are grave inequalities in the resulting health care outcomes. The most obvious consequence of shifting from public financing to private spending is to shift the burden from the relatively rich to the relatively poor.
Health activity: In countries where private insurance is relied upon, the level of access to health services is determined by the level of insurance cover that an individual can afford to pay. It will be the older poorer people in society that are considered by private insurers to have the greatest health risks and therefore face the highest insurance premiums. In the US this means that a significant proportion of the population has no access to health services other than in the emergency room.
Efficiency: Collecting and enforcing charges can incur high administrative costs.
Equity: Flat rate charges that are unrelated to income are regressive. They relate access to health care much more directly to ability to pay.
Health activity: Charges may discourage the public from using preventative services and seeking necessary treatment.
Efficiency: In social insurance systems, employer and/or employee earnings related contributions are usually paid to and managed by social insurance funds. These funds face little incentive to seek to contain the payments they make to health care providers because of their ability to raise contribution rates. This results in inefficient use of resources. Currently in Germany both employers and employees pay very high rates that employers claim cause cost problems. In France in recognition of this, there has been a shift in the balance of funding from social insurance to taxation. Both France and Germany are looking to learn from the UK system to provide gatekeepers to expenditure. It is inefficient in the use of drugs – at only 3 per cent generic prescribing rates in France are far lower than the 60 per cent in Britain
Equity: Money is raised from a narrower base than general taxation, with the costs of the health service falling mainly on employers and employees rather than on a wider group of taxpayers. In 1997 the NHS plan estimated that financing the NHS at current levels from social insurance would cost an additional Ll,000 a year per employee using the French system.
Health activity: In a recent survey, one in four French people declared that they had been put off seeking health care for financial reasons, with women, older people and the unemployed forming a large proportion of those not seeking care.
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