This is our contribution to What Next for Labour/ edited by Tom Scholes-Fogg and Hisham Hamid.
The NHS needs to change to meet rising expectations, demographic pressures of an aging population and advances in technology. It is vulnerable to the tremors running through our failed social care system. It needs to adapt a culture based on reacting to illness into one based on actively keeping people well; from cure to prevention; from care in hospitals to care nearer home. It relies too much, and spends too much, on care delivered in institutions, mostly hospitals, and not enough on prevention, community and primary care. We have to break down the institutional and cultural barriers which prevent care being delivered around the needs of patients; and remove the barriers between “health” and “social” care.
The founding principles of our NHS make it free at the point of need and that is seldom challenged. That it is also universal, comprehensive and paid for out of general taxation is still fundamental to our view but are no longer quite so certain. But change is necessary and all agree change is difficult.
The way ahead is not through reorganisation of structures or making health care into a regulated market. What is needed to improve the quality and efficiency of the NHS is not, primarily, organisational change, but changes in clinical behaviour. The answers are not found just through competition and innovation through the private sector. We set out the key themes for an alternative which can be achieved through incremental change – not another radical reform.
Our views are our own but informed by widespread discussion with clinicians, campaigners, and party members.
Public Health – Prevention and Education
We need to begin our thinking at the point where we could have the greatest impact in the long term, with public health. Clearing the slums, putting in clean water and sewers did a lot for our health, and better road design has reduced mortality as much as better surgery. In recent years the smoking ban was probably the most important single policy as far as effects on health are concerned. People who take enough exercise, eat enough fruit and vegetables, don’t smoke, and drink in moderation live on average 14 years longer than people who don’t. These are not things over which the NHS has much influence. The pricing and marketing of food, drink, and cigarettes are not susceptible to local action. They need intervention at a national level.
Top down legislation needs to be met by bottom up measures which try and educate or nudge changes. A major shift in thinking is required to put public health professionals into the key places where decisions are taken and to establish the function where it can be most influential. Responsibility for all of our wellbeing, including health, should be within local authorities so the links to environmental and social issues can be made. Moving responsibility for public health into local government will give elected representatives the opportunity to make a real difference to the health of their communities.
Active Care – Involvement
Involving people in their own health has a beneficial effect. The NHS has not been good at involving people as patients or in decisions at a local or a national level, and this is an area where there are gains to be made in both health and politics.
We need to move to active care – active in the sense that as patients we feel more confident to look after ourselves and share decisions with clinicians. Decision makers should embrace a proactive approach to public accountability, co-production and community development. Active communities must guide the development of local services. Clinicians should actively respond to needs and offer proactive care to people with long term conditions. We should be using well established mechanisms to predict whose health is most at risk and reach out to them, not wait for them to become ill.
Organizations which provide our care need to be active too; working in collaboration across organizational boundaries (not in competition) to share best practice; working with patients and commissioners to develop the services required. The best should help those trying to raise standards, not wait for them to fail. Active regulation should ensure problems are identified early, support is provided where needed but firm action is taken if that is not enough. We need regulation which does more than set up enquiries after the damage has been done.
Integration of Care
The boundaries between health and social care make little sense to anyone who needs both. Many are shocked to find that when they need social care they are subject to means testing. We need a National care service as much as we need a National health service. In time personal social care should be free at the point of need, as with health and for the same reasons, but the taxpayers are not yet ready to take this step in one go.
There is a wall between health and social care with different cultures, managed in radically different ways, and totally different accountability structures – not to mention health being national and free whilst social care is local and means tested. The failures of integration seen in bed blocking and unnecessary admissions cost money which could be better spent on improving care.
There should be an integrated assessment of need which is recognised across the country; recognising the needs of carers in the process; an assessment which is portable. The criteria used for the financial part of the assessment should be the same as for benefits entitlement and should be simple logical and consistent – including a single method for treatment of capital.
It remains the job of local government to decide how social care needs are to be met, reflecting local circumstances. There need to be incentives to ensure that measures which reduce the need for services – which often require a long term investment – are encouraged. This is not just about social services. It is also about housing, planning, education, transport and other policies under the control of national and local government.
Top down integration can be driven by making local authorities responsible for the overall wellbeing strategy for the area which will include health care requirements. Some services such as those for children or people with learning disabilities could be commissioned by them. Bottom up integration can be fostered by joint appointments, joint staff training and development, shared budgets, shared services and collocation. These have all been possible and have been used by the best but much stronger leadership is necessary and this has to come from elected representatives not from health bureaucrats!!
Shared Responsibility and Coproduction
We must all be encouraged, educated and supported to take more shared responsibility for our own wellbeing and the professions must be better trained in how to bring this about. The many barriers which face those most likely to suffer poor health need to be addressed in ways which encourage involvement and improve access for disadvantaged groups. The principles of co-production, where care professionals and patients work together, must feature more in medical training and professional development. The model of care which leaves the patient a passive object of the clinician’s attention is expensive and ineffective. Clinicians, especially Royal Colleges, must ensure that the idea of co-production is central to medical education.
Changing the Emphasis
Whilst we need more emphasis on prevention and less on cure we also have to shift where care is delivered. NHS culture is dominated by large hospitals and their large costs. Other systems work well with more care being delivered outside institutions, in more local settings and in the home, and medical and technological advances make this easier. If the appropriate infrastructure was in place outside hospitals then we could envisage perhaps a third of them closing and releasing resources back to fund local care.
Closing hospitals or even bits of hospitals raises local anxieties but the clinical model for concentration of high quality care in fewer centres of excellence combined with the ability to deliver a lot more care in more local settings has to be acknowledged and worked through. Effective engagement with clinical and community leadership is vital. Major investment in primary care is essential as is investment in public health, and that may imply less investment in PFI hospitals!
Raising the capital to invest in building up community facilities remains a major issue. New sources of funding might be necessary such as allowing the issue of local “Health Bonds”.
Choice and Information
Evidence shows that greater involvement of patients in their care improves outcomes. More patients want choice about how they are treated than about which organization they are treated by. But choice and involvement must be, and can only be, built on better access to simple, officially sanctioned, information about care and treatment options and care pathways; entitlement and rights. This kind of information is not available for either health or social care and nobody has responsibility for its provisions – this should be local authorities.
It also requires us to have access to our own records both health and other care. For the less able, such as the frail elderly or children, support and agency must be offered to assist with provision of information and so to enhance choice and involvement. The NHS has been slow to embrace the Internet. Portable electronic patient records, with access controlled by the patients, will not only drive process efficiencies but offer other avenues to personalise care and make it independent of organizational boundaries.
Communities need a greater say in local services, especially when changes to local services or closures are planned. This should be based on engagement rather than one off artificial consultations – but the trade-off is that harder decisions can be made in the wider interest. An alliance between clinical leadership and local involvement is essential for extensive reconfiguration of services, such as closing an A&E or a birthing centre.
Commissioning and Rationing
Commissioning is the process where decisions are made about how public money is spent and on what priorities are set and what standards apply. It is also about how we get best value for our public spending. Across local and central government commissioning has been separated from providing so decisions are not unduly influenced (though they must be informed) by provider power or conflicts of interest. This is hard in health care as the only place much of the necessary knowledge and expertise can be found is within the providers, so a more collaborative style to plan and then procure services is needed.
In such a model the local authority does the needs analysis and sets out the overall wellbeing strategy, guided by advice from public health experts. Care professionals specify requirements and establish care pathways. Those with expertise in procurement and contracting identify the providers, and develop the market to ensure the services are secured and best value is achieved. These functions interact but some are best done at national level, some at regional level and some locally. For some service design many clinicians may be involved (though not on a full time basis), for others a simple national template could be enough. It depends and this flexibility mirrors other functions local authorities deal with but not how the NHS operates. Over time leadership and overall responsibility for commissioning has to move to local authorities, although they will no doubt delegate much of it.
Private or Public?
In both health and care services we have, and always have had, mixed economies with private as well as public providers of services, and we have seen scandalous failures in both sectors. In social care most is now privately provided. In health care there have been many recent attempts to increase the role for private sector providers and even for them to support commissioning.
Private providers can produce innovative and sometimes disruptive solutions which public providers do not often develop. There are additional risks in employing commercial providers because of the external pressures to which they may be subject and anyone procuring services needs to consider how these risks and benefits could be managed. Continuing with an established public provider will often be the least risk and that must be honestly reflected in decisions; best value meets preferred provider.
Similarly there is some (limited as yet) evidence that competition for services can improve quality, and for teeth and eyes we have had competition between providers for many years. It is not that competition has no part to play; it is that competition is not the best driving force for change in all services as the market evangelists try to argue. We do not need a proper “market” system, even if we do need some elements of market behavior for some services.
Use What Works
If we have openness and transparency and publicly accountable decision makers then they can be left to make decisions, as occurs with most public services – but not the NHS. There will be national quality standards which must be met and are regulated. But they should not need prescriptive guidance, sets of rules and regulations and imposition from performance management or an intrusive regulator. We need a quality regulator but not an economic regulator as well! We don’t do that for education or social care so why do we do it for health?
Within this framework then using what works, locally if relevant, does make sense.
Patient centred care requires a major shift in resources from acute to primary care and a seamless joining up of social and health care into a single integrated system, but by evolving what works not by one off reorganisation – change coming from below where professionals learn to work together, more than from the top down. By evolving not revolving.