Impossible Challenge?

Where do we go with Labour Party Health Policy in 2012?

The healthier we are the greater the demand for care services. Care costs will rise faster than GDP driven by expectation, the relatively labour intensive nature of the process, technology and demographics.

Free comprehensive health care where there is equality of access and where the risks are truly shared through social solidarity is the mark of a civilised country. In our vision such care should remain free at the point of need and paid for out of general taxation. The aspiration of equal access and equality of outcomes remains and the gap between reality and aspiration must begin to close.

Key problems faced by our NHS are; unacceptable variations in professional practice and ability; increasing inequality; and fragmented services designed around organisational production not individual patients and their family. Hospitals can still suck in resources where primary and community care is allowed to be too weak to enable the shift of care closer to home. Public health, dealing with prevention and education, is in danger of becoming sidelined in England, The market system cannot align financial incentives to the outcomes required.

There are issues around the efficient use of people, and estate, poor use of effective care processes, and hence variable levels of productivity and a lack of focus on patient experience. None of these are new yet repeated attempts to deal with them through organisational change and financial incentives have largely failed. However, a sustained emphasis on instilling inter-professional values of individual care, based on evidence of good care processes, offers a better way forward.

Direction and Culture

The NHS focus has changed in some aspects from “cure” to anticipatory care but needs to change further away from providing unplanned episodic acute care in hospitals to managing long term conditions, where patients receive anticipatory social as well as medical care. Patients must be cared for by one system, not passed from one organisation to another. The inward looking culture must move to a patient- orientated approach highly intolerant of poor care with systems for open reporting and rapid remedial action, tackled through leadership from care professionals. The top down prescriptive bullying management style must be replaced by genuine alternatives, the Empire broken up.

Rather than some magic bullet solution we need to reach a broad consensus on what the problems are and then accept collectively the profound changes necessary to have an NHS fit for the current era. We need to get the improvements in outcomes and efficiencies to match the increased investment of the last decade. We have to do this during a period of reducing funding and do it without the constant upheaval and reorganisations that never appear to work.

A New Vision for Active Care

For at least two decades there has been a lazy and largely evidence-free consensus that somehow competition is the only and best force for rewarding “good” organisations and chastening bad ones. The current proposals would move our NHS to a full market, regulated like gas, water and electricity. Our alternative to the market approach is based on a new version of clinical and managerial professionalism, on co production supported by information provision, integration, and democracy with a political settlement where there is an accountable Secretary of State for Care.

We need to move to active care. We must be active as patients, feeling more confident to look after ourselves and share decisions with clinicians. NHS organisations must embrace a proactive approach to public accountability, co-production and community development. Active communities should guide the development of local services where clinicians seek actively to respond to democratically accepted “needs” including proactive care to people with long term conditions. Active providers working in collaboration (not in competition) and sharing best practice; working with patients to develop the services required. Active regulation to ensure problems are identified early, support is provided where needed but firm action is taken if that is not enough.

Health Joins the Family – A National Care Service

Health care, through the NHS, has been a separate empire or rather a federation of powerful vested interests. Since 1974 it has slowly been incorporated it into the family of public services. However, the artificial barrier between social and health care continues to cause problems. We need a national care service so patients only undergo one nationally agreed needs assessment process, with simple rules for eligibility and one national, portable, standard of entitlement. Over time personal social care should be made free as with health care; the argument that this is justified by risk pooling through social solidarity (as applies to health) is unanswerable. The rising costs of providing quality care for a growing elderly population should be met out of general taxation.

Involvement and Choice

We must all be encouraged, educated and supported to take more shared responsibility for our own well being 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. The principles of co production, where care professionals and patients work together, must feature more in medical training and professional development and in general education and citizenship .

Choice and involvement must be built on better access for patients to their medical records and on simple, officially sanctioned, information about care and treatment options and care pathways. For the less able, such as the frail elderly or children, support and agency will be offered to enhance choice and involvement. An information revolution is still required, years after the “project” commenced. 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 organisational boundaries.
Increasingly patients should be offered choice over where and when they can access advice, support or care, with the minimum of waiting. But this is choice about how care is provided as a key part of the personalisation of care, not choice of provider organisation as a device to force market solutions.

Care Closer to Home

Increasingly care should be provided in the home or closer to home, making use of a much more dispersed model for care provision but also of the emerging technologies around telemedicine and monitoring, with knowledge transfer permitting patient-led processes. Over time investment in primary and community care and the merging with social care will accelerate the closure of acute facilities: fewer beds, less in-patient procedures, more ambulatory care and more day case surgery. This is not a cost cutting approach and indeed can only happen after considerable investment in capacity building outside hospitals. But it has to overcome the vested interests and political interference.

Health education and illness prevention has to be tackled at community level with leadership from local authorities; and tackled in ways which, for example, treat the issue of family breakdown as seriously as we once took public health issues around slum clearance and sewerage.

Communities need a greater say in local services, especially when reconfiguration or closures are planned but based on engagement rather than one off and artificial consultations – but the trade-off is that the harder decisions can still be made in the wider interest. An alliance between clinical, managerial, and political leadership (and local involvement) is essential for the extensive reconfiguration of services, such as closing an A&E or a birthing centre.
All key decision making bodies must provide, as of right, places for patients and public.

Commissioning Care

Commissioning is a term for the long term planning processes by which decisions are made about how public money is spent, on what, and to what standards. We need some objective process since we can never fully address all care needs. It is also about how we plan continually to get best value for our public spending in the light of known and emerging health challenges. In the view of many, the “internal market” weakened the planning processes which, in the past had aided sensible health care provision. Health commissioning, and the split between purchaser and provider (PP split) has been largely weak and ineffective in bringing improvements.

Across all 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 to achieve 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. Indeed there is a growing sense that integration of services might be better achieved if the PP split was removed through mechanisms such as block contracting.

Increasingly care commissioning should be influenced by local as well as national government, through elected representatives, as it is (directly or indirectly) for all other local public services. They take responsibility to secure the provision of a comprehensive universal local service with specific access guarantees, reinforced by the NHS Constitution. Some specialist services, rare conditions, will be planned either regionally or nationally – nothing new for authorities. Population needs analysis and the strategy for wellbeing is already the responsibility of local authorities. Public health responsibility will soon (rightly) go back to local authorities.

There is already a good basis for this approach as mental health and learning disabilities show many excellent models for a shared, partnership approach to care provisions across NHS and local authorities.

The engagement of local authorities can be increased over time but should start with local NHS commissioning processes answering to local authorities. Local initiatives which deliver better integrated care should be encouraged through specific funding streams, shared posts, pooled budgets, and the success of approaches like Total Place can be built on. Funding systems must encourage and incentivised local integration. The bottom up approach should lead the organisational change rather than the other way round.

Integrated Commissioning

With integrated commissioning there is clear responsibility for whole populations, and consideration of protection and prevention resides alongside remedial care. All planning and delivery of services in community, primary, social and acute care eventually will become the responsibility of one structure; physical and mental health; all informed and directed by the clinical professionals in combination with patients and citizens – with public health, actuarial and health economics expertise resident in the same structure.

The key to effective commissioning would still be having the right information and evidence on which to base decisions, which would include accurate information about the actual cost of service provision and the reasons for its variation across providers. Getting this information is best advanced through investment in a Care Information Centre, with involvement of clinical professionals and the professional bodies, with all providers to the care system having a duty to provide the data.

For greater strategic coherence there would still be a regional structure (as there always has been) dealing with rare conditions, overseeing major reconfigurations, looking at major capital schemes and arbitrating on disputes. They could also play a leading role in training and development and research, and host functions such as the Deaneries.

Service Design and Procurement

Care pathway redesign, prioritisation of services (and restrictions), and clinical service specifications are best undertaken by the appropriate mix of clinicians at whatever is the appropriate population level; which varies by condition. It should be seen as a normal part of a clinician’s professional role to be involved in these decisions when required but not as full time managers. Some of this work could be done once as a national template; and it is work that only needs to be done periodically (in reality much of it has already been done).

The financial systems must be aligned so that they do not inhibit good pathway and service design and in many cases this will imply a move away from the constraints of a fixed tariff and payment by results (volume).

In stark contrast other components of “commissioning” – procurement, contracting, market management and contract management processes are more effective if applied continuously, are informed by the clinical models, but operate internally for the NHS and externally on behalf of the NHS. It is unlikely that clinicians would want to work full time on this set of functions, and most experts on procurement and contract management are not clinicians. These functions should be blended within one NHS planning/delivering organisation with explicit governance arrangements at Board level to both recognise and mitigate conflicts of interest.

The complex issues around the requirements of EU procurement and competition law as they relate to commissioning have to be resolved. Commissioners must be able to use procurement when they decide this is best but there must be a legal framework which ensures they cannot be compelled to put services out to tender if they decide this is not in the best interest of the NHS. It must also be clear that decisions to commission a range of services (such as those from a DGH) from a single provider can be made for reasons which cannot be challenged through the Courts under competition Law. This requires a return to a more coherent NHS working in collaboration rather than as a group of organisations joined by enforceable contracts. If the arrangements are not through legal contracts, as used to be the case, then competition law cannot be applied.

Preferred Provider – Best Value

Planning / Commissioning will continue to be based on the assumption that the NHS is the preferred provider and that integration of services is best achieved through partnership and collaboration not competition. The best value approach long ago adopted by the rest of public services allows the risks and wider considerations of using non NHS providers to be objectively taken into account. The need to assess the quality and cost of all services on a regular basis in an open and transparent way is essential to delivering improvements and to establishing public confidence.

However, the general rule would be that commissioners are free to use whatever methods are appropriate, without any fear of a regulator, the Courts, or prescriptive performance managers interfering. The likelihood would be that we would easily identify those care services which should not be subject to economic competition – most of mental health care, long term conditions, and most of emergency and urgent care.

Integration of services takes priority with, for example, commissioning of whole pathways or for whole periods of care. Lead providers would be free to sub contract parts of the pathway or aspects of the service, but how they achieve this need not be proscribed.

Some services would be simple enough to have an expected “tariff” so that budgets could be predicated by anticipated volume, but this would not apply to all or even most services. The expected cost base would be set nationally based on objective evidence on real costs experience by good quality providers; and the overt and more covert forms of price based competition would not be permitted.

Other Provider Models

Some services where there is enough information to be able to judge quality and where there is a high degree of independence from other services could be open to an any willing provider approach, where a patient could choose to get the service from any provider which had demonstrated in could meet the required standards (like eyes and teeth and pharmacy).

When a provider is unable to deliver a service to the required quality or where a new service is required then formal procurement (EU rules and all) may be necessary and either a single supplier or a framework panel awarded the contract. There would be an overriding requirement to ensure that the interdependence of care was considered; simply awarding a contract for one service whilst ignoring the possible consequential impact would not be permitted.

Private providers would play a part, as they always have, but the expectation is that the share taken would continue to be relatively small based on niche provision and adding capacity. All providers would be subject to the same level of scrutiny and could not hide anything behind commercial confidentiality, supplying required information and paying a fair levy to cover their opting out of NHS training development and research. The emphasis on a social solidarity model with most commissioning and provision within the public sector will keep the care provision parts of the NHS outside the scope of domestic and EU competition Law.

Integrated Providers

Benefits should come from the rise of integrated providers, such as a single provider for all urgent and emergency care and this could extend into the whole population approach where one organisation effectively accepts a block payment and delivers all care for a defined population. Whilst such arrangements are obviously anti-competitive, competition is a tool to be used when appropriate and no more than that.

New Professionalism

Change has to be led by clinicians. There should a greater role for Royal Colleges in improving practice and in supporting, but if necessary retraining or deregistering, professionals. Colleges could lead on the definition, collection and analysis of meaningful and accurate information to allow variations to be identified and peer support deployed. Use of peer support, National Service Frameworks and use of the National Clinical Advisory Team would be delivered through the colleges. The combined colleges should be required to use their role to drive up quality in a more general manner, rather than just in selective professional silos.

Public Health – Keeping us Well

Looking after our well being and ensuring decisions based on good evidence requires public health professionals to be at the highest levels of decision making within local authorities, leading on joining up services, on predictive support, and on wellbeing – linking together housing, education, and environmental health issues. There is a significant strategic role leading on needs analysis and guiding prioritisation of resources, working with other clinicians, actuaries and economists. Over time the balance of funding for public health would increase as investment in future health overrides paying for remediation of past underinvestment.

Providers of Services

Health care provision is badly fragmented and would be made worse by further competition. Those organisations which manage hospitals are separate; seen as pre-eminent and they wield disproportionate power: power which often prevents a rigorous approach to poor performance, whilst organisations set up to deliver primary or community care are generally smaller and less visible. Previous attempts at integrated trusts saw acute services swamp the rest. These cultural barriers must be removed but again only the clinicians can bring this about, working collaboratively and ignoring any artificial organisational barriers; impossible if competition is the driving force. Realigning financial incentives towards collaboration will help.

The “Foundation Trusts” which provide NHS care will be all shapes and sizes; from specialist tertiary providers to an integrated care provider covering all needs of a defined population. They would be part of the NHS whilst under moral ownership of the local community not set up as an excuse for a different business model led by accountants and marketing experts. They would work with their commissioning colleagues to help develop the most appropriate pathways and services. They would be able to merge, demerge, federate, partner, if they had local support and their local owners (governors) agreed, (but not free to dispose of NHS assets). As now they would be subject to scrutiny by the local overview and scrutiny arrangements.

If these organisations get into trouble as most do from time to time they would be able to call on support and even additional resources. There may be conditions attached to support and there may be changes in management but this is not supporting failure, it is ensuring continuity of vital services. The alternative, that they are business entities which should be left to go into insolvency and administration, is unacceptable.

Alongside these trusts would be many other forms of providers to the care service; social enterprises, third sector and private sector.
Given a high degree of autonomy in exchange for effective stakeholder governance but trusts would still be subject to ultimate intervention and in extremis could be taken back into being directly managed.

General Practice

There will be our quaint but surprisingly effective system of semidetached GPs but with the local authority as commissioner carrying out the performance management, something both will find uncomfortable but essential to the eradication of poor performing GPs effectively outside any proper performance or contract management. Here, again, support and guidance to authorities from the Royal College, and a clear determination to drive up standards, would be invaluable.

Quality at the Heart

The fundamental importance of quality would be accepted through the powerful role assigned to the independent quality regulator – there would be no “economic” regulation. Better definitions of what quality means, greater public access to accurate timely and relevant information, active involvement of patients and communities, and clinicians intolerant of poor performance will drive quality and improve outcomes.

A Better NHS

Such an NHS, within a care system, would be faithful to the founding principles and values, a genuinely national service. It would shift care from acute settings, integrate all care in one system, use competition and non NHS providers only where they add value and the focus would be on continuing the improvement of NHS providers especially through better information, greater clinical involvement and leadership.
Patients would have the central role but not as consumers, nor as the product which is competed for.

Irwin Brown