1.0 The SHA welcomes the opportunity to comment on the NHS Next Stage Review and supports Lord Darzi’s extensive and nationwide consultation. The comments below are a reflection of views expressed at a recent one-day conference held by the SHA to debate the report and discussions at our Central Council. Where possible, our response paper has made use of the framework set out in Lord Darzi’s letter of invitation to stakeholders.
The four priorities identified for the NHS (fair, personalised, effective and safe) are uncontentious. However, through omission, they fail to address the preventative and public health role of the NHS and primary care in particular. Although meeting the concerns of patients and the public as a whole is vital, recognition should be made that much of the work of reducing ill-heath – by detecting and treating disease risk factors (e.g. Obesity, consumption of alcohol and drugs, high blood pressure and diabetes) – is key to saving lives. A focus on preventative measures should therefore be top priority for the NHS. The present tariff system gives no incentive to the most powerful institutions – Foundation Hospitals – to reduce ill health. Quite the opposite. They are rewarded for interventions.
“In the age of scientific optimism it was believed that medicine had …. the answers to our health problems. …That optimism has passed and we are starting to sober up. Medicine has indeed delivered effective answers to some health problems and it has found the means to lessen the symptoms of many others, but by and large we remain with the necessity to do something about the incidence of disease, and that means a new partnership between the health services and those whose decisions influence the determinants of incidence. The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart.”
Geoffrey Rose, in “The strategy of preventive medicine”, 1992
Whilst personalisation of care is an appropriate objective, it has little to do with patient choice. Systems which have had beneficial effects in the organisation of planned surgery have little application in dealing with either chronic or acute medical care. Concern on the part of patients about feeling like a number rather than a person is engendered by difficulty navigating through a bureaucratic system. Patients often have to fit through the strictures of the system, rather than travel along a streamlined journey. Extending choice to new areas of the NHS does not address this systemic failure. For most patients, especially those with chronic conditions, personalisation is not about choosing from a menu which institution to deal with. It is about being treated as a human being and having ongoing relationships with other human beings. Social, family and work situation will have a bigger impact on their ability to live well despite the condition than most clinical and medical interventions. Breaking down the wall between health and social care has many potential benefits for these patients and their families.
3.1 We want to see a much greater emphasis on the conditions in which people, especially disadvantaged people, live their lives. Personalisation should start with attention to the factors which lead people into ill health. The health trainers initiative seems to show promise and we look forward to its evaluation, but we also need to address the factors which could be affected by local or central government. We do little to help people to make healthy choices. Our transport and planning systems do little to encourage people to walk or cycle because they are built on the assumption that everyone will travel by car. We do little to help people to eat healthy food and we do a great deal to encourage people to drink too much alcohol. In the face of these massive assaults on health the contribution of expensive medical interventions is trivial.
3.2 At the collective level, patients are a huge resource we also consistently neglect. We need to trust them to share planning and development commissioning decisions with us. With LINKs, we may have an opportunity to improve, but it is clear that the NHS would get better services, more rapidly, with more public and patient involvement. We are very close to a vision of this now.
- Community development in PCTs, bringing local people together in social networks that protect health, would also offer a strong basis for local engagement.
- Increasing involvement of Local Authorities in some form,
- elected PCTs,
- elected Boards for practices.
3.3 Trying to import the customer values of private services so that all patients and carers are treated with respect, sympathy, dignity and enabled to express their feelings, fears, concerns and worries should be implicit in everything all health professionals do, but clearly it isn’t. The question should be why not, rather than trying to overlay it and bring it in by the back door through importing market values. A standard of behaviour should be written into codes of conduct, employment contracts and anything that falls below that should be subject to severe sanctions. In reality this is often not managed well and poor behaviour is allowed to continue and patients are expected to deal with it through a complaints procedure which most of them find intimidating and ineffective.
3.4 Clinicians need to shift from merely informing patients about the treatment they need to sharing decision-making with them. That means
- listening and understanding health beliefs,
- offering clear information,
- supporting them in making choices from a menu of options,
- offering decision aids and
- continuing support for prevention and healthy choices
- patient access to their full GP record
4.0 Contractual and commissioning arrangements
Although the take up of practice based commissioning (PBC) has been patchy, it offers the opportunity to provide genuinely local solutions that improve services, whilst controlling costs. An explicit commitment to a long-term future for PBC would embolden practitioners who feel reluctant to participate in what sometimes feels like just the latest passing phase of reform. It would be possible to use practice-based commissioning as a mechanism for developing multi-specialty-based commissioning.
4.1 The present direction of government policy is towards a system of competing, largely independent providers, whose services are chosen in the market place by commissioners and then by patients. The argument runs that such a system will provide value for money, foster innovation and place patient satisfaction at the heart of the service. This policy has had some success in reducing waiting lists for planned surgery but it has little application in dealing with chronic conditions, especially for older frailer people for whom a local, accessible service is crucially important.
4.2 Such an assessment also neglects the adverse consequences of competition for what has for 60 years been a largely cooperative system. Furthermore there are very strong incentives in the system to encourage problems to be dealt with in hospital, rather than in the community. It is inappropriate to turn patients into consumers and public servants into businessmen, as if healthcare were akin to supermarket shopping. Using practice based commissioning to redress the balance invites GPs to deal with problems themselves which could more appropriately be dealt with in hospital. We want to see an incentive to clinicians to get together and work out the most effective way of dealing with cases.
4.3 We believe that the priorities set out by the report could better be met by a more radical solution, namely, a large scale shift towards co-operation within the NHS. We commend the recent Nuffield Trust report “Clinically Integrated Systems: the next step in English Health Reform?” by Chris Ham, University of Birmingham. This takes some of the very useful lessons from the Kaiser Permanente system and applies them in an English context. He proposes that budgets should be shared between primary and secondary care clinicians. We think collaboration, clinical integration and networks are the way forward for chronic medical conditions. His model needs to be developed to show how patients and the public could be involved. It is difficult to see how his suggestion that “patient and citizen choice between integrated systems” should be developed could be taken forward in an English context. The NHS Alliance have also done some interesting work in this are and the Committee might be interested in their May 2007 paper on “Competition or Co-operation.”
4.4 A system of largely cooperating social enterprises, whose membership was composed of staff and patients would reflect the value to communities of their local services – hospitals and surgeries – as well as give both groups powerful voices within the NHS at a local level. We view this as a more sustainable solution to the problems identified by Lord Darzi, one which maintains the public service traditions of the NHS whilst recognizing the need for radical change. This would be the largest transfer of power from government to the people in recent history and, as such, would be a fitting way to mark the 60th anniversary of the NHS.
5 General Practice
5.0 Equalization of GP provision across the country is long overdue. However, we have concerns about how the figures stated in the plan were arrived at. We hope that the Government will provide more detailed reasoning for the numbers chosen, based on epidemiological data.
5.1 It is crucial that the Next Stage Review makes a clear statement on the future of general practice. The UK’s system of registration with a GP provides a powerful tool for preventative and public health. The Government’s introduction of the new GP contract inherently recognizes preventative measures as a vital part of primary care.
5.2 GP surgeries are also widely viewed by the public as part of the community, in a similar way to schools. Any plans for the NHS must therefore recognize the value of the existing system and commit to supporting it. In this context, moves to weaken the registration system, by offering care through non GMS/PMS health centres, are misguided. Furthermore, it is well recognized that the provision of walk-in centres fails to reduce the burden on other acute centres, such as A&E departments.
5.3 Whilst feedback from the first stage of the review demonstrated a clear desire to increase GP’s opening hours, most attendances at GP practices are made by patients who are not in work and who might not benefit from longer opening hours. Increased hours could come at the expense of other GP activities in much the same way as the introduction of the QOF a number of years ago resulted in a shift from clinical to administrative work. Widening opening hours may have a contribution to increasing accessibility, especially for men of working age, but the need for such a change is likely to vary geographically, and there are other measures which might be more effective, especially the provision of occupational health services and the development of walk in centre provision.
6.0 . Developing community/neighbourhood public health
As recommended by the Acheson Report, all government domestic policies, programmes and projects should be subjected to such an assessment as all have some impact on health and on health inequalities. Local communities and neighbourhoods must play their part in promoting the public health, or as we prefer to call it, the health and wellbeing agenda; and that a key vehicle for this is community development. There are in our view three key platforms for delivering community/neighbourhood health and wellbeing namely:
- General practice
- community schools/colleges working in a coordinated way
- community development
6.1 Our proposed model envisages Practice premises or where they exist, Health Centres/ Polyclinics, providing a range of services, in addition to the traditional primary healthcare services, such as Benefits Advice and social services; and acting as a signpost to relevant services such as housing advice and environmental health. At the same time, by working with local community development workers, or health trainers where they exist, health protective social networks could be formed. The local secondary school acting as a community school or college would provide education and lifelong learning opportunities as well as sports facilities and opportunities for social activities of various sorts. Public health leadership would be provided from the platform of the local GP Practice or Health Centre/Polyclinic either by a suitably trained General Practitioner, or more likely, by a health visitor or health promoter working within the primary care team and relating to the local community and its key institutions, often through community development. This approach to developing community public health harks back to the revolutionary model adopted in the Peckham Pioneer Health Centre in the 1930s.
6.2. Tackling inequalities through the NHS
The scope for the NHS to contribute significantly to the reduction in health inequalities is very limited as demonstrated in the Acheson Report but this is no excuse for not using this scope to the maximum. Without affirmative action to identify the healthcare-deprived in order to provide appropriate high quality healthcare the NHS will continue to increase health inequalities because the health-advantaged currently get more out of it than the health-disadvantaged.
This affirmative action needs to be further developed at three levels – the Area level, the individual General Practice level and the focused Group level. Some Areas eg wards, can readily be identified, and have already been targeted in Spearhead areas, as comprising high numbers of healthcare-deprived people and here an Area-wide approach with increased provision of easily accessible relevant healthcare services such as health visitors, outreach outpatient and diagnostic services and branch surgeries is required. This is outreach at the area level.At individual GP level it should be possible to identify healthcare-deprived patients from the Practice List and then make contact with them to ensure that they take full advantage of all the relevant services they need. This should be supported and motivated by the creation of a QOF specifically related to the inequalities issue. This is outreach at the individual patient/family levelThere are also health-deprived people who are not on Practice Lists for various reasons, for example some homeless people. For these people a focused group outreach approach is required with staff actively seeking out such people and taking whatever steps are necessary to ensure they get the healthcare they require.