“Whole-Person Care” was at the heart of the proposal at the heart of Labour’s health and care policy review, formally launched this week, and presents a formidable task: a new “Burnham Challenge”? It may not be immediately obvious to people outside of the field, but whole books and a plethora of academic papers have been written on it. I agree its consideration is very timely, given the special set of challenges which the NHS faces, and it is yet another failure of the national media that this speech has not been discussed at all by the national media. Whatever your particular political or philosophical inclination, it does demand proper scrutiny.
It is described as follows:
“Whole-Person Care is a vision for a truly integrated service not just battling disease and infirmity but able to aspire to give all people a complete state of physical, mental and social well-being. A people-centred service which starts with people’s lives, their hopes and dreams, and builds out from there, strengthening and extending the NHS in the 21st century not whittling it away.”
Andy Burnham did not mention the Conservatives once in his speech yesterday for the King’s Fund, the leading think-tank for evidence-based healthcare policy. He did not even produce any unsolicited attacks on the private sector, but this entirely consistent with a “One Nation” philosophy. Burnham was opening Labour’s health and care policy review, set to continue with the work led by Liz Kendall and Diane Abbott. He promised his starting point was “from first principles”, and “whatever your political views, it’s a big moment. However, he faces an enormous task in formulating a coherent strategy acknowledging opportunities and threats in the future, particularly since he suffers from lack of uncertainty about the decisions on which his health team will form their decisions: the so-called “bounded rationality”. The future of the NHS is as defining a moment as a potential referendum on Europe, and yet the former did not attract attention from the mainstream media.
Burnham clearly does not have the energy for the NHS to undergo yet another ‘top down reorganisation’, when the current one is estimated as costing £3bn and causing much upheaval. He indeed advanced an elegant argument that he would be seeking an organisational cultural change itself, which is of course possible with existant structures. This lack of cultural change, many believe, will be the primary source of failure of the present reorganisation. He was clear that competition and the markets were not a solution.
Burnham identifies the societal need to pay for social care as an overriding interest of policy. This comes back to the funding discussion initiated by Andrew Dilnot prior to this reorganisation which had been kicked into the ‘long grass’. Many younger adults do not understand how elderly social care is funded, and the debate about whether this could be a compulsory national insurance scheme or a voluntary system is a practical one. It has been well rehearsed by many other jurisdictions, differing in politics, average income and competence of state provision. The arguments about whether a voluntary system would distort the market adversely through moral hazard and loss aversion are equally well rehearsed. Whilst “the ageing population” is not the sole reason for the increasing funding demands of all types of medical care, it is indeed appropriate that Burnham’s team should confront this issue head-on.
It is impossible to escape the impact of health inequalities in determining a society’s need for resources in any type of health care. Burnham unsurprisingly therefore suggested primary health and preventative medicine being at the heart of the new strategy, and of course there is nothing particularly new in that, having been implemented by Ken Clarke in “The Health of the Nation” in the 1980s Conservative government. General medical physicians including General Practitioners already routinely generate a “problem” list where they view the patient as a “whole”; much of their patient care is indeed concerned with preventive measures (such as cholesterol management in coronary artery disease). A patient with rheumatoid disease might have physical problems due to arthritis, emotional problems related to the condition or medication, or social care problems impeding independent living. Or a person may have a plethora of different physical medical, mental health or social needs. The current problem is that training and delivery of physical medical, mental health or social care is delivered in operational silos, reflecting the distinct training routes of all disciplines. As before, the cultural change management challenge for Burnham’s team is formidable. Also, if Burnham is indeed serious about “one budget”, integrating the budgets will be an incredible ambitious challenge, particularly if the emphasis is person-centred preventive spending as well as patient-centred problem solving spending. When you then consider this may require potential aligment of national and private insurance systems, it gets even more complicated.
The policy proposed by Burnham interestingly shifts emphasis from Foundation Trusts back to DGHs which had been facing a challenge to their existence. Burnham offers a vision for DGHs in coordinating the needs of persons in the community. Health and Well-Being Boards could come to the fore, with CCGs supporting them with technical advice. A less clear role for the CCGs as the statutory insurance schemes could markedly slow down the working up of the NHS for a wholesale privatisation in future, and this is very noteworthy. Burnham clearly has the imperfect competition between AQPs in his sights. Burnham is clearly also concerned about a fragmented service which might be delivered by the current reforms, as has been previously demonstrated in private utilities and railways which offer disproportionate shareholder value compared to end-user value as a result of monopolistic-type competition.
The analysis offered by Andy Burnham and the Shadow Health team is a reasonable one, which is proposed ‘in the national interest’. It indeed draws on many threads in domestic and global healthcare circles. Like the debate over EU membership, it offers potentially “motherhood” and “apple pie” in that few can disagree with the overall goals of the policy, but the hard decisions about how it will be implemented will be tough. Along the way, it will be useful to analyse critical near-gospel suggestions that competition improves quality in healthcare markets, if these turn out to be “bunkum”. Should there be a national compulsory insurance for social care? How can a near-monopolistic market in AQPs be prevented? Nonetheless, it is an approach which is well respected in academic and practitioner circles, and is potentially a very clever solution for the NHS, whatever your political inclination, for our time.
