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Living better with dementia: a “Year of Care” for dementia?
This is an extract from my book ‘Living better with dementia’ by me (Forewords by Prof Alistair Burns, Kate Swaffer, Chris Mason and Dr Peter Gordon), to be published by Jessica Kinglsey Publishers 2015. It comes from the chapter on whole person care (chapter 10).
Acute medicine is ideally suited to the medical model where you make a diagnosis on the basis of investigations, and then you immediately implement a management plan. There should of course be prompt action on acute situations for people living with dementia, but this is rather different to the usual needs of a person trying to live better with dementia. A person with a long term condition “lives with the condition day by day for their whole life and it is the things they do or don’t do that will make the difference to their quality of life and the long term outcomes they will experience” (Royal College of General Practitioners, 2011).
Shirley Ayres (2014) argues in her article entitled “The long term care revolution: a provocation paper” that “people in later life offer wisdom, experience, perspective and a wide range of skill sets and capacities”, reflecting that that long term institutional care is not the correct setting for them. This argument also holds true, perhaps, for people living well with advanced dementia.
The burning question still remains, as it was in the genesis of the first English dementia strategy, how a framework of post-diagnostic support for people living with dementia could best take place in England. I have already discussed earlier in chapter 10 of my book the policy of ‘whole person care’, and the critical rôle of social care practitioners and clinical nursing specialists in a multidisciplinary approach. It is also worth noting that the “year of care” initiative has seen some crystallisation of the approach for living well. It offers a framework that supports delivery of the Domain 2 of the NHS Outcomes Framework ‘Enhancing quality of life for people with long-term conditions’. Through this, it is hoped that ‘far more people will have developed the knowledge, skills and confidence to manage their own health’, but there are clear implications for the implementation of whole person care, namely, “care which feels more joined-up to the users of services”, and “care [which] centres on the person as a whole, rather than on specific conditions” (Year of Care website, accessed December 2014).
There will always be the criticism that self management, rather than having the prime goal of encouraging health and wellbeing, is meant as a ‘cover’ for essential services being cut. Benefits of “self management” which have previously been proposed are, nonetheless, proposed in Box 1.
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Box 1. Benefits of ‘self management’ [Source: Royal College of General Practitioners (Clinical Innovation and Research Centre) (2011) (authors: Nigel Mathers, Sue Roberts, Isabel Hodkinson and Brian Karet) Care Planning: Improving the Lives of People with Long Term Conditions]
When people self care and are supported to do this, they are more likely to:
- experience better health and well-being
- reduce the perceived severity of their symptoms, including pain
- improve medicines compliance
- prevent the need for emergency health and social services
- prevent unnecessary hospital admissions
- have better planned and co-ordinated care
- remain in their own home
- have greater confidence and a sense of control
- have better mental health and less depression
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Indeed, this policy agenda has been slowly ‘cooking’ for about year. For example, nearly a decade ago, Department of Health (2005) issued its document “Supporting People and integration with Long Term Conditions – An NHS and Social Care Model to support local innovation: Improving Care Improving Lives” had proposed a number of key priority areas, namely:
- To embed into local health and social care communities an effective, systematic approach to the care and management of patients with a long term condition.
- To reduce the reliance on secondary care services and increase the provision of care in a primary, community or home environment.
- Patients with long term conditions need high-quality care personalised to meet their individual requirements.
This follows on from an elegant analysis from one of Derek Wanless’ numerous reports, this time “Securing our Future Health: Taking a Long-Term View” from 2002. This one envisages one scenario for the future involving full public engagement.
Wanless (2002) describes this as,
“levels of public engagement in relation to their health are high. Life expectancy increases go beyond current forecasts, health status improves dramatically and people are confident in the health system and demand high quality care. The health service is responsive with high rates of technology uptake, particularly in relation to disease prevention. Use of resources is more efficient.”
(Derek Wanless, Public Enquiry Unit (2002))
It has become increasingly acknowledged that under this approach, the “care plan” is pivotal. The care plan “should set out the patient’s agreed health objectives and care needs, including what the individual can contribute towards their own self care, and what each professional and agency will do to help them meet these. It will include preventive and health promotion actions (such as avoiding accidents, reducing infection or nutrition).” (Department of Health, 2005).
In a pamphlet from the King’s Fund (2013), entitled “Delivering better services for people with long-term conditions”, the authors, Angela Coulter, Sue Roberts and Anna Dixon describe a co-ordinated service delivery model – the ‘house of care’ – that incorporates learning from a number of sites in England that have been working to achieve these goals.
They describe that the “house of care” model differs from others in two important ways:
- it encompasses all people with long-term conditions, not just those with a single disease or in high-risk groups;
- and it assumes an active role for patients, with collaborative personalised care planning at its heart.
This model is a system innovation, as applied to dementia, as it proposes a shift in power from professionals to persons living with dementia play an active part in determining their own care and support needs. Such an approach, it is hoped, would respect autonomy dignity, promote independence and offer maximum choice and control for need help from the health and care systems. The philosophy of “whole person care” moves the NHS towards an integrated health and care system, which is concerned about individuals during health as well as disease, a critical time when the coordination between the NHS and social care could not possibly be worse.
Self care is about individuals, families and communities taking responsibility for their own health and wellbeing. It includes actions people take in order to stay fit and maintain good physical and mental health, meet their social and psychological needs, prevent illness or accidents and care more effectively for minor ailments and long term conditions.
Both dementia and diabetes mellitus can be viewed as disabilities, and each may be a co-morbidity of the other. Sinclair and colleagues (2014) have outlined the key steps in an integrated care pathway for both elements of this clinical relationship, produced guidance on identifying each condition, dealt with the potentially risky issue of hypoglycaemia, and have outlined important competencies required of healthcare workers in both medical/diabetes and mental health settings to enhance clinical care. In the overall construct, people living with a long term condition, disability or a minor illness, as well as carers, can benefit enormously from being supported to self care.
The ‘Common Core Principles to Support Self Care’ aim to help health and social care services give people control over, and responsibility for, their own health and well-being, working in partnership with health and social care professionals (Skills for Care/Skills for Health, 2007) Seven principles have been elaborated. These are shown in Box 2 below.
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Box 2. Seven principles to support ‘self care’ [Source: Skills for Care/Skills for Health (2007)“Common core principles to support self care: a guide to support implementation” http://www.skillsforcare.org.uk/document-library/skills/self-care/commoncoreprinciples.pdf]
- Ensure individuals are able to make informed choices to manage their self care needs
- Communicate effectively to enable individuals to assess their needs, and develop and gain confidence to self care
- Support and enable individuals to access appropriate information to manage their self care needs
- Support and enable individuals to develop skills in self care
- Support and enable individuals to use technology to support self care
- Advise individuals how to access support networks and participate in the planning, development and evaluation of services
- Support and enable risk management and risk taking to maximise independence and choice.
—————
The “NICE quality standard for supporting people to live well with dementia: information for the public” is intended to support people to live well with dementia. It sets out how high-quality social care services should be organised and what high-quality social care should include, so that the best support can be offered to people with dementia using social care services in England (NICE, 2013). This has provided a very useful yardstick against which services which purport to improve the quality of life of people with dementia can be judged.
It is, further, reported that the ‘Year of Care’ (YOC) programme was successful in implementing the key features of care planning in diabetes, for example. The YOC Programme has two components, according to ‘Diabetes UK’ (2011). Firstly, it enhances the routine biomedical surveillance and ‘QOF review’ with a collaborative consultation, based on shared decision making and self management support, via care planning; and then it ensures there is a choice of local services people need to support the actions they want to take to improve their health, wellbeing and health outcomes.
People are involved in the care of their diabetes in quite a new way and enjoying it. People are setting personal goals and action plans relevant to their everyday life; take up of education programmes has improved and in very disadvantaged populations, poor attendance rates, biomedical outcomes and service use are also improving.
(Royal College of General Practitioners, 2011)
It is likely that the health and care sectors will seek to engineer the ‘best’ solutions on offer for post diagnostic support, within a framework of ‘whole person care’.
Such solutions might include ‘dementia advisers’, ‘clinical nursing specialists’, or ‘a year of care’. The solutions most appropriate for “living better with dementia” might be drawn, for example, from best practice in other long term conditions, such as diabetes or cancer. The quality of local commissioning, undoubtedly, is going to be pivotal in this. It will be a sensitive policy balance to make the argument that responsibilities of the State are not shunted across to the third sector in an unaccountable or unorthodox manner. But many will argue that there is valid and crucial role for the third sector to play. Actually, the policy imperative for this could not be clearer – many persons living well with dementia report not expecting to see a professional until the end of life phase, having seen one for the initial diagnosis. This is clearly not on if policy truly wishes to promote living better with dementia in England.
References
Department of Health (2005) “Supporting People and integration with Long Term Conditions – An NHS and Social Care Model to support local innovation: Improving Care Improving Lives”, accessed 6 December 2014,available at: http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/Browsable/DH_4965951
Diabetes (UK) “Year of Care: Report of findings from the pilot programme” (date June 2011), accessed 6 December 2014,available at: http://www.diabetes.org.uk/upload/Professionals/Year%20of%20Care/YOC_Report.pdf
Innovate UK (2014) The long term care revolution: a provocation paper. (author Shirley Ayres), accessed 6 December 2014,available at: https://connect.innovateuk.org/documents/15494238/0/LTCRprovocationPaper.pdf/45cf1947-c477-4f21-913e-4eb3f9061aa0
King’s Fund (2013) (authors: Angela Coulter, Sue Roberts and Anna Dixon, October 13) “Delivering better services for people with long-term conditions”, accessed 6 December 2014,available at: http://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/delivering-better-services-for-people-with-long-term-conditions.pdf
NICE quality standard 30 April 2013 NICE quality standard for supporting people to live well with dementia: information for the public, accessed 6 December 2014,available at: https://www.nice.org.uk/guidance/qs30
“Policy: A Year of Care”, accessed 6 December 2014,available at: http://www.yearofcare.co.uk/policy-0
Public Enquiry Unit (2002) “Securing our Future Health: Taking a Long-Term View. Final Report” (author Derek Wanless), accessed 6 December 2014, available at: http://si.easp.es/derechosciudadania/wp-content/uploads/2009/10/4.Informe-Wanless.pdf
Royal College of General Practitioners (Clinical Innovation and Research Centre) (2011) (authors: Nigel Mathers, Sue Roberts, Isabel Hodkinson and Brian Karet) Care Planning: Improving the Lives of People with Long Term Conditions, accessed 6 December 2014, available at: http://www.impressresp.com/index.php?option=com_docman&task=doc_view&gid=75&Itemid=70
Sinclair AJ, Hillson R, Bayer AJ; National Expert Working Group. Diabetes and dementia in older people: a Best Clinical Practice Statement by a multidisciplinary National Expert Working Group. Diabet Med. 2014 Sep;31(9):1024-31. doi: 10.1111/dme.12467.
Skills for Care/Skills for Health (2007) “Common core principles to support self care: a guide to support implementation”, accessed 6 December 2014,available at: http://www.skillsforcare.org.uk/document-library/skills/self-care/commoncoreprinciples.pdf
The NHS should not be like a conveyor belt
At first, I thought my criticism was simply because it was called “The Tony Blair Dictum”. For me, one of the most ‘successful’ Labour Prime Ministers in living history, and this is no time for hyperbole, was very good at knowing the price of everything and the value of nothing. This is what I thought was the heart of his failure to understand how modern business works, and the importance of people in the creation of value in the relatively new discipline of corporate social responsibility. But Blair was a lawyer and politician by trade.
The “Tony Blair Dictum” says “I don’t care who provides my NHS services ‘behind the curtain’, as long as it’s of the highest quality.’ Variants of it include the bit ‘as long as I don’t pay for it’, and indeed this bit is often tagged on to help to demonstrate that the reforms are not privatisation. However, if you include that the majority of contracts will be put out for competitive tendering, to avoid conflict, to the private sector – it is privatisation. It is taking away of resources to run a comprehensive, universal state-run service, and using the monies as consideration for entities running services for profit or surplus.
For ages, I thought my objection to this was purely in terms of my own business training. This training had taught me that increasing transactional costs was bound to magnify greatly the amount of wastage and inefficiency in running the system as a whole. Coupled with the loss of ‘economies of scale’, the likelihood of this process would be a fragmented service which costs money, and which is unlikely to be comprehensive. I don’t think my economic argument is incorrect. Nor do I think it’s somewhat disingenious for private contractors to run their services under the NHS logo, while it is well documented that programmed attacks on the NHS ideologically have taken place in parts of the media. Some parts of the media in an astonishing way have not reported on the ‘reforms’, estimated to cost about £2.5 bn so far, at all.
No, it’s not that. I think I find this Dictum potentially difficult, if it can be a different Doctor each time who sees you, and it doesn’t matter where they’ve come from. It suddenly dawned on me thanks to thinking about why Dr Jonathon Tomlinson (@mellojonny) loves general practice so much. My late father was a GP near Brighton for nearly 30 years, and he loved his job. He was a single-handed practitioner with a list of about 2500 with not a blemish on his professional record, and he did all his own on-calls. This means that he knew his patients (and often whole families) backwards – his families loved him as the community Doctor. He never breached medical confidentiality of course, but the continuity of care was of benefit to patients. This meant, like transactional costs, things would not get repeated to different people at different times, and things were not ‘lost in translation’ through Doctors reading the medical notes of other Doctors. My father knew his patients.
However, given that I have nothing to do with the medical profession, I am struck by how a ‘conveyor belt’ atmosphere had begun to emerge in the NHS, even in the brief time when I was a junior physician in busy Trusts in London and Cambridge. This means that the approach was that of a “production line”, what I would later know as ‘lean management’ (where it is very difficult to know the precise cause of clinical error because the system is literally firefighting all-of-the-time). In this production line, Doctors would never see the output of their combined efforts, the “product”, as the Doctor responsible for writing the discharge summary was invariably not the Doctor who had generated a ‘problem list’ when the patient was admitted to the Hospital in the first place.
This situation I feel is not unique to primary care, and certainly this is not meant to be any criticism of Group G.P. practices where Doctors are very keen to know the histories of all patients in their catchment. It is not meant to be a criticism of NHS Direct or the Out-of-Hours service, though the benefits of a patient seeing his or her own Doctor out-of-hours is not simply an issue of nostalgia. I think there is a clear parallel in the commodification of the legal profession. This commodification has seen law as not having a prominent place in one’s community (“There is no such thing as community” is possibly a more accurate phrase than “There is no such thing as society”), with the death of the high street law centre at odds with the flourishing multinational corporate law firms. Ironically, in the United States which has had a longer time to assimilate the effects of multinational corporates on modern life), there is now recognition from big-brand management consultancy firms that there is more value to be had inter-transactions rather than intra-transactions. This means that the approach of one ‘fee earner’ identifying and solving the legal problem, with that fee earner never to be seen again, is being replaced by a lawyer who is interested in the development of your issues over a long period of time.
This indeed had been the approach of the medical profession too. I remember being witness to some amazing physicians, who admittedly had remarkable memories but, who could remember events from the patients 20-30 years’ ago, which might have direct relevance to the symptom with which he or she was presenting today. Possibly, with the introduction of whole person care, this approach might take a comeback, and certainly continuity-of-care had previously been considered important for the conduct of medical professional life. Whether they intended to or not, my late Father and Dr Tomlinson have made me realise why I do actually find ‘The Tony Blair Dictum’, aside from macroeconomics, potentially very difficult.
Competitive tendering is no longer the solution; it is very much the problem
As part of the “Big Society”, medics and lawyers have now been offended over competitive tendering. Competitive tendering is no longer the solution; it is very much the problem.
Yesterday, it was the lawyers’ turn. The Bar Standards Board (“BSB”) yesterday extended (10 May 2013) the first registration deadline for the Quality Assurance Scheme for Advocates in the face of a threatened mass boycott by barristers. The Solicitors Regulation Authority is expected to follow. In a statement yesterday, the BSB said the deadline will be extended from 10 January to 9 March 2014 ‘to ensure the criminal bar will have more time to consider the consequences of government changes to legal aid before registering’. The end of the first registration period will now be after the Ministry of Justice publishes its final response to its consultation on price-competitive tendering. The SRA board is expected to approve a similar extension later shortly.
A group of leading academics, including Prof. Richard Moorhead from University College London, indeed wrote yesterday,
“As academics engaged for many years in criminal justice research, we write to express our grave concern about the potentially devastating and irreversible consequences if the government’s plans to cut criminal legal aid and introduce a system of tendering based on price are introduced. Despite the claim by Chris Grayling, the minister of justice, that ‘access to justice should not be determined by your ability to pay’, this is precisely what these planned changes will achieve. This is not about ‘fat cat lawyers’ or the tiny minority of cases that attract very high fees. As we know from the experiences of people like Christopher Jefferies, anyone can find themself arrested for the most serious of crimes. No one is immune from the prospect of arrest and prosecution.”
Previously, it had been the medics’ turn. That did not deter Earl Howe in collaboration with people who clearly did not understand the legislation like Shirley Williams in competition with the medical Royal Colleges, Labour Peers and BMA. The Royal College of Physicians set out their oppositions to competitive tendering articulated their position last month:
Competitive tendering is often considered to promote competition, provide transparency and give all suppliers the opportunity to win business. It may be that price tags are driven down, but most reasonable professionals would actually ask, “At what cost?” Competitive tendering, rather, has a number of well known criticisms.
When making significant purchases, frank and open communication between potential supplier and customer is crucial. Competitive tendering is not conducive to open communication; in fact, it often discourages deep dialogue because in many cases all discussions between a bidder and the purchaser must be made available to all other bidders. Hence, Bidder A may avoid asking certain questions because the questions or answers may help other bidders by revealing Bidder A’s approaches, features, and the like. At the moment, there is a policy drive away from competition towards collaboration, innovation and ‘creating shared value’. Dr. Deming also writing in Out of the Crisis, “There is a bear-trap in the purchase of goods and services on the basis of price tag that people don’t talk about. To run the game of cost plus in industry a supplier offers a bid so low that he is almost sure to get the business. He gets it. The customer discovers that an engineering change is vital. The supplier is extremely obliging, but discovers that this change will double the cost of the items……the vendor comes out ahead.” This is called the cost-plus phenomenon.
Competitive tendering furthermore encourages the use of cheaper resources for delivering products and services. A supplier forced to play the competitive tendering game may come under pressure to keep costs down to ensure he gets a satisfactory profit margin. One way a supplier can lower costs is by using cheaper labour and/or materials. If the cheaper labour and materials are poor quality, the procurer will often end up with inferior, poor quality product or service. However, warranty and other claims may result –raising the price of the true, overall cost. Another area where suppliers may be tempted to lower costs is safety standards. This current administration is particularly keen on outsourcing, and sub-contractors may cut corners and creating safety risks. This is obviously on great concern where patient safety in the NHS has recently been criticised, after the Francis Inquiry over Mid Staffs NHS Foundation Trust. Furthermore, then government agencies, and indeed, private companies use competitive tendering it can take several years to choose a successful bidder, creating a very slow system. The result is the customer can wait incredibly long periods for product or service that may be required quickly. Finally, insufficient profit margin to allow for investment in research and development, new technology or equipment. Already, in the U.S., private “health maintenance organisations” spend as little as possible on national education and training of their workforce.
So the evidence is there. But, as the Queen’s Speech this week demonstrated on minimum alcohol pricing and cigarette packaging, this Government does not believe in evidence-based policy anyway. In the drive for efficiency, with a focus on price and cost in supply chains, the legal and medical professions have had policies imposed on them which totally ignores value. This is not only value in the product, but value in the people making the product. One only needs to refer to the (albeit extreme) example of a worker being retrieved from the rubble of that factory in Bangladesh to realise that working conditions are extremely important. This is all the more hideous since the policies behind the Legal Aid, Sentencing and Punishment of Offenders Act (2012) and the Health and Social Care Act (2012) were not in any of the party manifestos (sic) of the U.K. in 2010.
Competitive tendering is no longer the solution; it is very much the problem.
Competitive tendering is no longer the solution; it is very much the problem.
As part of the “Big Society”, medics and lawyers have now been offended over competitive tendering. Competitive tendering is no longer the solution; it is very much the problem.
Yesterday, it was the lawyers’ turn. The Bar Standards Board (“BSB”) yesterday extended (10 May 2013) the first registration deadline for the Quality Assurance Scheme for Advocates in the face of a threatened mass boycott by barristers. The Solicitors Regulation Authority is expected to follow. In a statement yesterday, the BSB said the deadline will be extended from 10 January to 9 March 2014 ‘to ensure the criminal bar will have more time to consider the consequences of government changes to legal aid before registering’. The end of the first registration period will now be after the Ministry of Justice publishes its final response to its consultation on price-competitive tendering. The SRA board is expected to approve a similar extension shortly.
A group of leading academics, including Prof. Richard Moorhead from University College London, indeed wrote yesterday,
“As academics engaged for many years in criminal justice research, we write to express our grave concern about the potentially devastating and irreversible consequences if the government’s plans to cut criminal legal aid and introduce a system of tendering based on price are introduced. Despite the claim by Chris Grayling, the minister of justice, that ‘access to justice should not be determined by your ability to pay’, this is precisely what these planned changes will achieve. This is not about ‘fat cat lawyers’ or the tiny minority of cases that attract very high fees. As we know from the experiences of people like Christopher Jefferies, anyone can find themself arrested for the most serious of crimes. No one is immune from the prospect of arrest and prosecution.”
Previously, it had been the medics’ turn. That did not deter Earl Howe in collaboration with people who clearly did not understand the legislation like Shirley Williams in competition with the medical Royal Colleges, Labour Peers and BMA. The Royal College of Physicians set out their oppositions to competitive tendering articulated their position last month:
Competitive tendering is often considered to promote competition, provide transparency and give all suppliers the opportunity to win business. It may be that price tags are driven down, but most reasonable professionals would actually ask, “At what cost?” Competitive tendering, rather, has a number of well known criticisms.
When making significant purchases, frank and open communication between potential supplier and customer is crucial. Competitive tendering is not conducive to open communication; in fact, it often discourages deep dialogue because in many cases all discussions between a bidder and the purchaser must be made available to all other bidders. Hence, Bidder A may avoid asking certain questions because the questions or answers may help other bidders by revealing Bidder A’s approaches, features, and the like. At the moment, there is a policy drive away from competition towards collaboration, innovation and ‘creating shared value’. Dr. Deming also writing in Out of the Crisis, “There is a bear-trap in the purchase of goods and services on the basis of price tag that people don’t talk about. To run the game of cost plus in industry a supplier offers a bid so low that he is almost sure to get the business. He gets it. The customer discovers that an engineering change is vital. The supplier is extremely obliging, but discovers that this change will double the cost of the items……the vendor comes out ahead.” This is called the cost-plus phenomenon.
Competitive tendering furthermore encourages the use of cheaper resources for delivering products and services. A supplier forced to play the competitive tendering game may come under pressure to keep costs down to ensure he gets a satisfactory profit margin. One way a supplier can lower costs is by using cheaper labour and/or materials. If the cheaper labour and materials are poor quality, the procurer will often end up with inferior, poor quality product or service. However, warranty and other claims may result –raising the price of the true, overall cost. Another area where suppliers may be tempted to lower costs is safety standards. This current administration is particularly keen on outsourcing, and sub-contractors may cut corners and creating safety risks. This is obviously on great concern where patient safety in the NHS has recently been criticised, after the Francis Inquiry over Mid Staffs NHS Foundation Trust. Furthermore, then government agencies, and indeed, private companies use competitive tendering it can take several years to choose a successful bidder, creating a very slow system. The result is the customer can wait incredibly long periods for product or service that may be required quickly. Finally, insufficient profit margin to allow for investment in research and development, new technology or equipment. Already, in the U.S., private “health maintenance organisations” spend as little as possible on national education and training of their workforce.
So the evidence is there. But, as the Queen’s Speech this week demonstrated on minimum alcohol pricing and cigarette packaging, this Government does not believe in evidence-based policy anyway. In the drive for efficiency, with a focus on price and cost in supply chains, the legal and medical professions have had policies imposed on them which totally ignores value. This is not only value in the product, but value in the people making the product. One only needs to refer to the (albeit extreme) example of a worker being retrieved from the rubble of that factory in Bangladesh to realise that working conditions are extremely important. This is all the more hideous since the policies behind the Legal Aid, Sentencing and Punishment of Offenders Act (2012) and the Health and Social Care Act (2012) were not in any of the party manifestos (sic) of the U.K. in 2010.
Competitive tendering is no longer the solution; it is very much the problem.
Andy Burnham's "whole-person care" could be visionary, or it could be "motherhood and apple pie"
motherhood and apple pie
“Whole-Person Care” was at the heart of the proposal at the heart of Labour’s health and care policy review, formally launched yesterday, and presents a formidable task: a new “Burnham Challenge”?
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?
