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There is nothing more embarrassing than for hardworking clinicians in the NHS and practitioners in social care than to hear of Jeremy Hunt going to New York to lay the groundwork for a transatlantic trade deal or to go to international conferences to preach to others on patient safety. Whether the longest serving Secretary of State for Health chooses to admit or not, and he doesn’t, there is nothing to boast about in 20 hour trolley waits, or people being asked to sit in a toilet or corridor before being given a hospital bed. If the definition of patient safety is that nobody has died unnecessarily yet, then expectations are indeed very low. Indeed, Sir Robert Francis, whom Hunt used to quote all the time, now says another Mid Staffs is “inevitable”.
To be honest, this is the perfect storm which prominent campaigners, including junior doctors, themselves have been warning about. It might seem beyond ludicrous that Jeremy Hunt can shamelessly say that the performance of the NHS is ‘unacceptable’, but as far as he is concerned he is not responsible for the performance of the NHS. And the purpose of the 2012 Health and Social Care Act (2012) was not to promote the highest quality clinical care – symptomatic of that is the fact in the 500 pages of legislation the legislation found time to devote only one clause to patient safety, and that was to abolish the National Patient Safety Agency. The legislation instead was put in place to turbo-boost the transfer of NHS services to the private sector. This is – wait for it – the definition of ‘privatisation’. It also provided legislation for clinical commissioning groups, where is no statutory mandate for clinical skill. These clinical commissioning groups, which are even definite in size of population in law, are merely insurance entities which happen to reside in the public sector, assessing the potential risk of illness in a certain geography. In other words, this highly contentious Act of parliament, on which billions of £ were ultimately spent in a top-down reorganisation that nobody as such voted for, laid down the infrastructure for harmonisation between the public sector and the private sector for the ultimate piecemeal sell off of the NHS.
The ultimate issue that successive governments have had to face for the last three or four decades has been a desire not to go ‘public’ about transferring the NHS to the private sector, so that the NHS simply becomes a badge for the state deliverer of services, not the state provider. In an ideal world, Jeremy Hunt MP does not even want to be involved with anything to do with the NHS. Hunt, and many others of the same ideological ilk, would be perfectly happy for different providers, e.g. Capita, Virgin, G4S, in some corporate plutocracy to run the NHS using the NHS logo if need be.
Jeremy Hunt’s faux disdain at the performance of the NHS is completely understandable, if one realises that Hunt thinks the public will blame the fact the NHS is in the public sector rather than him for the poor performance of the NHS. And, to be fair to him, there are people who ring up local radio phone shows to say that the problems of the NHS are entirely due to mismanagement, the fact that the general public take no responsibility for their own health (a completely irrelevant argument if someone is born with a congenital disease such as heart problem or lung problem). And, furthermore, more in the post-facts milieu, the hope is that nobody can discern fact from fiction. In other words, with the help of a compliant media, the general public can be manipulated into thinking that the root cause of the NHS being overloaded is entirely due to the immigrant population. There is no discussion of non-indigineous doctors or other healthcare professionals in this utopia, just ‘small talk’, albeit dangerous UKIP pillow talk, of an aspiration of Jeremy Hunt to reverse decades of the NHS being propped up by foreign clinicians to train ‘home grown’ doctors. Mainsteaming British Doctors for British patients has never been easier.
But back to the fundamental issue of why I believe Jeremy Hunt does not care about the performance of the NHS is that his thinking rests on three assumptions. And, whilst a sizeable number of people in parliament think the same way as him, the likelihood of a cross-party commission on the NHS will come to the conclusion that some form of privatisation of the NHS, whether in terms of co-payments, vouchers or full blown increase in capacity of private insurance providers, will occur, rubber-stamped by all the political parties (except for some this time). It might, for example, be seductive for irritable, cranky people to ‘charge drunk people for attending A&E’, but think about the actual practical implementation of this policy – by what measure would you define the tipping point from ‘quite tipsy’ to ‘quite drunk’? Is it, for example, either feasible or desirable that healthcare professionals, including GPs, to carry Visa card or passport readers in addition to their numerous other duties?
A number of assumptions can possibly be made about this current Government and recent ones too:
1. There is no distinction between private and public providers in the NHS.
2. The Government believes in a ‘small state’ and low taxation.
3. The NHS is expected to make efficiency savings in keeping with an austerity approach.
That there is no distinction between private and public providers in the NHS is why Jeremy Hunt resents being in a centre of a tsunami about junior doctors’ pay. In an ideal world, he would like there to be complete harmonisation between private and public sectors, so that doctors could come and go as they wish in terms of employment. This is entirely the drive for the 24/7 NHS, which is why Jeremy Hunt is do keen to promote any fake research news coming out of the BMJ to further his ideology. You do not need to be an expert in sophisticated mathematical modelling techniques to realise that if you were to stretch out the already woefully inadequate resources for a 5-day elective service into a 7-day one the consequences on patient safety would be diabolical. What, furthermore, is quite incredible is for the current Department of Health to be so oblivious to the fact there already exists a 7-day emergency service running at full throttle, hence their need to spend valuable resources in making further metrics to measure A&E performance by.
Where junior doctors can come and go as they please, like where consultants can come and go as they please, or where nurses come and go as they please, is a strategy which is the direct opposite to the public sector keeping its workforce loyal, wellbeing promoted and well educated, and being contained budget-wise in terms of salaries. We already know that the agency spend has become out of control, due to poor planning of the Department of Health over many years, and to the weird hybrid private-NHS market we currently have. And all this is to ignore completely that private providers take no responsibility for, financially or otherwise, for the education and training of the workforce the vast majority of which start in the NHS. This is entirely in keeping in why Hunt is so intensely relaxed about applications for nursing training going through the floor after his devastating nursing bursary initiative – Hunt does not ideologically believe the Government should be safeguarding against a minimum body of doctors, nurses or allied health professionals in the workforce. The problem now of course for him now is #Brexit unless it looks like he can poach staff from the Asian subcontinent; but word is spreading fast how bad the working conditions of the English NHS are.
2. Unfortunately, the Conservatives and Liberal Democrats were able to converge on the ideology behind the Health and Social Care Act 2012 and the mirage that economic competition would drive up clinical quality because of the robustnesss in their belief in the small State. This does not envision the State to be a supportive thing to promote the health and wellbeing of its citizens, including so that they can be healthy enough to be in ‘gainful employment’ and be ‘productive’. This instead pre-supposes that everybody wishes to pay very low taxes, somehow living in a world where public services are still magically working well. But this falsehood is very easy to put in place if the main political parties are able to blame a ‘common enemy’ for all of their problems, e.g. immigrants. Such politicians want to divorce the link between improved public services and paying for them, which is why the Conservatives invest so much effort into depicting the Labour Party as incompetent (whereas the national debt under the 7 years of Conservatives has ballooned way above the previous 13 years of Labour).
Unfortunately, a hypothecated tax for the NHS would necessitate a debate about hypothecated taxes for everything else such as national security or education, and is well known to be yet another ‘zombie policy’ which won’t go away. Finally, whilst the Government gives the impression that the debacle in social care, causing delayed transfers of care from hospitals to care packages in the community, is seen as a ‘local authority’ not national problem, say for example through the ‘precept’ or the Surrey referendum, the impression is reinforced that social care is out of control, and its catastrophic state impacting on the performance of the NHS is nothing which can be reversed essentially.
3. Stephen Dorrell MP already has said that the NHS efficiency savings, first proposed by the management consultants, McKinseys have never successfully been tried before – and indeed many blame this drive for efficiency and for ‘foundation trust’ status to be at the heart of how disasters at Mid Staffs and other Trusts happened. It is a plain fact that if budgets are under enormous strain in providing a skeleton workforce (e.g. one junior doctor to cover all the medical wards in one large teaching hospital AND cover the cardiac arrest bleep), and to pay massive unconscionable private finance initiative payments (a form of a Corporate Wonga), something will have to give. There might be a temptation for such cuts to be hidden by commissioners and managers in mental health, despite all the Twitter infograms and rhetoric about ‘parity of esteem’ – unless of course there happens to be a spike in uncontrollable demand for mental health beds or suicides. So far, all the main English political parties have been very loyal to ‘efficiency savings’ – but this is essentially ‘austerity’, and a political choice for the NHS not an economic one.
If the ultimate aim is to increase transfer of public assets to private entities (the definition of privatisation), keeping the NHS at a low unsafe level of funding reinforces the impression the NHS is ‘unsafe in public hands’. That is why rolling coverage by the BBC of ‘specials’ of a NHS and social care system at breaking point might lead people to blame the public funding of the NHS, not Jeremy Hunt. This is of course fully intended, so that the green light can be given for a blatant privatisation of the NHS.
The correct conclusion, of course, is that the NHS has been chronically underfunded for years, and no Government wishes to admit they want to privatise the NHS as it’s so politically toxic.
It’s impossible to escape the conclusion that the failed coup (and it wasn’t even that in the end) did quite a lot of damage to the perception of Labour. At a time when the UK was reaching an existential crisis, as to whether it should be a Union or part of it, Hilary Benn made himself into a political Archduke Ferdinand and precipitated world war within Labour. Benn Junior’s legacy was a real “* you” to the membership, given that it is ubiquitously accepted that the general public will always punish divided parties as a rule of Newtonian classical dynamics.
The post-truth era for Jeremy Corbyn had of course begun long before his second election as Labour’s elected leader. It’s no mean feat for Rafael Behr or James O’Brien to continue their boring whingeing about Corbyn all the time, but to give them credit they need to pay their mortgages. But other people need a Labour government. The meme ‘Britain needs a strong opposition’ laying the blame at Corbyn of course is completely laughable given the torrent of abuse at Corbyn from all of the mainstream media, whether it’s on the inclination of his bowing in official ceremonies, the lack of singing at the National Anthem, or the alleged refusal to kneel and kiss at the Privy Council inauguration ceremonies.
Corbyn does not have the Twitter following with the magnitude of Donald Trump. He would not wish to boast about ‘expanding his arsenal’ either (pardon the unintentional pun about the Holloway Road in Islington). Nor is he best friends with Vladimir Putin. Talking of which, all of the pseudo-commentators who were spitting bullets at Corbyn’s morality seem to have gone deadly quiet about Trump’s ‘locker room’ banter, did you notice?
For all the talk about strong leadership, Jeremy Corbyn is no Adolf Hitler, Donald Trump or Nigel Farage. It’s hard to disagree with his ten pledges, which include the ‘bread and butter’ for many of us on the left wing of politics. Take for example the pledge ‘full employment and an economy that works for all’. George Osborne’s legacy, possibly not meriting a CBE, was to produce one giant ‘gig economy’, with workers having desperately and deliberately poor employment rights, many on zero hour contracts, and many being topped up with ‘working tax credits’ (hence becoming the ‘working poor’). Unsurprisingly, this has done very little to tackle the poor productivity of the UK in general, and the poor tax receipts have been a shocker for running public services safely.
A second pledge is impossible to disagree with. That is, “Secure our NHS and social care”. The emphasis of the current Conservative government has been a traditional one of ‘getting more bang for your buck’ and the euphemistically termed “delivery”, but the crisis in social care has been due to a toxic combination of imposition of private markets and lack of funding matched to demand since 2010. Even Conservative MPs are concerned about the parlour state of social care, which is also having a cost in the economy in people of working adult working age being unable to lead independent lives because of the need to care for “dependents”, for example people living with dementia with substantial caring needs. For a very long time, A&E departments nationally have been unable to meet their targets, and delayed discharges have gone through the roof. But this is not headline stuff due to a corrupt mainstream media – hellbent on their character assassination of Jeremy Corbyn.
No poll, even up until the night of Donald Trump’s eventual election, had predicted accurately the scale of the Republican victory. The general public are continuously being told about the unelectability of Jeremy Corbyn, however, even though British pollsters have a formidably catastrophic recent polling record, for example in the EU referendum or the 2015 general election. No amount of fiasco is too large to displace the vitriolic attacks on Corbyn, whether that be the failure of privatised rail services, the corruption of captains of industry for well known high street brands, an ability to curb the excesses of unconscionably paid people, and so on. But Corbyn himself would be the last person to bank on a three full terms with him as Prime Minister. He is currently 67 – not being ageist, but he would be over 80 if he completed three full terms for Labour. The succession planning for Tony Blair was an unmitigated disaster, reputedly because many of the successors did not want to ‘succeed’ taking up profitable jobs elsewhere.
Talking of which, Jamie Reed is doing himself and Labour simultaneously a favour. There is more of a chance of a pig landing on Mars, than there is a chance of Reed winning in the strongly Brexit seat of Copeland. It is a fact that Labour cannot triangulate itself into making itself very pro European Union for the benefit of many in Scotland and London, while also being anti European Union for very many in England. Whilst there are a few with extreme opinions such as ‘send Muslims back’, there are some who hold the opinion that EU workers are ‘stealing the jobs’ of indigenous citizens due to being able to work at lower salary rates. Theresa May MP has been consistently unable to stick to immigration targets, and Hilary Benn MP would have been better off campaigning on this than sticking the political knife into Jeremy Corbyn? It’s pretty unlikely that Theresa May will be able to deliver on both exiting completely out of the single market and exempting itself from free movement of people, meaning that there’ll be a lot of disappointed people around.
The LibDems have already made their bed, which they intend to lie in. The possibility of another Tory-LibDem coalition beckons (particularly if Kezia Dugdale keeps up her triumphant work of Armageddon in the Scottish labour vote; this catastrophe long predates the Corbyn factor). They in case are not the party of the 52% or the 100%, but the 48%.
I suspect people who claim to want a ‘strong opposition’ want nothing of the sort. They are prepared to continue to undermine Jeremy Corbyn at all costs in 2017, and are fully prepared to see Theresa May secure a mandate for a hardline exit from the European Union.
Jeremy Corbyn for the time being has taken back control of the Labour Party, but his strategy has paradoxically been to make himself not dependent on others to the point of being isolationist. But the strength for Labour will be, as always, when the whole works for the collective good, and is larger than the sum of individual parts. If some people with big egos don’t feel they wish to suffer the indignity of losing under Corbyn for their own beliefs, and want to leave, that can only be interpreted as a good thing. If they can offer constructive criticism as leading Commons select committees, that I suppose is good potentially too. Strictly isn’t bad either.
But if they’re just going to whinge holding onto minor London seats, or larger, they’re better off getting out for the sake of all of us.
Ed Miliband, Andy Burnham, and the whole of Labour have pledged robustly that a direction to repeal the Health and Social Care Act (2012) will be made in the first Queen’s Speech of a new Labour Government.
It is said that David Cameron and Nigel Farage are to be issued with a joint challenge to declare that they will rule out any attempt to repeal the ban on foxhunting if they form a pact in the event of a hung parliament.
Evan Harris on 6 March 2012 identified the impact that the Lansley legislation would have to turbo-boost marketisation and privatisation of the NHS.
He warned Liberal Democrat colleagues not to touch it with a bargepole:
“It has no friends among even the non-party-political royal colleges, and has no mandate in those areas where it goes beyond the coalition agreement. The political impact will be to retoxify the Tory brand – which they are welcome to do, of course –, but also, by association, to damage the Lib Dems.”
The assurances given by Lord Clement Jones have turned out to be hollow:
“In putting down amendments, we have no hostility to competition as such, merely a desire to make use of the opportunities that the TFEU and European competition law offer member states to avoid the NHS being treated like a utility, such as gas and electricity.
Under the EU treaties, Article 106 of the Treaty on the Functioning of the European Union states:
“Undertakings entrusted with the operation of services of general economic interest … shall be subject to the rules contained in this Treaty, in particular to the rules on competition, insofar as the application of such rules does not obstruct the performance, in law or in fact, of the particular tasks assigned to them”.
Member states have certain discretion as to which services are services of general economic interest. By ensuring healthcare services for the purposes of the NHS are services of general economic interest and that the “task” of co-operation between services is “assigned” to the healthcare providers, it should be possible to provide some protection from less desirable aspects of competition law.”
This year saw Cambridgeshire and Peterborough NHS Foundation Trust awarding G4S Integrated Services a £3.9 million contract to provide domestic cleaning, portering and catering support across its property portfolio. The three year agreement, with the option to extend for a further year, will see G4S initially delivering services to 34 sites across Peterborough and Cambridgeshire, with further locations likely to be added in the future. Cleaning will be provided across the contract, with additional portering services and catering support at some specific sites.
Privatisation does not require a complicated definition. It’s simply the transfer of public sector resources into the private sector. Even the late Sir Keith Joseph, widely thought to be “brilliant” by the late Margaret Thatcher herself, and who was thought to be the principal “architect” of Thatcherism, ended up trying to keep afloat businesses in the public sector rather than privatise them. This was during his time as Secretary of State for Trade and Industry.
There is generally a feeling that the Coalition government, a joint enterprise between the Conservatives and the Liberal Democrats, went much further in privatising the NHS than the Thatcher government even dared to. And the worst aspect of this was there was absolutely no inkling that this would happen. There was no mention of this even in the Coalition Agreement of 2010.
There is no official policy by UKIP on the NHS yet.
This is absolutely staggering. The late Tony Benn used himself to warn people against voting for people who are ‘false prophets’. UKIP seem alarmingly reluctant to acknowledge the number of people from black asian minority ethic background who actually work for the NHS and bring value to it everyday.
It is now felt that there is quite a high chance of a ‘hung parliament’, although Labour activists are desperate to fight for a Labour government at Westminster with a healthy majority. It appears that the mainstream right-wing press have given up the ghost, in the form of David Cameron.
It is curious why the Conservative Party haven’t ditched their leader, like they did famously in 2010, but the most parsimonious explanation is that it would make sense to find a new leader after the expected catastrophe of the 2015 election. Ditching Cameron now might mean that they would have to ditch a new leader further in 2015. Besides, the Conservatives and Liberal Democrats have become a tried and tested product as far as the City are concerned.
The current Government, and people who sail with her such as BoJo, have fiercely defending the City’s interests in Europe as far as banker bonuses are concerned. They have resisted the ‘Mansion Tax’, which is widely thought to be introduced by Ed Balls as Chancellor in the first Budget of a Labour Government, as a windfall tax to produce a cash injection into the NHS. Furthermore, the City still has lucrative contracts in the form of the private finance initiative which have yet to be renegotiated properly from this Government; and also they have been very successful in promoting social impact bonds, the PFI equivalent for social enterprises, with the current Government which has used mutualisation to Trojan horse rent seeking in response to Mid Staffs.
Certain dividing lines have now got to be laid for the sake of the public good.
I feel that it is essential that David Cameron, Nick Clegg, and Nigel Farage are to be issued with a joint challenge to declare that they will rule out any attempt to resist the repeal of the Health and Social Care Act (2012).
Nigel Farage, for all his faux socialist credentials, seems unseen to resist formally the privatisation of the NHS; in fact his henchmen over the years have prided themselves on the ‘efficiency’ of the private sector, despite the growing allegations of fraud and inefficiency from the outsourcing companies used by the current government to deliver the smaller State.
Nick Clegg not only has a PR problem; he has a major issue with the content of what the Liberal Democrats stand for. It is widely known that there is discontent about his party’s ‘differentiation’ policy, which has seen the Tories and the Liberal Democrats telling the voters why each other party is clearly unfit for government. The charge sheet against the Liberal Democrats, including a weak economy (not enough till receipts from income tax to fund public services), demolition of legal aid, privatisation of NHS, misery for a mass of disabled citizens through botched welfare reforms, is substantial.
As a minority party, the Liberal Democrats would be asked to repeal the Health and Social Care Act (2012) which is possible but simply weird. It is clear that the Liberal Democrats, Conservatives and UKIP are clearly capable of running the NHS into the ground.
A lot of energy was put into fighting the Liberal Democrats on the toxic firestorm hospital closure clause, clause 119, which the Liberal Democrats were instrumental in protecting. Norman Lamb, for all his soothing words, has been the Minister of State in office while social care has imploded; the social care budget has not been ring fenced, coincidentally, since 2010.
There was a popular joke on Twitter this year that turkeys joked, “It’s like humans voting for UKIP”.
David Cameron, if he is still leader in 2015, or whoever is in charge of that toxic brand, will clearly be in no position to repeal the Health and Social Care Act (2012). The least worst option is that the Liberal Democrats and UKIP should pledge not to resist the repeal of the Health and Social Care Act (“Act”), but the hope is that a strong Labour government will have renewed vigour in assessing the political weather. Even better, they should pledge to repeal the Act.
That is, the component of the private sector in the mixed health and care economy has gone way too far. The health and care sectors should never be run anywhere for the benefit for shareholders offering care in 15 minute slots or below the minimum wage. The health and care sectors should not be so fragmented as they are now. People should be collaborating with each other to offer excellent clinical care, not competing with each other.
The vote is the most critical weapon of influence any of us has. Even more than ever, it is vital that it is used wisely.
I’m essentially in two minds about whether the NHS is ‘a political football’.
On the one hand, I don’t think it should be.
I felt the way Mid Staffs meant some hardworking staff in that region came to be pilloried and demonised by the media was more than indecent.
On the other hand, I think you can clearly apportion blame for the current Government’s performance about A&E waiting times and other key metrics.
On balance, I’d like Labour to have a strong majority to get through repeal of the Health and Social Care Act (2012), without say relying on the Liberal Democrats who enacted it in the first place.
There’s also important legislative work to be done in bringing together health and care; and also an Act of parliament to consolidate regulation of clinical professionals.
While I have much sympathy for NHS campaigners, I most certainly do not want a weak Tory-led Government because of incessant criticism of Labour.
There is a huge amount to discuss about the NHS.
I believe, for example, that the private finance initiative, whilst it had a useful aim in improving the infrastructure of buildings of the NHS, clearly did not represent value for money.
I don’t think it’s ever justifiable to bring in the private sector because the NHS can’t ‘cope’. I don’t see why you should want to bring in locums either, because of ‘unforeseen circumstances’.
And, in total agreement with Jackie Ashley at a fringe meeting of the Fabians this year, there needs to be had somewhere a discussion of how health and care sectors are to be properly funded.
There is almost universal agreement that the NHS cannot function at anywhere near its best with social care in such chaos.
I do blame a supine media for not allowing discussion of ‘whole person care’, or discussion of topics that even Labour would like to talk about (such as PFI; see Margaret Hodge’s remarks).
We’ve got some brilliant brains involved – Prof Allyson Pollock, whose brilliant analysis of PFI shines, has had some very pertinent points about the Clive Efford Bill with Peter Broderick. Yes, Andy Burnham MP does not support ISPS/TTIP, but this policy is still being left hanging in an uncomfortable way.
I am fundamentally a socialist, so I take the perspective that if we’ve got money for war we’ve got money for the health service. And I think with debt going through the roof, and with the economy being fuelled with insufficient till receipts, we are a long way from the energy which saw the NHS created in the first place from the spirit of ’45.
Whilst supporting Labour, I don’t wish this to descend into tribalistic nonsense. I will support anyone who has decided that the current performance of the NHS is unacceptable, but I have no intention of actively campaigning against Labour.
I personally wish to see policy for living well with dementia progress under Labour, irrespective of whether Ed Miliband can eat a chip butty.
Whatever, we certainly need there to be a public discourse about the NHS more than Europe or immigration, for example. Socialism is social-ism; if you want to see how collectively we can pull through, just look at the energy generated by Jon Swindon (here) or Eoin Clarke (here).
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.
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
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.
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.
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 presentation may be awful, but sharing of information can be very useful for clinical decision making
When I saw a blogpost shared by a Twitter pal shared yesterday, a blogpost written by Sir Jeremy Heywood, my first instinct was completely to ignore it.
I am, though, mindful of the Civil Service’s prolonged campaign to measure wellbeing; this first came across my RADAR from Lord O’Donnell.
I have a disclaimer to make: I am not a corporate shill.
Having done certain training, I am aware of the hard sell of ‘Big Data’ as the next big thing by the multi-national corporates. “Big data” seem to have been given a somewhat pedestal status, like 3-D printers.
We are often told how intelligent technology rather than being a costly burden to the NHS could bring great benefits and outcomes for the NHS.
Undoubtedly, a lot of democratic deficit damage was done by the Health and Social Care Act (2012). At close to 500 pages, it was very easy to say it was too incomprehensible to be analysed. I always felt the Act, for anyone trained in commercial and corporate law, was in fact relatively straightforward.
The Health and Social Care Act (2012), often called “the Lansley Act”, has three essential prongs of attack: one to introduce a competitive market through legislation for a heavy penalty for non-one-commissioning not going out to tender, a beefed up regulator for the market (Monitor), and some detail about insolvency regimens (but not all).
In this, it was completely consistent with work by Carol Propper; and other noises from ‘independent think tanks’, such as the King’s Fund.
However, the acceleration of this Act through parliament by two parties which are extremely sympathetic to the free movement of multinational capital has done long-lasting damage.
I think there are problems with having data so transparent. When I did my Masters of Law practice-focused dissertation in cloud computing law, I unearthed a huge literature on data security and data confidentiality/sharing.
When I later did my pre-solicitor training, I discovered the regulatory requirements on the balance between confidentiality and disclosure to be complicated.
When I later came to revise ‘Duties of a Doctor’ (2013), the General Medical Council’s code of conduct, I found there to be equally onerous considerations.
I am aware of the problems in my own field of work; about concerns that NHS patients will be scared from going to see their GP for fear of being diagnosed, incorrectly, with ‘incipient dementia’ because of a GP’s practice wanting to meet a financial target.
Or a junior Doctor not wishing to share his alcoholism with his own Doctor, for fear that this information will end up with the clinical regulator, with a super-un-sympathetic sanction. This is a subject close to my heart, as you will well know.
Indeed, if you’ve been following me on Twitter, you’ll know that a year after erasure by the GMC (in 2006 to be endorsed by the High Court in 2007), I spent a year sitting in a pub with no family or job. I later was then admitted to the Royal Free Hospital having had a cardiac arrest and epileptic seizure, then to spend six weeks in a coma.
I am now knowledgeable about what both the legal and medical regulators expect me to do, as I am regulated by them.
The next Government will be wishing to implement ‘whole person care’. While I think some of Jeremy Heywood’s claims are a tad hyperbolic (for example saying unleashing data will lead to wellbeing improvements), and while I don’t feel he currently ‘owns’ the data (the data are confidential property of the people who provide the data), there are clinically-driven merits to information sharing.
From now on, I will avoid the word ‘data’ and use the word ‘information’. But ‘information’ does not necessarily mean ‘knowledge'; and it certainly doesn’t necessarily mean ‘wisdom’.
One scenario is somebody prescribed Viagra for erectile dysfunction in the morning. He then has sex with his partner in early evening, and has Angina. He has longstanding ischaemic heart disease, and then takes his GTN spray. His blood pressure then goes through the floor, and he collapses. He then is blue lighted into his local emergency room.
Do not take this anecdote as ‘medical advice’ or any such like where I could get into regulatory trouble please.
Viagra is a class of drug which can interact with the GTN spray to send blood pressure through the floor. If this information were known to an admitting Doctor in the emergency room, this would be useful.
I can come up with countless examples.
A lady from a care home turns up in hospital at 4am. An admitting Doctor wishes to prescribe a heavy-duty blood pressure lowering drug, but notes she has had a series of falls. This is found out by looking at her electronic medical record. She indeed has a history of osteoporosis; weak bones could mean that she might fracture a bone if she had another fall.
But I could come up with countless examples. And I won’t.
I am not a corporate shill. I understand completely the concerns about the loopholes in current legislation meaning that ‘big data’ could go walkies to drug companies, though this is vehemently denied.
I am also aware of ‘cloud failures’ – the Playstation one for some reason springs to my mind.
That’s another reason to keep an eye on ‘My NHS’.
But we do need, I feel, to take a deep breath and to discuss this calmly.
“The past is a different country. They did things differently there.’
One of the favourite weapons in the armoury of supporters of the present Coalition is that the warning claims over the NHS have been in the past ‘exaggerated’ or ‘scaremongering’.
And yet today broke records being broken, for the longest waits in the Accident and Emergency departments in England; and a record number of emergency admissions.
The National Health Service currently has a statutory duty to promote innovation. But nobody would have thought that Mr. Hunt (who is not a professional surgeon, or professional medic, to my knowledge) would have ‘done things differently'; by adding a ‘Spring Crisis’, ‘Summer Crisis’ and ‘Autumn Crisis’ to a ‘Winter Crisis’.
Put simply, sadly the claims by NHS supporters do not constitute merely ‘scaremongering’. It may have been urgent to ‘save the NHS’ in the past; as indeed Labour had to do in 2007 when the service was teetering on the brink last time. But the situation is now critical.
The last few years have seen a litany of errors in public health policy; such as in standard packaging of cigarettes, or minimum pricing of alcohol. It has been impossible for the Conservatives and the Liberal Democrats, who are both devoted to the multinational free movement of capital, to act in the true public interest.
But by far the worst event to have happened were the Conservatives and Liberal Democrats getting onto the state books the ‘Health and Social Care Act’.
The Liberal Democrats’ contribution to this statutory instrument cannot be underestimated by any means. Despite the noblest actions of a minority of ‘good LibDems’, such as Dr Charles West, the cheap words of some LibDems Peers in the debate over the toxic ‘section 75′ made their position perfectly clear.
Section 75 of ‘the Lansley Act’, which senior Conservatives now claim not to have understood, couldn’t have been clearer. It was a clear departure from the previous law. It laid out a clear threat in law for the first time a legal threat to any commissioners departing from putting contracts out to formal competitive tender, if there were not a sole bidder.
The Liberal Democrats, Conservatives and UKIP may now show what can best be described as ‘amnesia’ over this instrument which some of them actually legislated for, as well as the £3bn ‘top down reorganisation’ which David Cameron swore blind would never be introduced, but “the facts speak for themselves”: or, as my learned legal colleagues, put it, ‘res ipsa loquitur’.
Andy Burnham MP this morning in an article in the New Statesman laid bare the sheath of lies by Nick Clegg in the House of Parliaments over the NHS.
Sadly, while Jeremy Hunt and Dan Poulton fiddle while the NHS collapses, there is a record number of admissions in emergency departments in England, and the most vulnerable people are labelled ‘bed blockers’ by a supine and ineffective English media as they cannot leave hospital to a social care system which has now collapsed through starvation.
Labour argues that it last used the private sector in needing to address a ‘backlog’ in demand, but the question is how the NHS get to this state in the first place? It’s because for decades, as NHS campaigners rightly argue, the NHS and social care systems have been given the bare minimum to carry out their functions.
NHS managers, many of whom are generously paid more than their ability might suggest, and certainly much more than frontline nurses implementing a policy savaged by staffing cuts in the name of ‘efficiency savings’, have been trying to balance the books through a number of mechanisms, such as laying off staff, not giving existent staff a pay rise, or paying corporates loan repayments for PFI or lawyers for doing their administration.
Labour possibly can argue then it was a temporary measure to pay off people in the private sector to do the work the NHS had been carrying out, but the mainstream parties should be in the business of delivering a well functioning NHS. As Andy Burnham MP said in launching his party’s campaign on the NHS in the European Election in 2014, we’ve got a sad state when the Conservatives and LibDems are competing for the lowest social care bills irrespective of whether the services are awful.
And it’s sacracant to criticise the NHS managers, but any reasonable guardian of these managers will ask why they have allowed their own senior pay to balloon;
why performance management of Doctors and nurses in the NHS is so poor, with performance management being regularly done by the regulator not by human resources;
why so much money has been siphoned off for ‘transaction costs’ of law and admin the implement the NHS reforms;
why PFI contracts have been so poorly negotiated such that the cost to the State is enormous;
how come so many private providers are being directly paid out of the NHS monies provided by taxpayers;
why there seems to be an enthusiasm to pay short-term locum staff at exorbitant rates instead of investment in the current workforce;
and so on?
The Health and Social Care Act (2012) drove the NHS over the edge. Put simply, the NHS and social care systems would not be able to survive another sudden legislative mechanism designed to privatise the NHS?
On this Camilla Cavendish is simply incorrect. You would have thought with all her experience she should have come up with a better definition of ‘privatisation’ on BBC Question Time last night. it is the standard argument of those who say it is not privatisation to say that privatisation is accompanied by a ‘tell Sid’ type flotation (also called the “initial public offering’).
It is not.
Privatisation is simply wholesale transfer of assets and resources from the public sector to the private sector.
There has been every possible last-ditch effort to deny this was NHS privatisation from the current neoliberal Coalition parties. It is definitely privatisation. The taxpayer is paying private companies for functions which the State should be providing, without private companies footing properly their part of the ‘bill’ including for training of the current workforce of professionals.
The ratcheting up of how ‘it is not privatisation’ or ‘we should look at whether private provision is a bad thing’ is a testament to this.
Quite simply, the NHS would not survive another five years of the Conservatives. We should rally around NHS campaigners of all parties to ensure the Conservatives and Liberal Democrats are not re-elected nationally to run the NHS for their benefit.
The National Health Service is not supposed to be run for the benefit of private sector ‘rent seekers’, or MPs who also have interests in the private health industry. Keep our NHS public. Keep the NHS National run for the public good.
Support your NHS campaigner. He or she needs you.
I’m still unclear where and when the Prime Minister’s Dementia Challenge came about.
The lack of a clear audit trail for the Prime Minister’s Dementia Challenge
I know that it was launched in March 2012.
“Dementia” is not mentioned in the Conservative Party Manifesto for the general election of 2010. It is however mentioned in the Coalition Agreement, with broadly the same wording as the Liberal Democrat manifesto 2010, but that still doesn’t explain how this became the “Prime Minister’s Challenge”.
In summary, the one line in the Coalition Agreement is drafted as follows:
“We will prioritise dementia research within the health research and development budget”
But still no specific mention of that “Challenge”.
The distortion effect of the Prime Minister’s Dementia Challenge
The Dementia Challenge prioritises the Alzheimer’s Society, and it is clear that other charities, such as Dementia UK (which is experiencing threats of its own to its superb ‘Admiral nurses’ scheme) trying to plough on regardless.
The £2.4 million “Dementia Friends” programme emerged from the Social Fund and the Department of Health. The scheme has been launched in England at first, and it is said that the Alzheimer’s Society is hoping to extend it to the rest of the UK soon.
There is no official cross-party consensus on the “Prime Minister’s Dementia Challenge”, though individual Labour MPs support the activities of “Dementia Friends”.
The market dominance of the Alzheimer’s Society for ‘Dementia Friends’ compared to other charities does not seem to have been arrived at particularly democratically either. There is no conceivable reason why other big players, such as “Dementia UK” or the Joseph Rowntree Foundation, were excluded from this friendship initiative.
Ironically, Japan upon which befriending is modelled is not ashamed of its care service.
It is palpably unacceptable if people are ‘more aware of dementia’ without a concominant investment in specialist memory clinics, or care and support services.
Genuine concerns from stakeholders involved with dementia care
It is clear amongst my followers on Twitter that the nature of this “Challenge” is causing considerable unease.
— Liz Wilson (@aphidcatcher) April 13, 2014
Concidentally I was reminded of this this morning:
But there are now some very serious questions about this policy, particularly from the ‘zero sum gain’ effect it has had knock-on in other areas of dementia policy.
— Mark Barlow (@mark_b33) April 13, 2014
When @Ermintrude2 looked into this at the time, the response was a bit confused.
— Ermintrude (@Ermintrude2) April 13, 2014
And indeed Ermintrude has penned some thoughts at the time on this high impact blog.
What has happened to social care in the name of ‘improvement’, I agree, is very alarming.
@legalaware The Dementia Challenge – smoke and mirrors. Nice platform for government to make people think they are doing stuff..
— Ermintrude (@Ermintrude2) April 13, 2014
But we do know full-well about the ‘democratic deficit’.
False pledges and threats, and unfulfilled promises
The general public were unaware that a 493 Act of parliament called the ‘Health and Social Care Act’ would be sprung on them, with a £3 bn top-down reorganisation.
But this was Lansley’s “emergency conference” on Labour’s “secret death tax” in February 2010.
A number of views were expressed at the time, including the need for better care from the Alzheimer’s Society at the time under a different CEO.
The full thrust of ‘Dementia Friends’ is a total change of mood music from February 2010’s concerns of the Alzheimer’s Society reported here:
“Care and treatment for sufferers of dementia should be at the heart of the general election campaign, the Alzheimer’s Society charity has said.”
Where has the Society been in campaigning on swingeing cuts in social care?
Also, in February 2010, Gordon Brown’s speech at the King’s Fund was reported, where Brown made a significant pledge.
“Mr Brown also announced that the government’s planned reforms to community and primary care health services also included a commitment to provide dedicated “one-to-one”nursing for all cancer patients in their own homes, over the next five years.”
We do know that the NHS has been persevering with this programme with ‘efficiency savings’.
In October 2012, it was reported that nearly £3bn was indeed returned to the Treasury, and it is unclear how, if it at all, it was returned to front line care.
So it’s possible that Brown’s plan, the subject of a hate campaign at the time from the Tory press, might have worked in fact.
In 2010 Andrew Dilnot had been tasked by the then government to propose a solution to the crisis in social care.
The response was from February 2013, after the top-down reorganisation.
“Mr Dilnot suggested a cap on how much anyone would be required to pay for their care costs over the course of a lifetime, suggesting a ceiling of between £25,000 and £50,000 (in 2010/11 prices). Beyond this point, the state would take on responsibility for the majority of the bill.
The Government today announced that from 2017 it intends to establish a cap of £75,000 in 2017 prices which, according to Mr Dilnot’s calculations, equates to approximately £61,000 in the 2010/11 prices (the basis of his report). If we’re to make a claim about the extent to which the Government has ‘watered down’ Mr Dilnot’s proposal, it’s crucial that we account for this inflationary effect.”
Resurrection of the ‘National Care Service’ by Andy Burnham MP yesterday, Shadow Secretary of State for Health
This issue may have to be revisited at some stage. Andy Burnham MP yesterday in the Bermondsey Village Hall, without much press present, mooted the idea of how a social care service could be established on the founding principles of the NHS, and would be a significant departure from the piecemeal 15-minute slot carers.
Burnham stated that care provided by inexperienced staff on zero-hour contracts was a problem.
An experienced member of the audience highlighted the phenomenal work done by unpaid family caregivers particularly for dementia.
The topic of a compulsory state insurance is interesting.
Social health insurance systems share a number of similar features:
- Insured persons pay a regular contribution to a health insurance fund based usually on income rather than reflecting their risk of illness.
- Clinical need and not ability to pay determine access to treatments and health care.
- Contributions to the social insurance fund are kept separate from other government mandated taxes and charges.
In his classic article, Kenneth Arrow (1963) argues that, where markets fail, other institutions may arise to mitigate the resulting problems: ‘the failure of the market to insure against uncertainties has created many social institutions in which the usual assumptions of the market are to some extent contradicted’ (p. 967).
Rationale for this method of funding
A great advantage of ‘social insurance’ is, because membership is generally compulsory, it is possible (though not essential) to break the link between premium and individual risk.
There might be other important aspects. For example, both employers and employees pay contributions. Also, there might be Government support for those who are unable to pay goes through the insurance fund.
The philosopher John Rawls (1972) argues that in a just society the rules are made by people who do not know where they will end up in that society, that is, behind what he called the “Veil of Ignorance”.
Insurance can be interpreted as an example of solidarity behind the Veil of Ignorance: a person who joins a risk pool does not know in advance whether or not he will suffer a loss and hence have to make a claim. Insurance thus has moral appeal.
Ultimately there is a problem as to what type of care might be covered.
Does the policy cover only residential care, or also domiciliary care; is a person entitled to residential care on the basis of general infirmity or only if he or she has clearly-defined, specific ailments?
In the Dilnot recommendations, the cap on care payments did not include the “hotel costs” that a care home will charge. In other words, people in residential care will still need to pay (at the Dilnot report’s estimate) between £7,000 and £10,000 per year to fund their accommodation and living expenses.
Furthermore, how will the answers to these questions change with advances over the years with changes in the actual prevalence of dementia, or in the implementation of ever increasingly sophisticated medical technology?
It has been proposed (Lloyd 2008) that long-term care could be financed via social insurance, with the premium paid as a lump sum either at age 65 or out of a person’s estate. The idea behind this proposal is twofol.
Firstly, as a person gets older, the range of uncertainty about the probability of needing long-term care becomes smaller.
Secondly, if a person can buy insurance for a single premium payable out of his or her estate, the cost of long-term care does not impinge on his or her living standard during working life or in retirement, but can frequently be taken from housing wealth.
Development of social health insurance systems have normally been in response to concerns that inadequate resources were mobilised to support access to health services.
The continuing swingeing cuts in social care
And these cuts have continued: this report is from March 12 2014,
“An analysis by Mind found that the number of adults with mental health needs who received social care support has fallen by at least 30,000 since 2005, a drop of 21%. Cuts to local authority social care budgets – the majority of which have hit since 2009 – have left a funding shortfall for care of up to £260 million, the charity said.”
Since there is no simple answer to the question of how much is the appropriate level of support, the issue of adequacy is best thought of as being a level that is considered appropriate in the country given its total resources, preferences and other development priorities.
And where are people from charities campaigning on this issue?
This issue of course was not considered at all in the G8 Dementia Summit, which focused on more monies for personalised medicine, genetic and molecular biology research, in response to concerns from an “ailing industry”.
I am actually truly disgusted at this unholy mess.
Arrow, Kenneth F. (1963), ‘Uncertainty and the Welfare Economics of Medical Care’, American Economic Review, 53: 941–73; repr. in Cooper and Culyer (1973: 13–48), Diamond and Rothschild (1978: 348–75), and Barr (2001b: Vol. I, 275-307).
Lloyd, James (2008), Funding Long-term Care – The Building Blocks of Reform, London:
I have not set out to build a social movement, but I want to do this for persons with early dementia
I received this message last night.
The thing is, I don’t buy into the profoundly negative imagery of the media, including memes such as “crippling”, “horrific”, “timebomb” and “explosion”.
Whilst some people, and caregivers, are undeniably “suffering”, you can’t expect all people to agree with this particular narrative at all times, I feel.
One of the things I’ll never forget was when my Ph.D. supervisor, Prof John Hodges, received a complaint about me doing neurocognitive assessments in a person with frontal dementia back in 1997.
This type of dementia, commoner in an age group below 60, is characterised by a personality and behavioural change early on, often in the absence of deficits in thinking such as memory or perception. You need an account from someone very close to that person with dementia, as the person himself or herself can have no insight into the changes.
I remember saying to the wife of a young man with this type of dementia, “I would never have guessed that he had a dementia”. This comment had upset her very much, and by that stage I was years into my medical training.
This one event is something I’ve never forgotten in the 16 years subsequently.
I remember I literally didn’t sleep for a week, and I was profoundly upset by this. But it does lie to the heart of some of my reservations about the term ‘dementia friendly communities’. There are some people for whom you would not be able to tell they were living with dementia.
I understand the focus on memory problems in the general media, as this can be a dominant presentation in typical Alzheimer’s disease, the commonest form of dementia. But memory is only one of the cognitive functions we have.
What unites all people with dementia is that the law makes a verdict on whether they are able to make decisions. This is called legal capacity.
Decisions impact on many aspects of life, such as working out how to spend your money, or which treatment to go for in hospital.
And capacity is very topical. Not only is the House of Lords seeking to update the Mental Capacity Act (2005), but also neuroscientists currently want to know what members of the public think about their research on decisions.
This is therefore not about denying compassion or dignity for all persons with dementia. It’s about redressing a power balance, where I feel people who’ve just received a diagnosis of dementia might learn something constructive about dementia, decisions and science of how to influence decisions.
This is profoundly about having a discussion with persons with dementia.
I’ve been on the receiving end of ‘look at my website’ and I find it intensely nauseating. But I wish my website, which I intend to build with funds from a crowdfunding campaign and scientific grant bodies, to allow persons with dementia to think about their own decisions.
It’s well known in the science of decisions for example that some ‘bad’ decisions can be avoided by not following ‘hot impulses’ or following the ‘herd effect’.
So here is my explanatory video:
Whilst I have been urged to make this campaign so that ‘it touches every person with dementia’, I do also want a grown up conversation without dumbing down any of the concepts.
A lot of feedback has concentrated on the ‘social movement’ aspect of it, but I should like to say whilst I say I would like to build one, I really mean it’s important for me personally that this gathers some momentum.
And I think it will from initial feedback from persons with dementia, and even people involved in the NHS and social care.
All too easily dementia policy can have more regard to marketing and tokenism, which lends itself to commissioning ‘tick box’ culture. My campaign is not for them.
And I’ve got a bit of a shock for some people – I am determined to make a big success of it.
— Pollyanna Jones (@PollyannaJones) April 2, 2014
— #HelloMyNameis Pip (@pippa_dolittle) April 3, 2014
— James Murray-White (@sky_larking) April 2, 2014
@legalaware I have been trying to convince people the nhs needs it’s own kickstarter platform for a while. Will be great to see if it works
— Pollyanna Jones (@PollyannaJones) April 2, 2014
— Rebecca Wassall (@Bexmoxon) April 8, 2014
Andy Burnham's "whole person care" has a huge academic and practitioner literature, and demands discussion
“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.