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Why are English policy wonks fixated on the dangerous wrong policy of competition for their NHS?
A series of different amendments are coming from various sources to ask Andy Burnham to scrap the market in the NHS.
And indeed Andy Burnham claims to be well aware of the dangers of the introduction of a sort of-market to the NHS:
In recent years, there has been clear unease at policy wonks ‘doing’ the traditional circuits in think tanks, known to feather each other’s nests, with no clinical backgrounds (including no basic qualifications in medicine or nursing), pontificating at others for a cost and price how to run the NHS in England.
Think tanks have been part of the discussion, with blurred lines between marketing and shill and academic research, exasperating the real research community.
The King’s Fund boasts that, “Providing patients with choice about their care has been an explicit goal of the NHS in recent years. Competition is viewed by the government as a way of both providing that choice and giving providers an incentive to improve. The Health and Social Care Act set out Monitor’s role as the sector regulator with a specific role of preventing anti-competitive behaviour in health care.”
Chris Ham, who has previously marvelled voluptuously at the US provider Kaiser Permanente in the British Medical Journal, goes hammer and tong at it on an article on competition here.
The theme or meme comes up as a recurrent bad smell in the impact assessment for the Health and Social Care Bill here, citing in the need to consider equality concerns in competition the reference Gaynor M, Moreno-Serra R, Propper C, (July 2010) Death by Market Power Reform, Competition and Patient Outcomes in the National Health Service. NBER Working Paper No. 16164, July 2010.
The authors of that impact assessment nonetheless reassuringly observe that “Gaynor et al (2010) found competition impacted differently across certain areas with possible negative impacts on transgender and black and minority ethnic (BME) people. However, further evidence implies that these risks, associated with increasing competition, should not be overstated and may not impact upon equality issues.”
Andy Burnham – and Labour – have pledged many times that the repeal of the failed Health and Social Care Act (2012) will be in the first Queen’s Speech of a Labour government.
Policy wonks are human beings, and can fail.
It is well-known that many errors in anesthesiology are human in nature. It’s argued that because equipment failure is an infrequent explanation for mishaps in the hospital, clinicians should be aware of the human factors that can precipitate adverse events.
While there are various types of human errors that can lead to complications, “fixation errors” are relatively common and deserve particular attention. Fixation errors occur when clinicians concentrate exclusively on a single aspect of a case to the detriment of other more important features. This is exactly what has happened with the undue prominence of the benefits of competition in the NHS.
Put simply, without any of the bullshit, competition is simply the crow bar which puts private providers into the NHS.
Milburn and Hewitt have been reading from this narrative from ages, and it threatens to engulf Labour yet again. Burnham is fighting a battle for the soul of the party now, and one can only speculate how successful he will be. He has said on many occasions that collaboration is the key to running the NHS in England, not competition; integration not fragmentation; people before profit.
But if you look beyond the lobbying – you can find the evidence right before your eyes. Jonathon Tomlinson through an excellent blogpost of his refers to a large body of literature from Professor Don Berwick which has been in the literature. This is clearly worth revisiting now.
The New Statesman published last week an article which should make senior healthcare policy wonks in England weep.
Martin Bromiley is neither a doctor, or a health professional of any kind. He is not even a member of the revolving door policy wonks in English healthcare policy. Bromiley is an airline pilot.
“Early on the morning of 29 March 2005, Martin Bromiley kissed his wife goodbye. Along with their two children, Victoria, then six, and Adam, five, he waved as she was wheeled into the operating theatre and she waved back.”
A room full of experts were fixated on intubating her, instead of doing a tracheostomy, which indeed Bromiley indeed asked for. A tracheotomy is a cut to the throat to allow air in.
What happened next was incredible.
“If the severity of Elaine’s condition in those crucial minutes wasn’t registered by the doctors, it was noticed by others in the room. The nurses saw Elaine’s erratic breathing; the blueness of her face; the swings in her blood pressure; the lowness of her oxygen levels and the convulsions of her body. They later said that they had been surprised when the doctors didn’t attempt to gain access to the trachea, but felt unable to broach the subject. Not directly, anyway: one nurse located a tracheotomy set and presented it to the doctors, who didn’t even acknowledge her. Another nurse phoned the intensive-care unit and told them to prepare a bed immediately. When she informed the doctors of her action they looked at her, she said later, as if she was overreacting.”
This is not the first time that a ‘fixation error’ has had disastrous consequences.
Another example happened on 28 December 1978, the United Airlines Flight 173.
A flight simulator instructor Captain allowed his Douglas DC-8 to run out of fuel while investigating a landing gear problem.
It’s a miracle that only ten people were killed after Flight 173 crashed into an area of woodland in Portland; but the crash needn’t have happened at all.
In a crisis, the brain’s perceptual field narrows and shortens. We become seized by a tremendous compulsion to fix on the problem we think we can solve, and quickly lose awareness of almost everything else. It’s an affliction to which even the most skilled and experienced professionals are prone.
In March 2012, Professor Allyson Pollock wrote an article in the Guardian, stating ‘Bad science should not be used to justify NHS shakeup’.
In this article, Pollock argued that pro-competition arguments from economists Julian Le Grand and Zack Cooper at the London School of Economics had produced an incredibly distorting effect on what was an important discussion and, “[raised] serious questions about the independence and academic rigour of research by academics seeking to reassure government of the benefits of market competition in healthcare.”
Pollock argues that such colleagues had been sufficiently successful for David Cameron to declare “Put simply: competition is one way we can make things work better for patients. This isn’t ideological theory. A study published by the London School of Economics found hospitals in areas with more choice had lower death rates.”
It is reported in one case, the previous chief of NHS England, Sir David Nicholson KCB CBE “said a foundation trust chief executive had been told he could not “buddy” with a nearby trust ? under plans announced last week to help struggling providers ? because “it was anti-competitive”.
He continued: “I’ve been somewhere [where] a trust has used competition law to protect themselves from having to stop doing cancer surgery, even though they don’t meet any of the guidelines [for the service].”
“Trusts have said to me they have organised, they have been through a consultation, they were centralising a particular service and have been stopped by competition law. And I’ve heard a federated group of general practices have been stopped from coming together because of the threat of competition law.”
“All of these [proposed changes] make perfect sense from the point of view of quality for patients, yet that is what has happened.”
Meanwhile, there was more product placement for providers including Kaiser Permanente yesterday by Jeremy Hunt in parliament:
“From next year, CCGs will have the ability to co-commission primary care alongside the secondary and community care they already commission. When combined with the joint commissioning of social care through the better care fund, we will have, for the first time in this country, one local organisation responsible for commissioning nearly all care, following best practice seen in other parts of the world, whether Ribera Salud Grupo in Spain, or Kaiser Permanente and Group Health in the US..”
Everyone appears to be fixated apart from the most junior in the room, or people like me who wouldn’t want to touch these jobs in think tanks with a barge pole.
It is indeed a badge of honour for me that the feeling is likely to be mutual.
Competition does not explain whether a person who has had chest pains due to a clogging heart should have a physical stent to open up the pipes of blood in his heart, or whether he needs tablets he can take. That is down to clinical professional acumen.
Competition with few big providers can lead to massive rip offs in prices, because of the way these markets work (these markets are called ‘oligopolies‘).
And all too easily providers can be in a race to the bottom on quality, cutting costs to maximise profits.
Remember Carol Propper’s research being used to bolster up the failed plank of competition in the Health and Social Care Act impact assessment?
Wow.
Here she is again in the speech by Simon Stevens, the new NHS England chief, being used in a slightly new context for his speech before the NHS Confederation last week: of the “sensible use” of competition in the NHS (somewhat reminiscent of the use of the words “sensible use” in the context of another potentially disastrous area of policy – targets):
“If we want to be evidence-informed in our policy making and commissioning lets pay heed to research from Martin Gaynor, Mauro Laudicella and Carol Propper at Bristol University. They’ve spotted the striking fact that between 1997 and 2006 around half of the acute hospitals in England were involved in a merger. Their peer-reviewed results found little in the way of gains.”
These fixation errors are causing damage to the English NHS.
It’s time some people got out of the cockpit.
Thanks to Andy Burnham for emphasising “care co-ordinators” which I feel are pivotal to living well with dementia
This morning I had a present for Andy Burnham MP (@andyburnhammp), about to lead the Labour troops into battle for the European elections. The present is of course a copy of my book ‘Living well with dementia’, which is an account of the importance of personhood and the environment for a person living with dementia.
In my article entitled “Living well = greater wellbeing” for the ETHOS Journal (@ETHOSJournal), I highlighted the critical importance of the ‘care coordinator':
“So, if one had unlimited funds, what sort of service could be designed to provide care and support for people with dementia? In my opinion, the answer is a very different one. Ideally, all services, which could include healthcare, housing and legal systems, would adapt quickly and flexibly according to the needs of the individual living with dementia. This would need to be managed by a named, long-term co-ordinator of care and support.”
In reply to my article, Paul Burstow MP commented helpfully:
“The idea of a care navigator able to call on and coordinate all available health and social care, as well as housing support and voluntary sector provision is a persuasive one. It is something that the Richmond Group of charities, among others, have for a long time called for – and it is something I would like to see the Liberal Democrats deliver in the next government. Better managed and coordinated care would be a huge step forward and could make all the difference to dementia sufferers and their often strained carers.”
And Andy gave it much prominence this morning:
The King’s Fund (@TheKingsFund) has previously looked into co-ordinated care for chronic conditions.
In this framework, a “care co-ordinator” acts as a single point of contact and works with the patient, their carer(s) and the multidisciplinary team to develop a care plan.
Once this has been agreed, the co-ordinators work with the team, the patient, the patient’s family and other care providers to deliver co-ordinated and coherent care. Personal continuity of care is actively encouraged, and the care teams work hard to ensure an immediate response to care needs as they arise.
The care co-ordinator becomes he patient’s advocate in navigating across multiple services and settings ??providing care directly in the home environment.
He or she also ??communicates with the wider network of providers (outside of the core multidisciplinary team) so that information about the patient/carer is shared and any actions required are followed up.
The King’s Fund has previously found that the type of person undertaking the care co-ordination function varied greatly.
Most care co-ordinators had been community or specialist nurses, yet the role has also been taken on by non-clinical ‘link workers’ (in Sandwell) and health and social care co-ordinators (in Torbay).
There also appears to be a continuum from the non-clinical approach – primarily providing personal continuity to service users and acting as their advocate to ensure that care is co-ordinated around their needs – to the clinical approach, in which a case manager would also be able to provide clinical care directly.
This, I feel, is significant, as my book ‘Living well with dementia’ has a very non-medical thrust.
It’s very much a n0n-authoritarian, non-hierarchical approach where each person, including the person living with dementia, has an important part to play.
Influences on someone living well with dementia might include design of a home or ward, assistive technologies, ambient-assisted living, “dementia friendly communities”, for example.
With the introduction of ‘whole person care’, it’s possible that the care co-ordinator for a person living well with dementia might become a reality.
In this construct, Andy Burnham MP, Shadow Secretary of State for Health, is trying to stop the overhospitalisation (and overmedicalisation) of people.
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.
Andy Burnham’s “whole-person care” could be visionary, or it could be “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.” (more…)
'Whole-Person Care' A One Nation approach to health and care for the 21st Century
Andy Burnham’s speech to The King’s Fund – ‘Whole-Person Care’ A One Nation approach to health and care for the 21st Century
Andy Burnham MP, Labour’s Shadow Health Secretary, said on 24 January 2013 at the King’s Fund:
Today I open Labour’s health and care policy review.
For the first time in 20 years, our Party has the chance to rethink its health and care policy from first principles.
Whatever your political views, it’s a big moment.
It presents the chance to change the terms of the health and care debate.
That is what One Nation Labour is setting out to do.
For too long, it has been trapped on narrow ground, in technical debates about regulation, commissioning, competition.
It is struggling to come up with credible answers to the questions that the 21st century is asking with ever greater urgency.
I want to change the debate by opening up new possibilities and posing new questions of my own, starting with people and families and what they want from a 21st century health and care service.
For now, they are just that – questions. This is a Green Paper moment – the start of a conversation not the end.
But what you will hear today is the first articulation of a coherent and genuine alternative to the current Government’s direction.
It is the product both of careful reflection on Labour’s time in government and a response to what has happened since.
Everything I say today is based on two unshakable assumptions.
First, that the health and care we want will need to be delivered in a tighter fiscal climate for the foreseeable future, so we have to think even more fundamentally about getting better results for people and families from what we already have.
Second, our fragile NHS has no capacity for further top-down reorganisation, having been ground down by the current round. I know that any changes must be delivered through the organisations and structures we inherit in 2015.
But that can’t mean planning for no change.
Those questions that the 21st century is bringing demand an answer.
When the modern condition means we are all living with higher levels of stress, change and insecurity, how do we give families the mental health support they will need and remove the stigma?
How will we ensure we are not overwhelmed by the costs of treating diseases linked to lifestyle and diet?
And how can we stop people fearing old age and have true peace of mind throughout a longer life?
Huge questions that require scale and a sense of ambition in our answers.
When a Labour Opposition last undertook this exercise, the world looked very different. But it had to be similarly ambitious.
People were waiting months and years for hospital treatment, even dying on NHS waiting lists.
So Labour set itself the mission of rescuing a beleaguered NHS which was starting to look as if it was on the way out.
A big ambition and, by and large, with help of the professions, we succeeded.
We left office with waiting lists at an all-time low and patient satisfaction at an all-time high; a major turn-around from the NHS we inherited in 1997.
But that doesn’t tell the whole story.
I can trace the moment that made me think differently, and challenge an approach that was too focused on hospitals.
In early 2007, my sister-in-law was in the Royal Marsden dying from breast cancer.
After visiting one night, she called me over and asked if I could get her home to be with her four children.
I told her I thought I would be able to.
But, after a day of phone calls, I will never forget having to going back to Claire and say it couldn’t be done.
And I was a Minister who knew how the system worked, so what chance have families who are at a low ebb and don’t know where to start?
As a Government, we were talking about choice. But it was a painful discovery for me to find we were unable to deliver to this most fundamental of choices.
Concerns about the way we care for people in the later stages of life, as well as how it is paid for, has built and built over recent years.
Stories of older people neglected or abused in care homes, isolated in their own homes or lost in acute hospitals – disorientated and dehydrated – recurred with ever greater frequency.
I have thought long and hard about why this is happening.
It is in part explained by regulatory failures and we will of course learn the lessons emerging from the Francis Report as part of this policy review.
Changes in nursing and professional practice may also have played a part.
But, in my view, these explanations deal with the symptoms rather than the cause of a problem that goes much deeper.
My penny-drop moment came last year when I was work-shadowing a ward sister at the Royal Derby.
It was not long after the Prime Minister had proposed hourly bed rounds for nurses.
I asked her what she thought of that. Her answer made an impression on me.
It was not that nurses didn’t care any more, she said. On the whole, they did.
It was more that the wards today are simply not staffed to deal with the complexity of what the ageing society is bringing to them.
When she qualified, it was rare to see someone in their 80s on the ward after a major operation.
Now there are ever greater numbers of very frail people in their 80s and 90s, with intensive physical, mental and social care needs.
Hospitals hadn’t changed to reflect this new reality, she said, and nurses were struggling to cope with it.
They were still operating on a 20th century production-line model, with a tendency to see the immediate problem – the broken hip, the stroke – but not the whole-person behind it.
They are geared up to meet physical needs, but not to provide the mental or social care that we will all need in the later stages of life.
So our hospitals, designed for the last century, are in danger of being overwhelmed by the demographic challenges of this century.
And that is the crux of our problem.
To understand its roots, it helps to go back to the 1948 World Health Organisation definition of health:
“a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
A simple vision which stands today.
But, for all its strengths, the NHS was not set up to achieve it. It went two thirds of the way, although mental health was not given proper priority, but the third, social, was left out altogether.
The trouble is that last bit is the preventative part.
Helping people with daily living, staying active and independent, delays the day they need more expensive physical and mental support.
But deep in the DNA of the NHS is the notion that the home, the place where so much happens to affect health, is not its responsibility.
It doesn’t pay for grab rails or walk-in showers, even if it is accepted that they can keep people safer and healthy.
The exclusion of the social side of care from the NHS settlement explains why it has never been able to break out of a ‘treatment service’ mentality and truly embrace prevention. It is a medical model; patient-centred, not person-centred.
But, in reality, it’s even worse than that.
For 65 years, England has tried to meet one person’s needs not through two but three services: physical, through the mainstream NHS; mental, through a detached system on the fringes of the NHS; and social, through a means-tested and charged-for council service, that varies greatly from one area to the next.
One person. Three care services.
For most of the 20th century, we just about managed to make it work for most people.
When people had chronic or terminal illness at a younger age, they could still cope with daily living even towards the end of life. Families lived closer to each other and, with a bit of council support, could cope.
Now, in the century of the ageing society, the gaps between our three services are getting dangerous.
The 21st century is asking questions of our 20th century health and care system that, in its current position, will never be able to answer to the public’s satisfaction.
As we live longer, people’s needs become a complex blur of the physical, mental and social.
It is just not possible to disaggregate them and meet them through our three separate services.
But that’s what we’re still trying to do.
So, wherever people are in this disjointed system, some or all of one person’s needs will be left unmet.
In the acute hospital ward, social and mental needs can be neglected. This explains why older people often go downhill quickly on admission to hospital.
In mental health care settings, people can have their physical health overlooked, in part explaining why those with serious mental health problems die 15 years younger than the rest of the population.
And, in places, such is the low standard of social care provision in both the home and care homes, barely any needs are properly met.
What, realistically, can be achieved from a home care service based around ten-minute slots per person?
On a practical level, families are looking for things from the current system that it just isn’t able to provide.
They desperately want co-ordination of care – a single point of contact for all of mum or dad’s needs – but it’s unlikely to be on offer in a three-service world.
So people continue to face the frustration of telling the same story over again to all of the different council and NHS professionals who come through the door.
Carers get ground down by the battle to get support, spending days on the phone being passed from pillar to post.
So far, I have spoken about the experience of older people and their carers.
But the problems I describe – the lack of a whole-person approach – holds equally true for the start of life and adults with disabilities.
Parents of children with severe disabilities will recognise the pattern – the battle for support, the lack of co-ordination and a single point of contact.
CAMHS support at the right time can make all the difference to a young life but is often not there when it is needed.
Children on the autistic spectrum are frequently missed altogether.
The mantra is that early intervention makes all the difference. But it is rarely a reality in a system that doesn’t have prevention at its heart.
If we leave things as they are, carers of young and old will continue to feel the frustration of dealing with services which don’t provide what they really need, that don’t see the whole-person.
They won’t provide the quality people want.
But nor will they be financially sustainable in this century.
For One Nation Labour, this is crucial. Protecting the institutions that bind us together, like the NHS – the expression of what we can achieve together when everyone plays their part.
Right now, the incentives are working in the wrong direction.
For older people, the gravitational pull is towards hospital and care home.
For the want of spending a few hundred pounds in the home, we seem to be happy to pick up hospital bills for thousands.
We are paying for failure on a grand scale, allowing people to fail at home and drift into expensive hospital beds and from there into expensive care homes.
The trouble is no-one has the incentive to invest in prevention.
Councils face different pressures and priorities than the NHS, with significant cuts in funding and an overriding incentive to keep council tax low.
So care services have been whittled away, in the knowledge that the NHS will always provide a safety net for people who can’t cope. And, of course, this could be said to suit hospitals as they get paid for each person who comes through the door.
In their defence, councils and the NHS may be following the institutional logic of the systems they are in.
But it’s financial madness, as well as being bad for people.
Hospital Chief Executives tell me that, on any given day, around 30 to 40 per cent of beds are occupied by older people who, if better provision was available, would not need to be there.
If we leave things as they are, our DGHs will be like warehouses of older people – lined up on the wards because we failed to do something better for them.
But it gets worse. Once they are there, they go downhill for lack of whole-person support and end up on a fast-track to care homes – costing them and us even more.
We could get much better results for people, and much more for the £104bn we spend on the NHS and the £15bn on social care, but only if we turn this system on its head.
We need incentives in the right place – keeping people at home and out of hospitals.
We must take away the debates between different parts of the public sector, where the NHS won’t invest if councils reap the benefit and vice versa, that are utterly meaningless to the public.
So the question I am today putting at the heart of Labour’s policy review is this: is it time for the full integration of health and social care?
One budget, one service co-ordinating all of one person’s needs: physical, mental and social. Whole-Person Care.
A service that starts with what people want – to stay comfortable at home – and is built around them.
When you start to think of a one-budget, one-service world, all kinds of new possibilities open up.
If the NHS was commissioned to provide Whole-Person Care in all settings – physical, mental, social from home to hospital – a decisive shift can be made towards prevention.
A year-of-care approach to funding, for instance, would finally put the financial incentives where they need to be.
NHS hospitals would be paid more for keeping people comfortable at home rather than admitting them.
That would be true human progress in the century of the ageing society.
Commissioning acute trusts in this way could change the terms of the debate about hospitals at a stroke.
Rather than feeling under constant siege, it could create positive conditions for the District General Hospital to evolve over time into a fundamentally different entity: an integrated care provider from home to hospital.
In Torbay, where the NHS and Council have already gone some way down this path, around 200 beds have been taken out from the local hospital without any great argument as families have other things they truly value.
Unlike other parts of England, they have one point of contact for the co-ordination of health and care needs.
Occupational Therapists visit homes the same day or the day after they are requested; urgent aids and adaptations supplied in minutes not days.
If an older person has to go into hospital, a care worker provides support on the ward and ensures the right package of care is in place to help get them back home as soon as possible.
Imagine what a step forward it would be if we could introduce these three things across England.
For the increasing numbers of people who are filled with dread at the thought of mum or dad going into hospital, social care support on the ward would provide instant reassurance.
It is a clear illustration of what becomes possible in a one-service, one-budget world with prevention at its heart.
If local hospitals are to grow into integrated providers of Whole-Person Care, then it will make sense to continue to separate general care from specialist care, and continue to centralise the latter.
So hospitals will need to change and we shouldn’t fear that.
But, with the change I propose, we can also put that whole debate on a much better footing.
If people accept changes to some parts of the local hospital, it becomes more possible to protect the parts that they truly value – specifically local general acute and emergency provision.
The model I am proposing could create a firmer financial base under acute hospitals trusts where they can sustain a back-stop, local A&E service as part of a more streamlined, re-modelled, efficient local healthcare system.
So A&Es need not close for purely or predominantly financial reasons, although a compelling clinical case for change must always be heard and we would never make the mistake of a blanket moratorium.
I am clear that we will never make the most of our £120 billion health and care budget unless hospitals have positive reasons to grow into the community, and we break down the divide between primary and secondary care.
It could see GPs working differently, as we can see in Torbay, leading teams of others professionals – physios, Occupational Therapists, district nurses – managing the care of the at-risk older population.
Nerves about hospital take-over start to disappear in a one-budget world where the financial incentives work in the opposite direction.
NHS hospitals need the security to embrace change and that change will happen more quickly in an NHS Preferred Provider world rather than an Any Qualified Provider world, where every change is an open tender.
I don’t shy away from saying this.
I believe passionately in the public NHS and what it represents.
I think a majority of the public share this sentiment.
They are uncomfortable with mixing medicine with the money motive. They support what the NHS represents – people before profits – as memorably celebrated by Danny Boyle at the opening ceremony of the Olympic Games.
Over time, allowing the advance of a market with no limits will undermine the core, emergency, public provision that people hold dear.
So I challenge those who say that the continued advance of competition and the market into the NHS is the answer to the challenges of this century.
The evidence simply doesn’t support it – financially or on quality grounds.
If we look around the world, market-based health systems cost more per person not less than the NHS. The planned nature of our system, under attack from the current Government’s reforms, is its most precious strength in facing a century when demand will ratchet up.
Rather than allowing the NHS model to be gradually eroded, we should be protecting it and extending it as the most efficient way of meeting this century’s pressures.
The AQP approach will not deliver what people want either.
Families are demanding integration. Markets deliver fragmentation.
The logical conclusion of the open-tender approach is to bring an ever-increasing number of providers on to the pitch, dealing with ever smaller elements of a person’s care, without an overall co-ordinating force.
If we look to the US, the best providers are working on that highly integrated basis, co-ordinating physical, mental and social care from home to hospital.
We have got to take the best of that approach and universalise it here.
But there are dangers of monopolistic or unresponsive providers.
Even if the NHS is co-ordinating all care, it is essential that people are able to choose other providers. And within a managed system there must always be a role for the private and voluntary sectors and the innovation they bring.
But let me say something that the last Labour Government didn’t make clear: choice is not the same thing as competition.
The system I am describing will only work if it is based around what people and families want, giving them full control.
To make that a reality, we want to empower patients to have more control over their care, such as dialysis treatment in the home or the choice to die at home or in a hospice.
We will work towards extending patients’ rights to treatment in the NHS Constitution.
This would mean the system would have to change to provide what people want, rather than vice versa.
The best advert for the people-centred system in Torbay is that more people there die at home than in any other part of England.
When I visited, they explained that they had never set out to do that – a target had not been set – but it had been a natural consequence of a system built around people. A real lesson there for politicians.
So an NHS providing all care – physical, mental and social – would be held to account by powerful patient rights.
But, as part of our consultation, we will be asking whether it follows that local government could take a prominent role working in partnership with CCGs on commissioning with a single budget.
This change would allow a much more ambitious approach to commissioning than we have previously managed.
At the moment, we are commissioning health services. This was the case with PCTs and will remain so with CCGs.
The challenges of the 21st century are such that we need to make a shift to commissioning for good population health, making the link with housing, planning, employment, leisure and education.
This approach to commissioning, particularly in the early years, begins to make a reality of the Marmot vision, where all the determinants of health are in play. Improving PH will not be a fringe pursuit for councils but central to everything that they do.
But it also solves a problem that is becoming increasingly urgent.
Councils are warning that, within a decade, they will be overwhelmed by the costs of care if nothing changes.
They point to a chart – affectionately known as the ‘graph of doom’ – which shows there will be little money for libraries, parks and leisure centres by 2020.
One of the great strengths of the one-budget, Whole-Person approach would be to break this downward spiral.
It would give local government a positive future and local communities a real say.
The challenge becomes not how to patch two conflicting worlds together but how to make the most of a single budget.
To address fears that health money will be siphoned off into other, unrelated areas, reassurance is provided by a much more clearly defined national entitlement, based around a strengthened NICE, able to take a broader view of all local public spending when making its recommendations.
It won’t be the job of people at local level to decide what should be provided. That will be set out in a new entitlement. But it will be their job to decide how it should be provided.
That would provide clarity about the respective roles of national and local government, too often a source of confusion and tension.
But I want to be clear: nothing I have said today requires a top-down structural re-organisation.
In the same way that Andrew Lansley should have refocused PCTs and put doctors in charge, I will simply re-focus the organisations I inherit to deliver this vision of Whole-Person Care.
Health and Well-Being Boards could come to the fore, with CCGs supporting them with technical advice.
While we retain the organisations, we will repeal the Health and Social Care Act 2012 and the rules of the market.
It is a confused, sub-optimal piece of legislation not worthy of the NHS and which fails to give the clarity respective bodies need about their role.
This approach creates the conditions for the evolutionary change towards the Whole-Person vision rather than structural upheaval.
At a stroke, those two crucial local institutions – council and hospital – have an alignment of interests and a clear future role to grow into.
But the same is true for social care.
At present, it is trapped in a failing financial model.
The great attraction of the Whole-Person approach, with the NHS taking responsibility for coordination, is that it will be in a position to raise the standards and horizons of social care, lifting it out of today’s cut-price, minimum wage business.
Social care careers would be more valued and young people able to progress as part of an integrated Whole-Person workforce.
Of course, the change we aspire to, particularly in social care, won’t come by simply changing structures. It will need a change of culture including leadership, training, working in teams, better information and seeing patients and families as partners in achieving better health and care.
So Whole-Person Care is the proposal at the heart of Labour’s health and care policy review which is formally launched today.
It will be led by Liz Kendall, and will run alongside Diane Abbott’s separate Public Health Policy Review. Over the next six months, we will be holding events in all parts of England seeking views on two central questions.
First, do you see merit in this vision of Whole-Person Care and support the proposals for the full integration of health and social care?
Second, if you do, how far down this path of integration do you think we should go?
The fact is that, even if we move to a fully integrated model, and shift resources from hospital to home, it won’t be enough to pay for all of one person’s care needs.
We need to be very clear about that.
So this opens up the question of the funding of social care.
It is the case that, with the shift of resources out of hospital, more preventative social care could be provided in the home and, in all likelihood, better standards of social care offered, as we have seen in Torbay.
For instance, we have already proposed that this should include people on the end-of-life register. It would also include provision for those with the highest needs and at risk from going into hospital.
But rather than leave this unspecified, people need to know exactly where they stand. Currently, council care provision is the ultimate lottery.
In a single system, it would be right to set for the first time a clear entitlement to what social care could be provided and on what terms, as part of a national entitlement to health and care.
That would help people understand what is not covered – which is very unclear to people at present.
But the question arises: what is the fairest way of helping people cover the rest?
At present, beyond the £23,000 floor, care charges are unlimited.
These are ‘dementia taxes’: the more vulnerable you are, the more you pay.
As cruel as pre-NHS or US healthcare.
No other part of our welfare state works in this way and, in the century of the ageing society, failure to resolve how we pay for care could undermine the NHS, the contributory principle and incentives to save.
Some people might ask why they should save for retirement, when the chances of it all being washed away increase every year?
In this century, we can’t carry on letting people go into old age with everything – home, savings, pension – on the roulette table.
So there is a political consensus that the status quo is the worst of all possible worlds and it needs to change.
We agree about the need to find a fairer way of paying for social care, but not on what that system should be.
The Government have begun to set out their version of Andrew Dilnot’s proposals.
A cap, not of £35,000 but over the £50,000 Dilnot recommended, and possibly up to £75,000.
This is better than the status quo.
But we all know that setting a cap of up to £150,000 for a couple is not a fair solution.
For Labour, it fails a basic One Nation test.
Offering some protection to the better off, but doing little to help a couple in an average semi in the Midlands or the North.
But it also fails a sustainability test.
By failing to address the shortfall in council budgets, it leaves people exposed to ever-increasing care charges and more likely to pay up to the level of the cap.
This won’t feel like progress to many.
So, as part of Labour’s policy consultation, we will ask for views on other ways of paying for social care.
We will only have a solution when all people, regardless of their savings and the severity of their needs, have the chance to protect what they have worked for.
There are two basic choices – a voluntary or all-in approach – and, at this stage, we are seeking views on which path people think we should take, building on the foundations of a fully merged health and social care system.
Both would represent a significant improvement on the status quo, but both present significant difficulties in terms of implementation.
Andrew Dilnot’s proposed cap and means-test would help everyone protect their savings.
It would mean people only pay as much as they need to, but, in the worst case scenario, could stand to lose a significant chunk of their savings.
If people support this option, we would be interested in hearing views on how it could be funded.
One of the problems with the voluntary approach is it assumes the continuation of two care worlds – one charged for, the other one free-at-the-point-of-use – with all its complexity.
So it is right to ask whether we can move to an all-in system, extend the NHS principle to all care.
This would mean asking people to pay differently for social care to create a level playing field on how all care is provided.
But it would only work on the all-in principle and that is its major downside: all people would be required to contribute, rather than just those needing care.
People’s exposure to care costs in an all-in system would be significantly lower. But, as with any insurance system, people might pay and never end up using the service.
As with the voluntary option we would be interested in hearing people views on the pros and cons of the all-in principle and options for how this could be done.
It is an open question whether a broad consensus can be found on funding social care on either a voluntary or all-in principle.
But Labour is clear that this must not stand in the way of progress now to get much more for people from what we currently spend on health and care.
To Beveridge’s five giants of the 20th century, the 21st is rapidly adding a sixth: fear of old age.
If we do nothing, that fear will only grow as we hear more and more stories of older people failed by a system that is simply not geared up to meet their needs.
A One Nation approach to health and care means giving all people freedom from this fear, all families peace of mind.
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.
A service which affords everyone’s parents the dignity and respect we would want for our own.
There will be many questions which arise from what I have said today.
I don’t yet have all the answers.
But that’s why Labour is opening this discussion now.
It’s an open invitation to anyone who has anxieties about what is happening to the NHS right now to help us build a genuine alternative – integrated, collaborative, accountable.
I don’t want to do the usual politician thing of pulling a policy out of the hat at the time of the next manifesto that takes people by surprise.
Instead, I want to involve as many people as I can in shaping an alternative they can believe in.
The task is urgent because the NHS is on the same fast-track to fragmentation that social care has been down.
The further it carries on down this path, the harder it will be to glue it back together.
Unlike the last Election, the next one needs to give people a proper choice of what kind of health and care system they want in the 21st century.
That’s why I started by saying it’s time to change the terms of the debate and put more ambition into our ideas.
Labour is rediscovering its roots and its ability to think in the boldest terms about a society that cares for everyone and leaves no-one behind.
People need One Nation Labour to be as brave in this Century as Bevan was in the last.
That’s the challenge and we will rise to it.
An ethos of collaboration is essential for the NHS to succeed
As a result of the Health and Social Care Act, the number of private healthcare providers have been allowed to increase under the figleaf of a well reputed brand, the NHS, but now allowing maximisation of shareholder dividend for private companies. The failure in regulation of the energy utilities should be a cautionary tale regarding how the new NHS is to be regulated, especially since the rule book for the NHS, Monitor, is heavily based on the rulebook for the utilities. The dogma that competition drives quality, promoted by Julian LeGrand and others, has been totally toxic in a coherent debate, and demonstrates a fundamental lack of an understanding of how health professionals in the NHS actually function. People in the NHS are very willing to work with each other, making referrals for the general benefit of the holistic care of the patient, without having to worry about personalised budgets or financial conflicts of interest. It is disgraceful that healthcare thinktanks have been allowed to peddle a language of competition, without giving due credit to the language of collaboration, which is at the heart of much contemporary management, including notably innovation. (more…)
David Cameron is wrong on the NHS corporate restructuring for these reasons
In an interview where David Cameron tried to tell John Humhrys he was wrong, Humphrys identified that Cameron was showing no leadership on the bankers.
The interview can be heard here:
http://news.bbc.co.uk/today/hi/today/newsid_9363000/9363655.stm
David Cameron is wrong about the NHS restructuring for the following:
It is wrong simply to focus on outcomes at the treatment end; much more could and should be done at the diagnosis end (health policy analysts find outcomes useful, but what they’re actually measuring are objective benefits). Much of the fundamental issue for the next decade will be the early diagnosis of the disease especially cancer, and there needs to be some focus on the efficacy of screening methods at the other end too (e.g.for colon cancer, breast cancer, COPD).
It is no good just talking about length of survival times, because there has to be a proper analysis of the quality-of-life and well being of patients with chronic morbidity including dementia.
The Doctors were not asking for the changes – the BMA is opposed to it, and to my knowledge the Royal College of Physicians shows little interest in it in a very positive direction. The King’s Fund certainly think it is a calamity.
2-3 years is a very short time to produce ‘the biggest reorganisation’ in the first time; it will involve £1.4 bn in the first year. John Humphrys was right to correct the figures that Cameron produced on the basis of actual evidence from the Kings Fund.
Satisfaction is at an all time high now with the NHS – this cannot be divorced from the record spending by Labour in the last parliament.
David Cameron denied the NHS IS getting better. This must means that he thinks that all aspects of it are getting worse. THIS IS A LIE.
John Humphrys asked that the NHS was in fact changing to a Federal Health Service. Cameron saying that there are already regional variations is frankly irrelevant. Humphrys is correct saying that an analogy between GPs and free schools is an extremely poor analogy; I am shocked that David Cameron is idiotic enough even to suggest it.
There’s no point Cameron trade-union bashing, as there are many ordinary nurses, doctors and other health-professionals who are non-Labour members who are highly critical of his insane policy.
If Andrew Lansley is so well respected, why does the whole of RCN disagree with him? The man is not well respected amongst the health professionals.
Dr Shibley Rahman Queen’s Scholar; BA (1st Class), MA, Bachelor of Medicine, Bachelor of Surgery, Doctor of Philosophy, Diploma of the Membership of the Royal College of Physicians (MRCP(UK)); FRSA, LLB(Hons).
Member of the Fabian Society.
The clinical iceberg of dementia and nursing
“Clinical Iceberg” is a term used to describe the large amount of illnesses that go unreported. For example, medical statistics are created based on information from the doctors, these statistics go on to make government policies on healthcare. According to Last (1963) as much as 94% of illness is not reported to doctors. It is the vast amount of unreported illnesses that are known as the ‘Clinical Iceberg’. Almost a million people in England will have dementia within a generation and the bill for dealing with the disease will rise to £35bn a year.
[Picture from the US: Acute Care Geriatric Nurse Network: link here.The Acute Care Geriatric Nurse Network (ACGNN) was established in British Columbia in 2003 by a collaborative of Clinical Nurse Specialists in gerontology, geriatric medicine, geriatric psychiatry and geriatric rehabilitation and orthopaedics. The purpose of the collaborative and the ACGNN is to enhance nurses’ ability to provide evidence based care to acutely ill older adults.]
Almost two-thirds of people living with dementia have Alzheimer’s disease. Andrew Ketteringham, head of external affairs at the Alzheimer’s Society, said: ‘The projected growth in people with dementia is huge. Our own research has shown that by 2025 more than a million people in the UK will have the disease, so it will touch the lives of every one of us because every family in the country will have someone with dementia. The society predicted last year that 1,735,087 people in the UK would have dementia by 2051. Numbers are increasing sharply, mainly because of the UK’s ageing population. But mounting evidence also suggests that lifestyle-related conditions, such as obesity and physical inactivity, increase someone’s chances of developing dementia. Martin Knapp, a professor of social policy at the London School of Economics, and Dr Paul McCrone, a health economist at King’s College London. Sir Derek Wanless, chaired its steering group for a paper on this from the King’s Fund.
Now the King’s Fund have reported that people with dementia in general (including to Alzheimer’s disease) are having NHS-funded care withdrawn in the later stages of their illness. It says relatives have to pick up the bill for additional nursing support. Barbara Pointon, from Dementia UK and the Alzheimer’s Society, today described: “What’s happening with NHS continuing health care is it’s getting more and more difficult to get in the first place, and when people with dementia move into the advanced stage and need more care, it’s being taken away from them.” This finding is important because the King’s Fund is calling for a shake-up of the system that differentiates between health care, which the NHS pays for, and social care, which local authorities and individuals have to fund.