Replacing the Health and Social Care Act

Simple repeal of the reviled Health Act 2012 cannot be an end in itself.  What is needed is a clear vision of an alternative approach to make our care system better.  We need to repeal and replace.

Legislation and structural changes to pursue some ideological end have been shown time and again not to work.  Imposing change on a reluctant and unmotivated workforce is unlikely to end well.

New proposals must be subjected to discussion resulting in long term plan with the degree of support enjoyed by the 2000 NHS Plan. Once elected, a Labour administration should set aside one year for detailed consultation, planning and mobilisation before implementation.  This is the opposite approach to passing an Act which was inconsistent with the white paper that launched it, which broke election promises and which nobody supported.

The analysis of the issues that need to be confronted are widely shared.  We need:-

  • the fully engaged scenario in which patients and communities are collaborators
  • better integration of care services
  • efficiency gains to match the increased levels of investment
  • resolution of the issues around how care is funded
  • reduction in the unacceptable variations in outcomes
  • a new conceptual model with public health leading, primary and community care far more prominent, less emphasis on acute capacity
  • and above all to directly address the key social determinants of poor health.

But the approach to developing our NHS needs to be based on new foundations – shared decision making, community development, reinvigorated public service, local autonomy, integration around the needs of the patient, and a new professional approach which takes these factors into account.  We need to begin with behaviour, attitudes and relationships more than organisational structures and regulation.  The founding values which apply to our NHS must be preserved and encompassed in all care.

Changes must be possible without further major structural reorganisation.  Replacement legislation should implement our vision and simplify and consolidate current law, which is a mess.  Consolidation would include those parts of the 2012 Act that have been found to be beneficial.

“The NHS is not just a whole set of separate organisations with their own autonomous responsibilities but a group bound by “values and principles” which transcend that. Because of those values and principles “you have to take our people with you.”  Well said – David Nicholson – NHS Chief Executive.

An Alternative Vision- A Public Service to Deliver Whole Person Care

The Tory vision is that healthcare should be provided through a regulated market.  Whilst they claim to support a universal service free at the point of use, it is clear that they intend  to move away from our “socialist” NHS model to one based on private providers, competition, charges, co-payments and insurance.

We have to clearly establish our support for an alternative to the regulated market not just because regulated markets are seen to be failing but also because our ideology is for an NHS based on social solidarity. The provision of care is a public service rooted in public service values.

Use of market forces reduces patients to the role of shoppers and introduces moral hazard and conflicts of interests. The evidence for the benefit of marketisation is extremely weak. The real need is to engage patients in their own care, engaging communities in the wellbeing of their locality and making all key decisions within the system subject to proper public accountability and democratic control – a wholly different view of how we engage with people.  It means valuing staff and working with them not seeing them as the source for cuts.

We must frame our approach to the NHS within a broader overall vision for public services based on fairness, personalisation, democratic accountability and responsibility. We need different leaders less focused on the business model and a new leadership style that encourages engagement with staff, initiative and innovation rather than bullying and blame. Above all we need changes in the culture which has taking some of the “caring” out of the system and a relentless focus at every level on safety and quality.

Traditionally reform of the NHS has been driven by organisational change.  We need to address behaviour, training, management culture, attitudes, and leadership directly not merely hope that they respond in some way to indirect changes.

Key Themes – Different things to Discuss

This is by no means a complete list (we say nothing about Regulation) and it is not in any priority order.  Each paragraph could expand to a chapter!  But this is where the discussions should start – not about how many CCGs there should be.

1          A Public Service Approach to Health

Improving health requires addressing the social determinants of poor health of which income inequality tops the list.  Addressing these issues needs to be based on the principle that there is a role for an interventionist state, for redistribution of wealth and power and a role for public services not just in planning and commissioning but in delivery.  We need a collective approach.

There is now a strong economic argument, particularly in a recession, for increased investment in public services rather than cuts. We need to make the case for investing in a way that will offer the most benefit in terms of jobs and health gain.

2          Moving to a system for whole person care

Many patients have multiple complex needs, few have a single episode of care, and we need a system which recognises this.  Primary care professionals should be able to assess all patients with complex needs and working with the patient and (where appropriate) their carer, jointly develop a written “plan” for care which is monitored and independent of the organisations which may have to provide that care.  If this is done proactively, across (say) a whole GP Practice, then prevention and avoidance can be built in.  We have some care planning but almost no real care plans.

The plan must support self-care and shared decision-making. Involving the patient in their care improves outcomes. Successful and efficient delivery of the plan is clearly in the best interest of the patient but also a route to more efficient service delivery.

Funding the plan through a personal budget may be suitable for some, but clearly not for all, and only by agreement.  Where it is suitable it should be supported but there is not enough evidence yet to support widespread use either as a route to better care or as a mechanism to contain costs.

The case for linked electronic patient records and electronic medical records is as strong as ever.  The need to bring all the information together at the level of the individual is fundamental, and progress is being made.   We need to ensure that patients have access to all data; GP, hospital and social care and that this record becomes a portal to a range of interactive personalised information and opportunities, ensuring data protections works for us instead of protecting institutions.

3          Embracing Community Development (CD) and Shared Decision Making (SDM) – Collective and Individual Shared Decision-Making

Communities should be involved in the planning and commissioning of their services with a major say in how to improve the health of their locality. Decision makers must be obliged to make this a reality and should be monitored on the effectiveness of doing so.

We achieve more when we work together and we should firmly embrace the importance of community development which works with communities as assets not as problems.  Asset-based community development approaches need to be highlighted and promoted. We need communities to take more control of their environments and work closely with statutory agencies through residents-based partnerships. That has been shown to improve health, help behaviour change, and help tackle health inequalities – as well as save money.

In addition, we should make involvement in our individual care a reality by embracing shared decision-making and self-care.  We can do this through pre- and post-graduate clinician training, making tools available such as Decision Aids and patient record access and by changing the culture of the consultation and the relationship between patient and clinician

4          Choice but not shopping

Patients should not be viewed as consumers of healthcare: shopping for the best deal from a range of competing providers. In general patients want greater involvement in their care and they should be offered informed choice about the treatment options open to them.  They should have the right to see whatever information is held about them and should have access to independent but quality controlled information about their condition and their options.  There is good evidence that this leads to safer, more appropriate and often cheaper care.  But some will not want to be proactive and just wish to be guided, advised and supported; they should not be forced into anything.

In many cases, once their care plan is determined, patients should be able to choose which NHS venue they attend and should be able to select the appointment that best suits their needs.  These are not market choices and the likelihood is that the vast majority will be guided by professional advice and also are likely to choose facilities in the locality.

5          Moving to free personal social care funded from taxation

An obvious barrier to whole person care is that social care is on a separate planet – funded differently, structured differently and means tested.  Chronic under-funding is as significant as it used to be for healthcare pre 1997.

The case for free personal social care is exactly the same as the case for free health care, and in other parts of the UK this has been recognised.  The risk of high costs which are not predictable and which cannot be insured requires a form of social protection. The way this can be funded is not agreed and so the system still subjects many to demeaning and unnecessarily complex means testing.

There will be savings from moving to free care (especially through reduced bureaucracy and administration) and outcome improvements through easier integration of services.  Over time better social care reduces healthcare costs, but the net cost has to be met – through progressive general taxes as with healthcare.  But issues of inter-generational fairness obviously arise and a transitional period will be necessary.

A start can be made by the state meeting all costs above a certain limit and making care free for some such as those who have disabilities.  The only suggested method so far for funding the additional net cost is through a levy on all estates (the nearest we have to a wealth tax).  A feasible alternative is to use income tax/national insurance.  We have to make the case

6          Enhancing the role for Public Health – a Social Determinants Approach

Whole person care is about prevention as well as optimum care.  We need to reinforce the value of a public health led approach to dealing with the social determinants of poor health.  Public Health professionals should have a seat wherever key decisions are being taken – so the public health aspects are not overlooked.  A social determinants approach to Health Inequalities must be encouraged. Focusing on smoking of itself, for instance, is inadequate. Initiatives must involve key social determinants, including housing, employment, sustainable communities. Public Health should see itself as a political and social vehicle that challenges social and economic factors that cause a drain on health. Putting the functional aspects of public health into local authorities should assist in this wider approach, so lon as resources are adequate and the “voice” is not drowned out..

7          Enhancing the status and role of primary care

There is widespread agreement that moving care closer to home, and out of hospitals, is better for patients and may in some cases also be more efficient.  Everyone is in favour of reducing admissions to hospital through better system management and better prevention although we have a financial system which pulls the opposite way.

The new direction towards integrated proactive community-based care places great demands on primary care. There is evidence of variable quality in primary care; variance that we need to reduce.  Fundamental to primary care are the GP Practices and over recent years access to GPs has worsened and GPs no longer have responsibility for out of hours care; we should reverse this trend.  The increasing expectation for shared decision making puts additional requirements on GP Practices requiring improved premises, better IT, more nurses and health visitors. Improving primary care is not a cost free option.

We must recognise that ensuring that primary care has sufficient capacity so that it is easily accessible, particularly for disadvantaged groups, is more important than local access to hospitals. Local primary and community care, providing a wider range of traditionally hospital-based services, are key to improving outcomes and equity, of course still with support to access hospital care when it is needed.

Although it appears to work, the small business independent contractor status for GPs may no longer be appropriate for high-quality integrated care. As the patient becomes the centre of integrated multi-disciplinary care, we may need a clinician whose orientation is centred around the patient not the practice.  There should be more GPs directly employed within the NHS. We should encourage other organisational models whilst still supporting the traditional practice model.

8          Developing local leadership

A disadvantage faced by Primary Care is the well established predominance of the acute sector which spends far more resources and is more “glamorous”.  Previous attempts to integrate services have often simply been a takeover by acute interests and led to cuts and downgrading of primary and community care.  Most senior managers come from an acute background; most tv interviews are with the leaders of large acute trusts.

What is needed is leadership for the whole of care in the locality – leadership not associated with or drawn from one particular sector.  The local system needs managing as a whole to optimise use of resources and that cannot be done through allowing a system of competition and market failure applied to providers, it needs direction.

Somewhere in the system has to be this leadership – the kind that was claimed would result from a commissioner led approach but which never happened, partly because the commissioning organisations were perceived to have vested interests.  As with other public services the natural place for such leadership is through the local councils we elect and Health and Wellbeing Boards could become system leaders.

Community budgets may be helpful, aligning spend to need and facilitating financial integration locally; we must learn from the 4 pilots. This sort of model reduces problems caused by benefits accruing to one budget (say health), having been paid for by another (say housing). These would also make community development easier and more effective.

9          Valuing our District General Hospitals

The debate over “hospitals” has continued since the 60’s.  Everyone is in favour of moving care closer to home, out of hospitals, but everyone still wants a local hospital which provides every service.  However barmy the current configuration and often regardless of issues around safety and sustainability of services, every attempt to reconfigure services is opposed.   Our general hospitals should be seen as valuable but only as part of a whole system and should be as much a base for primary care as a setting where acute care takes place.

If we use the market approach then we have a failure regime, similar to that used in the private sector, and local trusts go bust and get broken up – at least in theory. But that won’t stop local arguments and challenges.  The market solution for a challenged service or organisation, which is to diversify or to attract additional customers (hence income) just plays one part of the NHS against another.  Markets rely on failure but the aim should be to prevent it happening.  Regulatory structures to protect services as failure occurs are complex and expensive to administer and may not work in the interest of patients.

Too often communities see proposed service changes as imposed or driven by cuts.  Much better more inclusive longer term planning is required based on safety, access and efficiency and also on the idea of whole system benefit – not on playing commissioners off against providers or one provider off against another.  We need professional bodies to be more open and explicit about the requirements for safe care and openness and transparency about financial reporting so evidence informed decisions can be made.  That won’t be enough without local system leadership which is weak or even absent in the current market based system.

10        Joining up the Urgent and Emergency Care System

DGHs are usually where the A&E Department is located – with 24/7 facilities to deal with all medical and surgical emergencies on the same site; maybe 150 for the country. Outside the DGH there should be a primary care system for ensuring those with urgent needs get the response their condition requires – mostly not by being taken to an A&E.

The system which deals with emergency and urgent care is a clear example of how breaking up the NHS and fragmenting it into multiple competing providers does not work.  Effective urgent care needs an overall architecture which can only be possible if there is some overall system design and development – and having some loosely defined “network” which does not control the funding or the performance is not enough.

We need a single NHS body, probably based on the ambulance trust, clearly responsible for securing provision of all emergency and urgent care outside of the A&E for a locality. This works only with a single system for assessing the required response; ensuring patients go to or are taken to the best place to meet their needs regardless of how they choose to communicate their need.  The components for this are all available but cannot be deployed properly because the system has been fragmented in the interests of competition – for example, opening the market to private out of hours providers.

11        Removing organisational barriers to whole person care

Organisational definitions which separate social care from health care and also separate mental health care from physical health are all unhelpful to the patient.  Some argue for organisational integration (in the form of ICOs or HMOs) but we should be wary of structural reorganisation as a solution to anything.

The alternative is to remove barriers and to enshrine patients’ rights.  One key mechanism is also now a consensus (but not implemented) – moving to a national single assessment process.  As this covers social care it also applies a common financial assessment (whilst we continue with means testing).

Without significant additional funding for social care progress on integration will be stifled.  Raising the quality of the contribution from social care requires that additional funding is used to professionalize the workforce and eliminate practices such as “minutes of care” time management.  We must have increased funding in the short term and free personal care in the longer term.

We already have a requirement for a strategic needs assessment and for a wellbeing strategy for each tier one local authority area, so an integrated plan for commissioning across all public services follows.

We should make the environment conducive for integrated provision where this can be evolved without major structural upheaval through incentives for joint appointments, joint budgets, collocation, information sharing, and shared services across the NHS and local authorities.  Initiatives such as “year of care” and “programme budgets” must be encouraged and coupled to incentives for joint working.

12        Aligning financial incentives with requirements

The introduction of competition and payment by volume for acute providers is inconsistent with care closer to home and fewer acute admissions.  It is a major barrier to integration of services, and introduces significant additional administrative costs.  It inhibits sharing best practice – why would you help out a competitor?

There are counter arguments, but after more than a decade there is still no compelling evidence that using such financial incentives has increased efficiency although it probably helped in reducing waiting lists. Such mechanisms with a price for everything is a necessity for a “market” approach with level playing fields and plurality of competing providers  but it does not appear to work. Mental health providers lobby for more payments by volume as they mistakenly assume that will protect them from funding reductions.

Reducing the prices in a payment by volume system is a major policy instrument for driving “savings” but the unintended consequences of such a blunt instrument, such as hospital closures, can be severe.

Other incentives through QOF and CQUIN are being tried but so far there is little or no evidence this improves quality or drives efficiency.

Block funding and block contracts without incentive adjustments and with little or no transaction costs might actually be most efficient.  In addition, programme budgeting with shared budgets across primary, secondary and social care where savings in the pathway can be reinvested in that pathway are likely to result in more integrated care with more of an emphasis on upstream work.

13        Encouraging development of integrated providers as a “local” NHS

One way to reduce the barriers to whole person care might be to reduce the organisational complexity.  The “market” approach is creating a hugely complex (and expensive to administer) web of commissioners and providers linked by legal contracts – much like the first model of rail denationalisation.

We do have some examples of integrated providers which link aspects of primary care to social care (through versions of Care Trusts) and successful Mental Health Trusts also delivering aspects of social care.  A few Acute (Hospital) Trusts have recently taken over delivery of Community Care.

In Wales and Scotland integrated providers cover most health care for a geographical area.  We could go further in England and have a large scale trial with a fully integrated provider which covers delivery of all primary, secondary, mental health and social care.  This could be for a single County or City – like NCS Hampshire or NCS Manchester. Such an arrangement removes one barrier to integration and would also make meaningless the current financial trade offs and perverse incentives around patient flows.  This ought to make rational reconfiguration of local service easier.

Such integrated providers would require a very different funding approach – probably a single block payment based on population.  This would save a significant proportion of the overheads associated with the quasi market with its multiplicity of transactions between commissioners and multiple providers.

It is worth a try in an area where joint working is already established and where there is enthusiasm to think about such an approach.

14        Making our NHS a genuinely national system

On international comparison our NHS comes first for ease and fairness of access, but no service on NHS scale can provide identical levels of access everywhere.  We do have a common sense idea of unfairness which is exemplified by distaste for the post code lottery; yet we support localism.  So a national system with some local, but fairly determined variations.

The N in NHS requires national standards, national service frameworks, national outcomes frameworks and inspection and regulation on a national basis.  What defines the “comprehensive” nature of the NHS is defined nationally and guaranteed by the Secretary of State.

The rules which determine how the NHS approaches issues around cooperation, procurement and competition (which reflect domestic and EU law) should be binding throughout the NHS.

National terms and conditions for staff should apply so staff can move within the NHS, although there can be the kind of flexibilities Agenda for Change already provides within the same overarching national framework agreement.

Revenue funding should derive from a national formula based on weighted capitation.  Capital funding can distort financial performance since switching from old buildings into new inevitably puts up cost as the cost of capital is met, regardless of how the capital funding is provided.  One solution is to have all NHS property owned by NHS PropCo even if there are systems of local charging. Programme funding which is aimed at specific outcomes rather than at organisations can, as now, be controlled at the appropriate level most usually national or regional.

There are strong arguments for national shared services and some national procurement framework to lever in economies of scale. The record for delivering this is terrible!!

We already have national systems for collection of data and we must have an obligation on all providers to supply that information with proper sanctions – we need high quality comprehensive data.

But it’s a NATIONAL service above all else because it is shaped by the common requirements placed upon it not shaped by market forces.  So far as makes sense, the service you get does not depend on your economic status or on where you live.

But then there is localism.  This national service must however be tempered by patient and public involvement. If we are genuine about being responsive to local population need, then there will of necessity be differences in local planning. At the very least, if you have a significant black population, you will need a significant sickle cell service, for instance. So long as the differences in area provision are properly explained and seen to be logical, it is no longer a lottery, but evidence of responsiveness to local need.

This balancing act requires the SoS to have ultimate responsibility for securing the provision of services and power to intervene in any part of the NHS and to issue binding directions – although they would only rarely ever use the powers.

15        Allowing earned local autonomy for NHS providers

For two decades we have had an NHS where the “providers” are separate independent entities with a governance structure through a Board containing non executive as well as executive directors.  The alternative was where the whole system was a single structure managed top down by employed professionals.

If we have local governance for providers are the board members appointed, elected directly or indirectly, or some combination?

In Scotland and Wales local health boards have a mixture of elected and appointed directors.  So far in England all attempts at introducing democratic accountability have been successfully opposed.

The current model for NHS Foundation Trusts with the idea of “membership” brings some sense of local ownership, with some freedom from top-down performance management, although there is no evidence this brings any benefits in terms of quality or efficiency.

FT style stakeholder governance with local autonomy within an overall national system should work well, but is being distorted by attempts to make FTs into private providers divorced from the NHS.  They aspire to be businesses with diverse interests and with many non NHS sources of income.  Another problem is that some FTs draw patients from such a huge area that “local” has little meaning.

The FT model is still relatively new and to avoid further reorganisation we have to make stakeholder governance models work by ensuring the “stakeholders” within the FT model are properly engaged; that the governors are appointed (or elected) with the skills and time to do a good job.  They must have real influence and there is some genuine sense of local ownership by a membership base.  A few FTs have gone some way down this road – most have not; and it will take significant investment and effort inside FTs and in the wider stakeholder communities to improve the model.

If we have a stakeholder model then we could allow providers to have local autonomy and freedom from top-down intrusive performance management but if they fail, then the autonomy is removed and they are taken back into direct management.

The other type of NHS provider are the GP Practices which are mainly small businesses loosely attached to the NHS, bound in by contracts but with considerable autonomy – but no sense of local community or stakeholder ownership.  We should encourage all practices to adopt what the best already do in terms of patient and public involvement through local groups.  We should also continue to work with the profession to see if other ownership models, such as salaried GPs, need to be promoted and developed.

Beyond the NHS providers are those in the private and third sector which have their own, autonomy and very different governance, but which must be subject to stringent licensing and regulatory control over quality and provision of information.

16        Using competition and private providers within a managed system (only when the NHS itself is unable to provide the service to the necessary quality)

A model for the NHS based on regulated markets and competition between providers is rejected, but there is and always will be a role for competition and for private providers.  It should be a matter for commissioners to decide how best to secure the provision of the necessary services but only within a very clear national framework.  Nothing in domestic or EU law should be able to compel a commissioner to end an existing relationship with an NHS provider or force a tendering or similar exercise.

Where a commissioner is unable to secure provision of the necessary service from an NHS provider to the required level of quality then they would be expected to look beyond the NHS and run a competitive process.  Commissioners would be expected to test the quality and efficiency of all services on a regular basis to be able to demonstrate value for money.

There are a small number of services which could be secured through an AQP arrangement (as we have had for many years with eyes and teeth) but only if there was no suitable NHS provider able to meet the standards and the volumes required, if the service was simple to specify as regards quality, if the service was independent of other care services and if there were already multiple potential providers. The scope is very limited.

17        Using a sector specific competition framework

The NHS should be set up as a single national system founded on the basis of social solidarity and all relationships between commissions and NHS providers should be within the NHS and not the subject of legally enforceable contracts.  While there are no contracts there can be no intervention through competition law.

The NHS can adapt its sector specific rules around competition (and less obviously cooperation) and keep its own advisory body – all part of a clear policy set by the SoS. The EU procurement regime must obviously be followed (as it is now) but it should be made clear that it applies when commissioners (or providers when they sub contract) decide they will use procurement – they cannot be forced or directed to put a service out to tender – it is their decision.

18        Protected from vested interests – separation of planning functions

The separation of commissioning from providing has remained controversial since its introduction in the 90’s.  Commissioning is seen as the part of “reform” which has proved most difficult and using the Clinical Commissioning Groups is just the latest experiment.

The functions included within commissioning around needs assessment,  pathway design, planning of services, setting of required standards, ensuring continuity of provision,  and the monitoring of performance and quality have to be done somewhere.  The functions should be separated from NHS provision because:-

  • Planning for improving care should cover more than just the NHS providers
  • There has to be some strategic layer than allows resolution of the wicked issues like reconfiguration where there will be winners and losers
  • Acute providers are always dominant and Community Care, Mental Health and other “Cinderella” services lose out – hospitals get bail outs – not Learning Disabilities
  • Too many “providers” have vested interests (especially GPs).

The expertise which resides within providers needs to be captured to help inform service design, pathways and specifications but they should inform the decision making processes not take part directly in them.  But there should be some sense that “we are all in this together”.

19        Giving elected representatives the powers over commissioning  – informed by clinicians and NHS staff

In a market resources are allocated by market forces, in a public service decisions have to be made. For care resource allocation at every level decisions are based on judgement and supported by professional advice and sometimes even evidence.  But judgement is required to balance what will often be competing priorities and even local politics.  Those who exercise these judgments ought to be accountable to us.

This is accepted in Scotland where a pilot scheme is evaluating having mostly elected local health boards, although in Scotland these boards fully integrate health commissioning and provision.  In England it has been accepted in principle that (with agreement from relevant CCGs and NCB) the HWB could become the budget holder for a single health + social care pot and HWBs have some democratic legitimacy (if not much).

It’s a simple principle – those who make the key decisions about how resources are allocated and about how priorities are set within a tax funded, cash limited, system should be elected.  There must be one single democratic body which oversees the whole of the commissioning of services for a locality – usually a tier one local authority area.

A model with separation previously advocated would have clinicians, especially GPs (who have greatest contact with patients), closely involved in pathway design, service specification, monitoring quality and outcomes.  But this would mostly be on an occasional part time basis – pathway design might only be done once every few years and in some cases there might be an acceptable template already in existence.

The more transactional aspects of commissioning around data gathering, procurement, contract management, invoicing, and other back office functions which are continuous need to be carried out by others.  We do not have enough GPs, so why make some of them into managers and bureaucrats?

In the end those who are elected take the decisions, informed by the relevant clinicians and officers.

20        Reinvigorating professionalism

The clinical professional bodies should collectively agree on how they can adapt their practices, training and professional development to meet the new challenges posed by revalidation, appraisals, CD, SDM and the information revolution.  They have also to confront some of the messages from the various enquiries which show that their role in ensuring high standards and enforcing best practice is inadequate.

We should revive the National Service Framework approach. This emphasised clinical collaboration and evidence-based practice and was well respected by the public, clinicians and organisations such as NICE.  NSFs could be used for a wider range of concepts, such as PPI or primary care quality.

Making the Change Happen

We should be committed not to repeat the folly of another top down redisorganisation.  We would need some new legislation, not least in the area of social care funding, but this should be kept to a minimum.  The requirement would be for a replacement Act also consolidating those parts of existing legislation to be retained.

Even under current legislation there are considerable powers of intervention and the ability to issue guidance or make regulations.  The system is just a framework and everything depends on the approach of the political leadership and of those put in the key positions by the politicians.  If the right system managers are complemented by the right approach from the clinical professions then much is possible. There is no harm in having an NHS Board, with or without local outposts, if the right people are appointed on to it.

New organisations within the current architecture such as the HWB’s and CCGs can be made to work in slightly different ways fostering cooperation and integration rather than overseeing competition.  Licensing can work for patients rather than for organisations and regulations around quality and probity can replace regulation for competition.  All you need is a SoS who believes in public service rather than markets.

The approach to making changes in a more evolutionary and less disruptive fashion would entail some system modifications such as these:-

  • Going back to the idea of a long term Plan for care (so embracing all care) with some objectives and some targets. An outcomes framework is good but some targets are a good too.
  • Build a wide consensus before publishing the Plan then once elected take a year to plan and mobilise.
  • Restoring unambiguously the power of the SoS to direct and to intervene in any part of the NHS where the SoS considers it is necessary
  • Within the Plan signal the convergence of health and social care through:-
    • progressive introduction of free personal social care
    • a single assessment process which is national and portable
    • incentives to share staff, facilities and services between LAs and NHS bodies
    • Keep Monitor as the financial regulator of all providers. Use a licensing system to shut out or to close down unsuitable providers and enforce the requirement of all providers to supply publicly all the information needed to monitor their performance (ie no commercial confidentiality protection).
    • Remove any suggestion that Monitor promotes competition or even acts to prevent anti-competitive behaviour. Over time Monitor and the CQC should be merged into a single regulator.
    • Ensure there is a single overall set of rules covering the use of competition as with Principles and Rules for Cooperation and Competition, and keep the Cooperation and Competition Panel to advise on cooperation and competition issues.
    • Move responsibility for price setting to DH/NCB – with a good input of independent advice. The flexibility to have alternatives to a fixed national tariff price should not be confused with bringing in price competition.  Allow local variations but evaluate the impact.
    • Widen the membership of the National Commissioning Board to include representatives from local government and from the PPI community; with less from banking.
    • Put all specialised commissioning into a separate Special Health Authority.
    • Keep the National Provider Development Special HA to oversee and performance manage those providers which do not make FT status and FTs which are de-authorised.
    • Require Health and Wellbeing Boards to produce an integrated commissioning plan to support the local wellbeing strategy.
    • Give HWBs the power to sign off commissioning plans and the power to intervene if any commissioner appears to be departing from agreed strategy and plan.
    • Open up the membership of HWBs to give more voice to patients and public
    • Give each Clinical Commissioning Group a proper Board with a majority of properly appointed NEDs (eliminates conflicts of interest issues)
    • Give CCGs responsibility over primary care services (currently with NCB).
    • Over time allow convergence of HWBB and CCGs to give local commissioning authorities (as suggested by Health Committee).
    • Ensure local Healthwatch bodies are properly resourced and supported and make HealthWatch England into a powerful separate body with its own resources.
    • Accept that a small number of NHS Trusts will remain and allow for a FT to be deauthorised.
    • Bring back the Private Income Cap, set locally by governors and with an overall limit which can only be exceeded with approval from SoS.
    • Reinforce the idea that FTs are part of the NHS. Allow FTs and commissioners to sign NHS Contracts, which are not legally enforceable and so outside scope of procurement competition law.

None of the above implies major structural reorganisation.  The changes would adapt the current structures but move away from the market regulation architecture and towards a public service approach which gives space to address directly the cultural and behavioural issues that are central to genuine reform.

Dr Brian Fisher  Chair Socialist Health Association

Richard Bourne   Vice Chair Socialist Health Association

July 2012

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2 Comments

  1. Richard Grimes says:

    In general I am in favour of these proposals as a careful balance between national delivery and localism, providing checks and balances without resorting to the market. Here’s some observations:

    GP as contractors. Actually, I am in favour of this. The practice model means that GP partners are embedded within a community – they have a financial interest, and often it is life-long commitment. A salaried GP can move after a short amount of time (whatever their notice is). I worry that this would break the link to the community. I am also worried that moving to salaried GPs would make it easier for a future government to privatise primary medical services: all that need to happen is change the contract holder. Look at companies like Assura/VirginCare, UnitedHealth or The Practice.

    Health and Wellbeing Boards have potential, but the democratic legitimacy is only as good as the councillors on the board. It appears that the model at the moment (the Act is characteristically vague about this) is that the health portfolio holder in tier one local authorities and the portfolio holders in the district or borough councils sit on the board. This is fine, but these are people who have not had *health* responsibilities before (though they have been responsible for social care). No councillor is elected *specifically* to be a health portfolio holder, I would challenge anyone to find health policy mentioned in any councillor’s election leaflet. Is a solution to this to have directly elected health portfolio members? I would like to see local councillors getting a lot more involved in the planning of services, rather than the current situation where they are only involved through their opposition to any closures.

    That leads me to the question of DGH reconfiguration (which you carefully skated around). People like local services; policy makers love centralised services. We have to find a way to find the compromise. I suggest that local councillors should be involved as early as possible in reconfigurations. If you like, they have to get their hands dirty. Local councillors communicate well with local communities, that is, effectively, the only reason why they are elected. So who else is better to explain the reasons for reconfiguration – safety, finance, lack of skilled staff – than councillors? If a local health service can convince the local councillors that a reconfiguration is needed, then the local community will be convinced too. So get local councillors involved in this decision making: politicise the NHS at the local level.

    This leads me onto another aspect of local ism: urgent care. GPs are the first point of contact that most people have with the NHS, so it is natural for them to be seen as the local leaders of the NHS. I think that contracting out OOH services is GPs abrogating a significant part of their responsibility for a community. There should be a policy to move responsibility for the OOH service back to GPs (not CCGs), if they do not have the resources to deliver it themselves (which I cannot believe since many OOH companies are GPs moonlighting) then a practice should be responsible for the contracting.

    The “NHS PropCo” idea is an interesting one. But first we have to make sure that NHS Property Services Ltd (the recently created PropCo) is made a statutory body. The current situation with FTs paying a “dividend” on Public Dividend Capital seems bizarre and a PropCo solution would remove this (and centralise PFI debts). FTs should aspire to have annual balanced budgets, but that should be on the delivery of health services, not as a property developer.

    Governance. As you mention there is a wide variance across the country of what FT Governors are responsible for. Perhaps we could move to a model like local authority councillors? Councillors instruct local government officials and they are elected or re-elected based on their policies, is there something we can learn from this for FT governance? Some FTs have budgets bigger than many district or borough councils.

    Competition and private providers. It is not possible to have a wholly public sector delivered system, and it is not desirable either. My background is as a software developer. If the company I worked for was contracted to do a job that they did not have the skills, they would employ contractors temporarily whilst training up the permanent staff. This works well in the private sector, I do not see why a model like this cannot work in the public sector: use outside contractors short term when you need the capacity or expertise.

    A couple of issues that you have not mentioned. Personal responsibility is key to people with long term conditions managing their care better, though from my perspective the incentive for the patient is to feel better and have a better quality of life. Patients will only be able to be active in SDM if they are properly trained. Patient training is vital and a right to be fully informed about their care is perhaps the most important right that LTC patients can have.

    Allied to this is advocacy. Patients need to have someone who is “on their side”. Each patient should have a single point of contact, someone, and advocate who will have the responsibility for helping the a navigate through the NHS. Ultimately I would want the advocate to be able to guarantee that the patient will get the care they need. Too often we see patients being pushed from pillar to post as primary care and secondary care providers say that its “not their responsibility” and the patient – with no skills in healthcare cannot see a solution.

  2. Brian Gibbons says:

    Plenty of food for thought. Some ideas are well worth pursuing both others would be much more controversial.

    GPs and their practices are less and less embedded in their community. There was a time that patients lived within walking distance of their practice and would expect their doctor to recognise them in the street. As group practices have evolved they provide more services in the community but at greater distance from their patient. And as more corporates get involved this distancing is likely to increase and make practices more remote.

    As the main article acknowledges, the independent contractor status of GPs is becoming more and more problematic not least with the changing nature of the medical workforce. Returning a requirement to provide / contract for “out of hours” would be a further nail in its coffin. Only a (?small) minority of GPs are now involved in “moonlighting” in out of hours services.

What do you think?

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