Response from Dr Kathy Teale and Councillor David Ellison, Members of SHA and Didsbury West Labour Party Manchester Withington CLP
Many studies have shown that the NHS is an extremely cost-effective health care system. A recent Commonwealth Fund report from 2010 repeated this finding. This report compared health care systems in 6 developed countries including the UK, the US, Canadaand Germany. They looked at 5 areas – Quality of care, Access, Efficiency, Equity and population life expectancy. The UK ranked 2nd overall, with a much lower cost per capita – $2454, as opposed to $US 7290. However it did badly on “long healthy lives” (many of the determinants of which are determined by social conditions and not a reflection the quality of health care) and “patient centred” care, (which reflects how convenient and pleasant the service is for patients, rather than looking at outcomes).
The NHS is therefore not a “broken” system – and it’s high cost-effectiveness may be particularly relevant at a time of restricted government budgets. However, there are elements which we need to improve, especially as the population ages and comorbidities such as obesity increase. In particular, it needs to be more “patient-centred”.
We currently, under the purchaser-provider split, have a system which has discouraged integration between primary and secondary care, and where rehabilitation services, community care and social care have been grossly and systematically under-resourced. We have also inherited a network of acute hospitals which has not changed for the last 60 years, despite major changes in population distribution and needs. Yet the recently-passed HSCA does nothing to address these problems, and in fact will lead to an increasingly fragmented and disparate service with differences in provision and access between regions becoming increasingly common.
This paper looks at some of the ways we can improve on the current provision of health care in theUK– both in acute services and long term and social care.
Response to Questions;
1/ an integrated approach to Health and Social Care
- Is whole person care the correct approach to healthcare in the 21st century?
A Yes, the consensus view is that that this is the way forward
- How can whole person care be funded so that it becomes free at the point of use?
A. Healthcare should be provided by the Public sector. The celebration of the humanity of the NHS was a key part of the Olympic Celebrations by Danny Boyle. Evidence from theUSAdemonstrates that costs of private provision are substantially higher due to administration, bureaucracy costs, excess provision to the wealthy, and still with inadequate provision to the poor and non-insured. An extended state-backed insurance-based system for social care may need to be provided in theUKto fund care needs of the elderly in the future as costs of care and the number of elderly increases. Planning for this whole life care should start now.
The principal of free Health services at the point of use must be maintained however. Up-front payments, as inFrance, disadvantage poorer patients and discourage access from the very patients that often most need to access services quickly.
More emphasis should be placed on access to primary care, which evidence shows has become more restricted since the current government came into power. Easy and prompt access to primary care is essential for early diagnosis and reducing health inequalities especially in hard to reach groups.
“Empowering primary acre is associated with better health outcomes and lower costs – primary care has been outmanoeuvred by a health industry intent on opening access to lucrative down stream services and resources “Brian Kiepper, US health commentator
- How can we ensure a better experience of patient care?
A Ensure that service providers are responsive to patient requirements. That a complaints service continually responds to patients and that a system of continuous improvement is in place. Ensure that there is strong scrutiny of NHS services with an independent patient watchdog put in place.
The emphasis on patient choice should be changed so that patients have choice over the treatment they have, and at which hospital, clinic, or care home. However, the expectation should be that the patient’s local provider is of high quality and most patients would want to go there
- How can we better extend services to hard to reach families and communities?
- Make sure that people know about the services that are available, through public health promotion, use of community outreach services. There must be a concerted drive to reduce health inequalities and differences in life expectancy that only began to close with injection of resources into the NHS by the last Labour government. Evidence is growing now that health inequalities are growing again. Access must not be affected by wealth, education, comorbidities, age , gender, or race .
- How the health and social care service should be funded in the future?
A The most equitable way of providing healthcare is by population risk pooling i.e. funded by everyone through general taxation or state insurance system . Co-payment systems reduce access to those with low incomes and introduce a two tier service, reducing the impetus for service improvements for those on the lower tier. This will only serve to widen inequalities . Even a small charge to see the GP when trialled inWales, resulted in later presentation of morbidities . Specific insurance systems introduce a smaller risk pool with the danger of cherrypicking .
- How can services be made more accountable to patients , public and staff ?
A There needs to be democratic accountability for the Health service at the highest level to Parliament . Democratic accountability at local level should be increased by strengthening the role of local authorities in the provision of public health and social care services . Authorities should have a role in driving down health inequalities . However to do this they will need sufficient resources. The poorest parts of theUK, which are the areas of shortest life expectancy, have the highest health needs and therefore need appropriately increased funding to improve the health outcomes for these vulnerable populations.
- How can we learn from the Dilnot Commissions about how we fund social care ?
A The Dilnot Commissions recommendations for social care need to be looked at. A state backed insurance system to meet the needs of an ageing population will be the fairest way of providing the increasing levels of social care required by a growing elderly population in the future .
2/ Principles of Health and Social Care
- What would you list as the key principles for any health and social care service ?
A Health services should be funded by the public sector through general taxation or insurance to provide general healthcare services for all citizens free at the point of use .
There should be equality of access for all citizens. However, in order to reduce health inequalities the service should positively seek out those in need of care and meet those needs.
Treatments available should be evidence based and in accordance with best practice . Variability and idiosyncratic practice must be discouraged .
Information about services and outcomes should be freely available to patients . There should be a continual process of public health education and promotion
Healthcare provision should be planned and commissioned to ensure the changing health needs of the population are matched in line with advances in medical science and improved methods of care . Public Health services based on the needs of the population should drive change and improvement .
Healthcare provision should be adequately funded and commissioned at a local level where possible to ensure that is responsive to the needs of the population .
Patients should have choice over the type of treatment they receive and where they receive it from . However it should be on the basis that the standards of service throughout Health service are consistently high . Choice of provider alone does not drive up standards, as patients are unable to choose on the basis of any criteria reliably linked to quality of outcome.
- How can we put the patient back at the heart of the NHS and re introduce cooperation rather than a market free for all ?
A What do we mean by patient at the heart of the NHS ?
Patient centred – The commonwealth fund definition is “ care delivered with patient preference and need in mind, including good communication . continuity , feedback and engagement “ This does not involve outcomes, which are assumed.
1/ Ease of access to primary care provision – 80% of healthcare contact is through primary care . Good communication , continuity of provider and emergency care when required are vital
2/ Involve patients in decision making about their treatment
3/ Emphasis on whole person care –not fragmented across different services especially for elderly and multiple co-morbidities
4/ Abolish private sector competition which segments service and hives off profitable parts and introduces perverse incentives . Providers should not be “for profit “ , free flow of information and patient details between providers is vital . All centres to publish data, not just NHS providers.
5/ Rigorous audit and monitoring against quality targets e.g. fractured NOF care – with payment attached to providers for fulfilment of targets .
6/ rationalize secondary care services e.g. specialist care in a few big centres , less specialist in other and more local hospitals , balanced against access requirements
7/ Conflict between efficiency and patient experience – e.g. theatre list efficiency – some patients have to wait and risk cancellation in high utilisation systems . Therefore improving patient experience may lead to greater costs
8/ Improved communications once being treated , including with relatives
9/ In turn patients have a duty to understand how the NHS works and is funded. Some patients are largely ignorant at the moment and don’t appreciate the service they receive. There is a social contract at the heart of the NHS
3/ Tackling Health inequalities
- How do you think the NHS can best work to reduce Health inequalities?
A the Marmot report in 2010 identified 6 objectives to reduce Health inequality
1/ Give every child the best starts in life.
2/ Enable all children to maximise capabilities and have control over their lives
3/Create fair employment for all
4/Ensure Healthy standard of living for all
5/ Create and develop healthy and sustainable places and communities
6/ Strengthen the role of ill health prevention
The NHS alone cannot solve the health inequalities in society alone; it is only part of the answer. Improving health prevention and promotion services will assist in driving social change to improve health. , tackling obesity, smoking drinking, drug taking and improving diets etc.
One of the key ways of preventing premature morbity is ensuring that early intervention is available. This will over time reduce costs as it reduces late presentations, improves care and reduces some of the need for expensive secondary care services
- Which services need to work together to tackle health inequalities?
A Across each region of the country the NHS needs to work together to provide an integrated service to patients;
1/ There needs to be an overall planning function Matching the health needs of the population at a national , regional and local level with health care resources
2/ Integration between primary and secondary care to create a seamless care pathway for patients. The vertical integration of services can take places through a range of service providers in different areas, dependent on local circumstances
3/ The Acute care services need to be arranged to continually drive up standards and bring the latest advances in medical science to the population. The model of Hub and spoke services is beginning to drive provision of specialist services.
4/ Changes in future demographics especially the increasing numbers of elderly and long term conditions need to be reviewed and planned . The balance between primary and secondary care needs to ensure the best use of resources.
5/ If rehabilitation, elderly and long term care is to move a hospital setting to the community, there needs to be massive investment in community care services to enable provision of 24/7 care, with the ability to provide intensive nursing care in the home .
6/ There needs to be integration with social care functions currently proved by local authorities. Some of the most needy families are in receipt of large amounts of intervention and this needs to be brought together in a co-ordinated way
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