In Brighton Ed Milliband and Andy Burnham (together with his excellent team) set out more about the emerging policy for an integrated care system providing whole person care.  As they have said this represents the rebirth of the NHS and the next major step on the journey started by Labour in 1937.  Changes rooted in Labour values, changes which will win widespread support.  Changes supported by the SHA.

We know the framework to enable whole person care.  Putting people before profits with competition and markets removed.  Healthcare once more predominately publicly delivered and public provision defended.  With planning replacing commissioning and health joined up to other public services through local authorities.  With healthcare, for the first time, being properly publicly accountable. Building up from dealing with the social determinants of poor health with a key role for Public Health throughout the public sector.  Ending the scandal of malnourished, zero hours, 15 mins slots social care.  Having a well paid, well trained workforce across all of care, in the right numbers to do the job properly.  Repealing the H&SC Act – a necessary but far from sufficient condition for change.

Through many random conversations and many fringe meetings, not all of which were with those who are generally supportive, there was an overwhelming sense that this approach was right from those who work in the various services and those that use them.

The contrast with the Cameron/Lansley idiocy is stark. Labour has listened and is setting out its plans at the earliest stage; welcoming and inviting the widest consultation and engagement. Long before the 2015 election Labour will have set out what it proposes. And unlike the Cameron approach there will not be a ludicrously expensive and disruptive top down redisorganisation.

With the key themes established the hard work follows.  How can the transition to a much better integrated system be achieved without a reorganisation and without the benefit of significant real terms growth in funding?  What can be developed to bring genuine accountability and involvement and ensure patients and communities are viewed as assets?  How must the roles of professionals and others in the workforce change?  How can “free” health be merged with “means tested” social care?  What evidence we have about where integrated care works appears to show that relationships and local leadership are far more important than structures so how can these be fostered?

The challenge is daunting and suggests that an incoming Labour administration may have to think much longer term.  It could start by setting out its broad vision in something like a Green Paper before the election and start serious discussions with patients groups, local authorities, Royal Colleges and Trade Unions.

An initial Bill could repeal the Health & Social Care Act, restore the powers and duties of the Secretary of State to ensure a comprehensive and universal health service, extend the scope and powers vested in Health and Wellbeing Boards, change the weak governance around Clinical Commissioning Groups, strengthen the role of public health, and set out measures to enable improvements rather than inhibit them.  Clear direction could be set by the Secretary of State and appropriate appointments (and removals!) made to key positions.  There could be local freedoms to try different approaches; a ban on top down changes, guidance and directions; and major restrictions on the use of the big consultancy companies who appear to be present whenever expensive (and usually botched) changes are made. The disruption and waste caused by the market system could be stopped and local initiatives towards integration supported rather than being blocked by competition rules or the Office of Fair Trading!  Royal Colleges could be asked to work together!  Organisations could be encouraged to collaborate not compete.

Then take a year to work towards a 10 year plan for care – a plan with the widest possible support – even offering to include other parties.  And build public support so we never again see the “save our xxx” campaigns and have the genuinely and rightly concerned public as allies rather than portraying them as enemies.  And we can lift staff morale by protecting terms and conditions and by not constantly denigrating them.  We can deal with problems that arise by making sure they don’t happen again not by using them as an excuse to attack the whole NHS.

If we can deal with “culture”, “leadership” and “relationships” then the only problem will be the money.  Now it gets even harder.

Whatever is claimed the reality is that funding for care has been decreasing in real terms putting impossible strains on social care and the NHS.  It is possible to take some costs out of the system through integration, through consolidation and by taking out the market mechanisms but it won’t be enough.  Moving care out of hospitals and building up primary and community care is essential for better care but may not be cheaper care and investment will have to precede any savings.

If we truly want a 21st century care system, amongst the best in the world on outcomes and quality of experience, and which is universal and comprehensive then it has to be paid for.  If we want social care on the same “free at the point of need” basis as health care (and we do!) that too requires funding.

So alongside discussion around whole person care we have to discuss how to raise additional tax funding to pay for good care.  And that too could even be a popular campaign; the voting public are probably way ahead of the political classes.

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  1. Brian Fisher says:

    Excellent, Richard. The SHA should now set up a series of policy meetings looking at these difficult issues. Including how to handle PFI when it is crippling local care.

    1. Richard says:

      We should have some meetings around policy as we did with social care recently. The Role of GPs, Personal Budgets, Reconfiguration would be good ones. There we could add some value. I dont think we have anything more that is useful to say about PFI, we did try a few months ago.

  2. Simon Kirk says:

    Commissioning is, or should be, more than just competitive tendering so let’s not throw the baby out with the bath water – recognising that planning, central or otherwise, hasn’t previously of itself produced culture change in defensive institutions like hospitals. Strategic planning is not something that a patchwork quilt of local authorities have any real form with either, is it – seems to me there’s plenty of experience of local politicians being at the front of bandwagons that argue in favour of local rather than effective, efficient or safe. While we’re at it, lets sort out local authorities’ governance in relation to social care too. And what are we going to do about primary care for the future? Finally is Andy Burnham the right person to lead the dismantling of much of that which was originally put in place by the Blair/Brown governments? Like you say, plenty to think about and do (we could do worse than look back to things like Our Healthier Nation) – let’s hope the time is taken as you suggest.

    1. Richard says:

      Commissioning NHS style is a twenty year disaster story, and the nhs record on major projects, procurement, PFI etc is also dismal.
      The people who allocate public resources and decide spending priorities should be elected not unaccountable and unrepresentative people motivated by vested interests which is the NHS way.
      Andy is absolutely the right person he started down this approach before last election.

      1. Simon Kirk says:

        We need to distinguish between local experience and national – Govt and DH policies and procurement methods – when looking back over the last twenty years I’d have said. And personally I’d prefer that democratic accountability continuing through Parliament until such time as there’s a well worked out approach that commands confidence if we’re ultimately handing responsibility to Councils – maybe NHS issues would have a beneficial effect and help revitalise local elections too.

        1. Richard says:

          I have spent a lot of time locally as well as nationally and still suggest long history of poor perfromance in key areas. NHS style commissioning does not work and never will.
          Andy has made clear he agrees with us that the new approach does need a dramatic change in the attitudes towards local councils as well as tranfers back of powers and responsibilities. But I am with him in saying we should give trust back to those we elect.

  3. Harvey Ward says:

    The Town and Country Planning Association are running a growing campaign to Reunite Health with Planning – (recalling that town and country planning started with public health in the nineteenth century). There is vast potential in linking T&CP with the NHS – primary care is going to need a lot of new build, co-location of GP practices with social services, secondary care reconfigurations that all need careful consideration of the spatial element – i.e. where things are located in relation to town centres, public transport, complementary activities etc. Who better to deal with these issues than statutory town and country planning?
    But another big issue for Labour is to amend the National Planning Policy Framework because Pickles and Osborne require any ‘sustainable development’ to be approved. The devil is in the definition of ‘sustainable’ – not what you or I would think (green, conservation etc) – no, the definition is sustainable = profitable. This allows developers to ignore local plan requirements for affordable housing, for example, by stating that affordable housing affects their scheme’s profitability. Town planning has been hit as badly as the NHS by coalition and is increasingly ineffective just when the UK needs sensible planning.

  4. Karin Smyth says:

    Great summary of the goal and the challenges Richard. As we discussed at Conference my democratic heart is with you on the move to local authority planning or commissioning this new model but my managerial head is feeling nervous about the ability of councillors to take this on in the next few years given how emasculated local government has become in many parts of the country. There is great appetite in the county to make this work but we cannot underestimate the NHS weariness of more organisational change. To make it work will require inspirational leadership and good motivated management. The group of people missing from last weeks speech were of course managers. Pity. With my election hat on it is my experience that NHS managers are largely core or target voters, living in target seats. Assurance on the pace of change, the long term plan and a willingness to have widespread discussion much as we did pre 1997 would be very welcome

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