A review of the Independent Commission on Whole-Person Care commissioned by Andy Burnham.
“One Person supported by people acting as One Team from Organisations behaving as One System”
This report is intended as supporting documentation to the Labour Party policy review consultation document “Health and Care” published in March 2014. It provides an insight into what may happen if there is a Labour Victory in the General Election in 2015, and indicates some of the thinking behind the proposals.
The driver for the report seems to this commentator to be a desire to draw a clear line between the approach of the Labour Party and that of the Conservative Party. While Labour “stands for One Nation, Whole Person Care, Combining care for Physical Health, Mental health and Social Care into a single service”, the Conservatives are seen as promoting privatisation and fragmentation, exemplified by the Health and Social Care Act 2012.
The report spends some words on trying to define whole person care although never satisfactorily. Thus, whole person care is defined as seeing people not as recipients or consumers of services but as genuine and active partners in “designing and shaping their care and support”.
The next Labour Government will “integrate health and social care into a system of whole person care. Integration will deepen over time and different areas will develop different models.” “Central to whole person care is the idea that people with chronic conditions should be empowered to manage their conditions”. “Central to the vision of whole person care is the idea of a single named contact for the co-ordination of an individual’s care needs”. “We will ensure patients have a formal role in drawing up and deciding on proposals for service change”. All so many nice words but lacking in any real substance.
But the substance is revealed when the report states “unless action is taken the maintenance of the existing service could require £30 billion across health and social care. …status quo is not an option”. The Commission claims not to seek major changes in services saying “We do not believe the answer includes yet another major structural reform at this time”.
But nevertheless the report is structured to consider the case for considerable change. It reveals its underlying beliefs: the problem is the lack of evidence for most of them. Thus the report is predicated on:
- A belief that empowering people is a serious objective.
But unless individuals possess an enforceable right to healthcare and providers are paid automatically for treating the patient as soon as possible such strictures are misleading. The reality is cash limited budgets, incentives for delays, denial, dilution etc and the requirement for sharp elbows before entitlements are received. There has been little empowerment over the years. Much was made of ‘Choice’ when the Labour Party was last in power but the experience of most people is there is very little choice; actually what people want is access to high quality local services. It was the massive injection of funds that floated the NHS off the rocks in the early 2000s not choice and competition as some suggest.
- A belief that preventative medicine will somehow square the circle between rising demand and politicians desire to reduce taxes.
It will not. Of course it is a good idea that the sick do not become sick and if there were no sick people we wouldn’t need the NHS. The reality is the NHS needs more money and politicians are reluctant to raise taxes. Promoting preventative medicine is merely a tactic politicians are happy to accept because it makes it look like they are creating more resources without increasing taxes.
- A belief that spending on social care is an alternative to spending on healthcare.
It is not. Most social care is provided by self-help and family support. If the state provides more then individuals and families are relieved and it doesn’t necessarily result in more social care. Better social care may take some of the pressure off healthcare providers and expedite discharge but by muddying responsibility for social care it only delays discharge while people haggle.
- A belief that centralising the purchasing of health and social care will in itself solve issues.
It will not. It is by no means clear how bringing all the commissioning bodies together under the auspices of Health and Wellbeing Boards is a major step forward. It looks like tokenism and newly formed GP commissioners are resisting this fiercely.
- A belief that increased spending on primary and community care is an effective substitute for acute care.
It is not. It has ever been the policy to promote primary and community care as a substitute for acute care. The fact is that although the quality of care may improve, primary and community care are not a substitute for acute care but are complementary. There is precious little evidence that investment in enhanced community care results in reductions in acute services.
- A belief that increasing public spending on healthcare is politically unacceptable and unnecessary.
It is not. This report refers to the very idea of spending £30bn extra on healthcare as politically beyond the pale. Yet this is how much less the UK spends on healthcare compared to comparator countries like France, Germany or the Netherlands. Plus the report holds out the promise that by following the reform package suggested it may be possible to avoid unpopular tax rises. It will not.
- A belief that transformational change to acute services is both self-evident and inevitable.
It is not. This is where we detect the influence of the big consultancies who have supported the Commission. Transformational change is the latest big thing; it used to be called business process re-engineering. It promises a lot and delivers little. But it pays well.
- A belief that obstacles to necessary change have to be removed.
This is sinister and implies that obstacles such as the lack of a compelling business case; the reliable existence of substitute services, and the informed consent of local people and stakeholders may be swept aside in future.
These biases make it difficult to engage enthusiastically with the report. In its favour it says some sensible things and identifies how better services and better input by patients, families and carers would limit the demands made on the NHS. There appears however to be a naïve faith that good intentions, relationships and culture trumps an implacable Treasury and cash-limited budgets. They don’t.
It does not make clear how better co-ordination will be achieved in the future compared to now; especially if there are to be no further structural changes. The experience of Health and Wellbeing boards is not encouraging.
Change is much more likely to be technology-driven and provider-led than commissioner-led. Local access to INR results has transformed anti-coagulation clinics and the ability to properly support local chemotherapy services will be similarly transformational. But the development of personalised medicine and better diagnostics will more likely increase the scope of future interventions not reduce them and the increased levels of obesity, sedentary and unhealthy life styles will lead to increased demand not less in the future. Increased immigration, raised birth-rates and increased multiple morbidities amongst the elderly and chronically ill do not justify premature plans to cut back acute care. Reduced social care provision and the reluctance of people to self-fund their social care suggest increased problems not less in future.
The reception of the report has been mixed. The Kings Fund has characteristically fallen over backwards to reinforce the messages. In an interview in Total Politics Oldham reinforces the division between his approach and the Government’s saying,
“The system brought in by this government… means that you can never really deliver whole person care because it created and increased the fragmentation we have to address,” “a completely fragmented approach which sees people as body parts rather than a whole… even people who are adept at the system find it a torturous and really difficult system to work through.” But this requirement for bureaucratic rationing will be largely retained and many of the reports core ideas are being fully supported by the existing Government, as other reviewers have pointed out.
My fear is that the primary purpose of the report is political in helping to bolster Andy Burnham, the shadow Health spokesman, to make it look as though he would increase spending (if agreed by an all-party review and a National Conversation) sometime after the next election; and, helps him hold out the promise to local government of greater access to NHS budgets to help deal with the distress of funding withdrawn from social care. It provides an eye-catching contrast between Labour and the Conservative at a superficial level but in reality it leaves much in place and presents ideas on integrated care being enthusiastically taken up by this government already.
Overall it doesn’t do a lot for me. Talk of removing obstacles to reconfigurations and transformation is ominous and betrays acceptance of an agenda to downsize the hospital sector. Consultant bashing was always a popular refrain at Labour Conference and the Labour Party is being egged on by GPs and others who have their own interests to promote.
I hope Labour is seeking other advice. Otherwise they may have to do some rapid rethinking once in power. That is if they win the next election.