The fundamental principles underpinning the 1948 NHS remain strongly supported; comprehensive, universal, free at point of need, funded out of general taxation.
Evidence shows that our NHS is amongst the best performing health systems in the developed world; but it has weaknesses around accountability, public and patient involvement, patient experience, and healthy lives (measured through mortality amenable to health care; infant mortality; and healthy life expectancy).
We have a fragmented care system, social care is a mess, health inequality rises when we should be seeing it improve and variations in outcomes are unacceptable. The model of the patient as a passive recipient of expert care from professionals is as wrong as the model of the patient as a consumer shopping for care. The change in the professions to viewing patients and communities as valuable assets, co producing better care, is a long way off.
Major changes to structures and reorganisation achieves little; market competition does not really work; and “commissioning” has failed to achieve what was claimed. Reductions in social care funding have seen a market led race to the bottom – poor quality care, poor treatment of workforce. Reducing funding makes things worse (especially in social care) but just increasing funding may not be enough, or politically acceptable!
It appears obvious that whilst the NHS is top in terms of value for money, at its current level of funding it cannot achieve what we are saying we want from our care system. Many “zombie” policies like ending the market, out-of-hospital-care and better procurement (all commendable in their own right) are touted as magic solutions but our rate of funding as a %GDP is falling when it needs to increase!
Change could make the care system better, but there are three constraints:-
- Part 3 of the Health & Social Care Act has to be repealed (more complicated than it appears!)
- no top down major reorganisation
- no immediate injection of additional funds (at least until after issues around efficiency have been seen to be addressed).
There are some difficult questions: these are a few. 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? What does integration actually mean in practice – how do small business GP practices fit in?
How can “free” health be merged with “means tested” social care? How can essential relationships and local leadership be fostered? How can local freedoms be balanced against post code lottery? If (big if) we can prise control away from the centre then the key has to be to do as little as possible from the centre and permitting local freedoms. How can a permissive regime be brought about without redisorganisation; what are the risks? And what replaces “commissioning”; do we trust democratic accountability around planning care?
How do we harness the power of information and social media? How far do we push openness and accountability and allow “voice” to drive improvements? How do the professions take responsibility for reducing unacceptable variations?
Labour should continue setting out its ideas; inviting the widest consultation and engagement; admitting it does not have all the answers yet. But well before the 2015 election Labour should set out what it proposes. 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 Part 3 of the Health & Social Care Act 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; enhance the weak governance around Clinical Commissioning Groups; give Healthwatch some teeth and resources; strengthen the role of public health; and set out measures to enable improvements rather than inhibit them. No big reorganisation needed.
Clear direction could be set by the Secretary of State and appropriate appointments (and removals!) made to key positions.
Once the direction is clear then there could be local freedoms to try different approaches; a ban on top down imposed changes through guidance and directions, and restrictions on the use of the big consultancy companies. The disruption and waste caused by the market system could be stopped, the freedoms in the EU Procurement Directive being embraced vigorously, NHS Contracts restored. Local initiatives towards integration can be 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 with incentives to share posts, share systems, collocate staff, and jointly develop the workforce (as described in the Oldham Commission Report).
Having established some stability there could then be a year to work towards a 10 year plan for care – a plan with the widest possible support, building public support so we have the genuinely and rightly concerned public as allies rather than portraying them as enemies. And steps could be taken to improve staff morale by protecting terms and conditions and by not constantly denigrating them. Quality problems that arise can be dealt with by an open and honest approach and making sure they don’t happen again instead of using them as an excuse to attack the whole NHS. This may add up to a “culture” change. Change will take time but the 4 years of decline and disruption can be reversed.
If we can deal with “culture”, “leadership” and “relationships” then the only problem will be the money! crucially initially money to save social care.