October 12, 2014
Bristol Festival of Health Ideas
by Karin Smyth
The recent Festival of Ideas on Health at Bristol’s Watershed gave an opportunity to consider potential sources of change in the health and care system. Given that much of the political debate about the NHS involves more platitudes than facts or first hand experience it was a good debate and I was glad to be able to take part. What follows are my thoughts as presented on Saturday.
Our discussion needs placing in the context of the first 60 years of the NHS and the failure of both state planning and the market to achieve the change we need. My contribution centred upon my view that the change must come from us, the women and men who are supporting and using a system we know is in need of overhaul.
The interplay between health and politics has driven my political activism — and constantly challenged and formed my political philosophy and view of the NHS. Thirty years ago I read the Black report into health inequalities. What I learnt about the power of provider interests and the professional middle class, and about the wider determinants of health and the lack of our power as patients or citizens made me want to join the NHS – I was going to change it.
I have subsequently spent most of my adult life working within the NHS
There has been a massive improvement in all parts of the NHS, but health inequalities persist, as does the power of provider interest and, indeed, the power of the middle class.
The Politics of Funding
In the 1990s, having decided the first 30 years of centralised state planning didn’t work, Governments of both colours looked to the market and various forms of the purchaser-provider split have been used to drive change.
Broadly, we have cross party political support for a nationally funded NHS free at the point of need.
Last year the Kings Fund, with Ipsos Mori, ran consultation events with the public on how we should pay for health care in the future. Support for the funding model remained strong. But they reported one key lesson for politicians – that people needed convincing the current system was running as efficiently as possible before making more radical changes to funding.
So, should we persuade the public they should pay more – not with their credit cards but through a greater percentage of the country’s Gross Domestic Product?
The NHS is not yet the biggest political issue or problem facing people in south Bristol. The availability of decently paid secure work, especially for the young is critical. So too is a decent home. Access to good education and skills opportunities, transport and childcare – removing the barriers to work- are all bigger issues
Can we ask people in south Bristol to pay more for an NHS that we know does not make the best use of the resources it has? More crucially to pay more for an NHS that does not have responsibility for the causes of poor health or health inequalities. Shouldn’t we prioritise the treatment of the causes of so many of our health problems?
As the Marmot Review into health inequalities reported in 2010, the lower one’s social and economic status the poorer one’s health is likely to be.
People’s current experience of the NHS
It is often said it takes a generation, 30 years, to deliver change and I believe we are at that point again. This time the change will come from us – the people who use and pay for the system and in particular from those who expect it to work and know it doesn’t. There is an army of extraordinary people caring for very elderly family with little or no support; an overwhelmingly female army who grew up grateful for the welfare state and expectant of it doing good. There are over four million carers of working age in the UK – 57% of them are women. One in five carers gives up work to care. They know that the social care system doesn’t work. They also know that community based health support is not keeping up with demand.
There have been many high profile reports into the inadequacy of social care and primary and community care but no agreement on the model of health and social care for how we live now.
Today’s experiences are of families left to do the caring with little support; of those once grateful for the NHS but now experiencing poor GP access; of long waits on trolleys in A&E; of a lack of local or national accountability for decisions; of poor use of technology; of austerity and reduced funding to local authorities and the NHS; and of zero hours contracts and low wages in the care sector too.
All have come together in a perfect storm – to force a debate about the future.
The NHS of the future
I believe that our NHS of the future must address three core issues. It must:
- be accountable & democratic,
- prevent disease, and
- treat the whole person.
Accountability & Democracy
We can’t ask the public to pay more without going through the transition to an illness preventing system and we can’t just ask them as part of a general election campaign every five years. We have to think about how we make decisions about the allocation of resources, having accepted that the market doesn’t work and centralised planning does not work.
But we can take inspiration from recent events in Scotland. When people are motivated by something they care about, and impacts on them, they will engage and decide how they wish to governed.
It is time we started to give the people who love the NHS, who pay for it as equal to the professionals that have run it, some power in how it is run.
Patients should have better access to their records. There should be much greater shared decision making on treatment. And we must harness the energy and innovation in our communities. We need to see patients as an asset to draw on, not as nuisances.
The change we need is being held back by the undemocratic decision making processes and influence of vested interests. Although health authorities and Primary Care Trusts were local, they were accountable to Whitehall. To compound this, clinicians look to their professional bodies for accreditation and development, whilst managers are protected from local democracy. NHS careers are advanced by and within national professional bodies.
Following the Health and Social Care Act no one inside or outside the NHS knows who is accountable for the service.
Who does make difficult decisions on planning and resource allocation? Does anyone know?
We need to look at what works well elsewhere. The truth is that local government has a good history of making difficult decisions involving the public.
It is not a popular view in the NHS but I believe we will never get the sort of reforms we need without linking to local government. The Health and Well Being Boards set up under the Act are not functioning well but there is an opportunity here — they are well positioned to make use of the best parts of the local government experience.
The Black report and successive public health reports clearly set out the priorities towards tackling inequalities in public health and Labour did a lot in government. The Black Report had 3 objectives underpinning its recommendations:
The first was to give children a better start in life. That’s why Labour launched Sure Start, providing parental support and early education, often in the poorest areas.
The second was to encourage good health among a larger proportion of the population by preventive and educational action. It is why Labour banned smoking in public places, put healthy eating onto the curriculum, and invested in public health in our communities.
And the third was to help people with a disability, reduce the risks of their early death, and improve their quality of life in the then large institutions.
By the vigorous pursuit of these three objectives inequalities in health can be reduced.
Since the Black report we have also learned the impact of income and wealth inequality on health. The impact of reducing health inequalities does not only affect the more vulnerable. The Marmot review, in 2010, estimated an annual cost of health inequalities as being between £36 billion and £40 billion through lost taxes, welfare benefits and cost to the NHS. Amongst the challenges for politicians is to communicate the interdependence of the whole population on disease prevention.
Treating the whole person
The new system has to look at an individual’s mental, physical and social needs. The system has to be located in communities and has to extend to those who are supporting those in need. The core vision of whole person care poses some fundamental questions about;
- What is a social care need?
- What support is defined as ‘social services’?
- What will be defined as social care cost?
We need to be clear at a national level about entitlement to health and social care — about a National Care service. But we should also encourage and support innovation and collaboration at a local level to deliver a better integrated service.
There will be no top down imposition from a Labour government. There doesn’t need to be. We are already evolving towards different provider and commissioning models in different parts of the country. Every month sees a change in functions between the fragmented parts of the system.
This is the reorganisation that never ends.
We have to stabilise the system and we must unleash the innovation and power that is located in ourselves. It will take a long time but Labour has opened the political debate acknowledging the system needs more money and a refocusing on the whole person. It’s a debate that’s been had for years largely away from the political world. Now it is the time to bring that debate into mainstream discourse, which I am very much looking forward to as a politician.
The NHS is a precious asset. It belongs to all of us. And we must all have a greater say in its future.