The key challenges for care are:-

  • the level of funding is inadequate
  • not enough is done on primary prevention, social determinants of health and inequalities compared to remedial care
  • waits are too long especially for diagnostics
  • the outcomes from the system are not good enough
  • the variation in outcomes is unacceptably large
  • our experience of care is often poor in both health and social care
  •  provision of care is not joined up around the needs of individuals
  • not enough is achieved in terms of reducing inequalities
  • care is still in silos (acute, primary, social, mental health etc)
  • focus on the individual, little concern with populations or community
  • poor accountability

Root causes of key issues are:-

The level of funding is inadequate

  • magic solutions do not work
  • needs investment to enable changes
  • needs higher level of revenue funding in both social care and health
  • inefficiencies through fragmentation

Not enough is done on primary prevention compared to remedial care

  • Clinical culture focued on interventions
  • No tradition of focus on population health and poor evidence base
  • We are an individualist society and getting more so.

Waits are too long especially for diagnostics

  • Poor management of the workflow
  • Inadequate investment in people, systems and admin

The outcomes from the system are not good enough

  • Inadequate useful data to clinicians which is then used to encourage better practice
  • Inadequate inspiration by leaders and the system
  • Inadequate peer competition
  • General practice not interventionist enough
  • Inadequate funding in some areas
  • The UK population has poor health literacy and knowledge

The variation in outcomes is unacceptably large

  • General practice is poorly managed and poorly organised
  • Lack of effective role for Royal Colleges in publishing and enforcing standards
  • Lack of commitment to collect/publish high quality comparative data

Our experience of care is often poor

  • Chronic underfunding of social care and resulting poor quality of workforce
  • Little shared decision-making or for self-care
  • Inadequate respect as a patient
  • Admin across the NHS for non-urgent care is poor
  • Clinicians are not interested or familiar in responding to patient experience

Provision of care is not joined up around the needs of individuals.

  • Although the NHS is a single system, silos around power bases remain
  • Inadequate records, poorly coordinated records and patients don’t yet have access to their information
  • Little research and guidelines
  • Differentiated provider bodies and royal colleges
  • Separation of a means tested social care system
  • GPs as small businesses
  • Fragmentation caused by H&SC Act
  • NHS separate from rest of public services

Mental and physical health are split, intellectually and functionally

  • A Cartesian system
  • A historic divide
  • Different nurse training in the two sets of hospitals
  • Few liaison psychiatrists, even fewer in paediatrics
  • Difficulty in doing diagnostics in mental hospitals
  • Difficult responding to recurrent problems with no diagnosis

A frightened and bullied and multiply inspected NHS

  • Stressful work and defensive attitudes
  • A hero culture, little support for clinicians
  • A legalistic approach to failure
  • The simplest response to failure is to inspect rather than find causes and holistic responses
  • Little trust across the system
  • Little experience or trust in formative processes outside general practice.

Poor accountability

  • NHS has never had any democratic accountability
  • Hostility of professions to Shared Decision Making and Community Development
  • Cultural divide between health as bureaucracy and social care as democratic accountability
  • Public distrust of elected representatives
  • poor quality of some elected representatives; lack of training and development.


Increase Resources in Health and Social Care

  • £2bn into transformation fund
  • settle pay disputes
  • increase funding into social care
  • invest in development of councillors, governors, senior managers in care system
  • invest in community development and PPI
  • take strategic control over capital spending and asset management
  • remove role of competition authorities
  • stop competition in the NHS
  • new funding scheme – to channel most funding through LAs based on weighted capitation set up a transformation fund
  • Challenge Treasury on the drive to austerity
  • centralise major property management (eg PFIs)
  • renegotiate PFIs
  • Begin reverse PFI for redundant land, working Has to lease it out and gain substantial profits

Primary prevention, the social determinants, reducing inequalities

  • Boost Public health (how?)
  • Promote community development
  • Introduce in training for all community staff and all clinicians
  • Assurance and inspection regimes insist that this is a vital focus
  • HWBs to become the commissioners
  • Harness the Social Value Act
  • A Living Wage

More focus on communities

  • Community development throughout primary care
  • A stronger PH focus
  • A clear evidence base
  • Community reps on Boards and on all key commissioner committees


  • Use modelling
  • Improve management
  • More staff
  • Online booking and customer management systems
  • Invest in diagnostics

Outcomes and variation

  • Improve role of Royal Colleges in publishing and enforcing standards
  • collect/publish high quality comparative data
  • peer competition
  • NICE to focus more on multimorbidity
  • Invest in diagnostics
  • Restart the National Service Framework approach
  • Performance manage primary care, with a more formative approach than now.

Poor Experience of care

  • Patient experience outcomes as part of performance measurement
  • Training for all clinicians in promoting shared decision-making and self-care through techniques such as motivational interviewing
  • Making available and in all clinicians’ consciousness techniques that encourage SDM/SC, such as record access, decision aids, patient agenda setting, group appointments
  • Reduce waits through more staff, far more use of IT, more diagnostics, modelling, buddying poor performers with better ones, comparing performance publically.
  • Improve admin through shared electronic records, tripadvisor feedback, more staff.
  • plan to bring social care staff into A4C
  • consult on new workforce planning system
  • support staff through systems such as Schwartz rounds

Siloed care

  • remove role of competition authorities
  • remove payment by results payment and replace with a range of options that could be trialled, based on success in other countries
  • rebuild and invest in partnership structures (like SPF)
  • repeal HASCA
  • social care free at the point of use, eventually, starting with palliative care.
  • Commissioning through HWBs, then through LAs – will need significant boost to existing HWBs.
  • Community development supported to integrate statutory services from the ground up

Mental and physical health are split

  • Nurses to have physical health training
  • More liaison psychiatrists, including in paediatrics
  • ??

A frightened workforce

  • Formative assessments
  • Dismantle much of the inspection regime
  • Support staff through Schwartz rounds and similar interventions
  • Either make all hospitals FTs or get rid of the FT concept (my preference) while keeping the PPI aspects
  • Remove failure regimes
  • No competition in the system except for peer competition
  • NSFs
  • Social care staff into A4C

Poor accountability

  • Assume participatory and representative democracy
  • move to a rights based approach to entitlement
  • community development throughout primary care
  • lay people in all key committees in commissioning organisations
  • improve the FT-type structures and include in all commissioning organisations
  • remove competition and marketization in the NHS, thus almost removing the corporate influence
  • democratically accountable commissioners
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