Those who listened to Andy Burnham’s Kings Fund speech can only have been encouraged and even a bit excited – but remember it only becomes real if Labour wins the election and probably only if Andy is the Secretary of State.

The Ten Year Plan announced elsewhere is a political document as much concerned with bashing the Tories, making the mandatory bullet point pledges and pushing the usual buttons about management and bureaucracy and GP appointments and sheds little light on anything. In fact much of its tone and style is in direct conflict with the messages Andy Burnham sends out about building consensus around long term solutions. There is to be freedom over how things are done but a plan that sets out how many nurses are needed.

Anyway so far as I can see nobody at the Kings Fund disagreed with the vison for whole person care and service integration that Andy described so well; even Reform agreed!

A few key points show the approach fits well with much of what the SHA has advocated:

  • Taking a long term view; being clear on what the long terms aims are
  • Secretary of State accountable for the whole system with powers to intervene
  • Looking at the system as a whole nationally and locally
  • Ending enforced competition; introducing preferred provider and a predominantly publicly provided system
  • More staff, better paid and more opportunities and incentives for recruitment and training of staff
  • New approach to care staff and to the allied professions
  • More care closer to home and out-of-hospital when appropriate
  • Better defined role for voluntary sector and support for it when it adds value and capacity
  • A rights approach backed up by an effective Constitution – not post code lotteries
  • Nationally determined entitlement (what) locally deliver (how)
  • Moves to integrated commissioning – single budget with democratic accountability for the major decisions
  • Using existing structure but making them work in different ways – no top down reorganisation
  • Move to integrated provision through lead provider, accountable care organisation, integrated care organisations or whatever else works – but led by public provider.

This is a sound and credible set of ideas and over time would deliver both stability and worthwhile improvements in the quality of care and wellbeing.  It is brave enough to challenge long established barriers and obstacles to change.

The biggest issue is of course the money.  The injections of an additional £2.5bn early on will help of course but may not even be enough to deal with the crisis in social care let alone do anything as regards healthcare.  And there is an impending winter crisis to be bought off.

Let’s be honest.  Even with quite heroic assumptions about efficiencies and productivity within the NHS funding for care will have to increase at a rate above inflation and almost certainly above the rate of GDP growth, for the whole ten years! And that is what all the (respected) commentators are telling us.  The percentage of care costs to GDP has to increase and so we have to find ways to achieve this with the SHA strongly behind increases in progressive general taxation.

The costs savings touched on in the Ten Year Plan are made to sound huge but were tiny in comparison to the scale of the gap.

More problematic is that the suggestion that integration of care brings savings is more about faith than evidence; better identification of problems and better management of these might drive up ‘demand’ and so costs.  With staff numbers increasing and pay and conditions improving it is hard to see where savings are going to come from.

There are still a few other major issues to be worked on – but there is time for that:

  • How do CCGs merge into the wider commissioning structure?
  • Will CCGs walk away rather than engage with local authorities?
  • Can Local Authorities and Health and Well being Boards really rise to the new challenges?
  • What to do with Monitor? CQC? Healthwatch?
  • How do we develop the new methods of funding?
  • What do we do about the 20 off ‘failing’ localities – just more money?
  • Do we keep Foundation Trusts and what about non FTs?
  • Do we allow Better Care Fund to continue?
  • What about personal budgets?
  • Can politicians ever really devolve power?
  • How do we get the necessary IT systems?
  • What role for community development?
  • Etc

Long way to go, lucky it’s a ten year plan.  More important might have to be a 10 day plan to get over the major challenges presented by a system in crisis.

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  1. 28 January 2015

    Dear Socialist Health
    I applaud Andy Burnham.
    Rosemary Cantwell

  2. bhfisher says:

    Savings, no. But there are quite a few things that can increase capacity. Intelligent application of online patient record access, for instance, could save 10% of GP practice appointments and 100s of telephone calls a year. The Greenwich experience suggests that intensive support for ill people at home can significantly reduce hospital demand – though I don’t know whether that overall has saved money.

    I agree that there is little evidence that community-based care is cheaper.

    And I think we MUST now make the case that, as a default, we do not endorse bed closures, except in exceptional cases with good clinical evidence. We don’t, after all, need TB sanatoria any more – clinical needs change There are fewer hospital beds in the NHS than elsewhere in Europe and they are running at something like 90% capacity all the time which is almost certainly unsafe.

    1. Irwin says:

      Who is suggesting bed closures?

  3. Simon Kirk says:

    All the right questions Irwin, thank you – especially the money (particularly in local government), especially the question of the quality of local government political leadership, and particularly whether a Secretary of State will, for the first time ever, resist initiative-itis. Two more for me too: how can repeal of the current Act not result in reorganisation, and what’s the mechanism for legitimate national strategic direction going to be?

    1. Irwin says:

      Good questions. Think the changes can be made without major top down reorganisation but with changes in roles and accountabilities – depends on how you define reorganisation., But it wont be directed from above, it wont be across whole system on one day and structures for oversight, commissioning and providing will evolve locally given enough time. Places like Manchester are already setting out how it could be done.
      Strategic direction harder to answer especially if strong localities do emerge to rival the centre; one for more work.

  4. “Moves to integrated commissioning” – single budget with democratic accountability for the major decisions

    Doesn’t this scream from the rooftops, We are selling NHS services, doesn’t that mean more not less fragmentation, but of course they are calling it joined up care, so it can’t be.

    I really do think people need to look at what they are actually planning and not what you think they are.

    Start asking what it all means before you get into bed with this.

    Or do New Labour supporters not care who delivers the care services that we have seen so dramatically fail?

  5. mike.roberts says:

    Since the three of us from the SHA Richard, Brian and myself ( who was Irwin?) were at the launch of the 10 year strategy we’ve had the usual right wing Sainsbury Group members with vested interests ( Its about time Alan Milburn’s highly paid flirtation with the private sector was not glossed over) coming out and saying that tis all too difficult and we need more unresponsive and regulated private sector cherry picking.

    We’ve all seen where that has gone and even Andy said that we have had enough experience to confirm that this approach does not work.

    He also referred to new structures on an even balanced bias for staff in NHS and Social Care rather than crude integration not forgetting mental health, public health and I would say the importance of relating health to planning, Transport, environment communities ( health inequalities)and the main stream policies.

    I think now the time is right to make sure that those whose day has gone without the lead singer playing in the band should just go away and let the rest of us get on with the real world issues and those we need to respond to..

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