Category Archives: SHA policy

These posts are discussions of policies that have not – or had not when posted – been adopted as our policy.

The SHA is committed to NHS care, free at the point of use and funded out of general taxation, provided by public bodies. We challenge austerity which we agree is a political choice not an economic necessity.

We recognise that the devolved nations make their own policies. These draft policies apply mainly to England.

A NATIONAL HEALTH AND CARE SERVICE

We call on Labour to bring together our separate health and social care systems to become one unified care system driven by the political values and professional / organisational principles that underpin the NHS. This can be achieved by a gradual, non-disruptive process.

The political values needed are:

  • a system with national standards;

  • funded from progressive taxation;

  • delivered by locally accountable bodies that rely on committed staff many of whom have professional training and professionally established responsibilities;

  • evidence based policies
  • relying on the notion of “co-production” between service users and professional staff – people playing an active role in their care and professionals welcoming, respecting and responding to that role.

We call on Labour to adequately fund the National Health and Care Service, reaching the upper quartile of EU average spend, so that it provides a comprehensive service.

Discussion paper on NHS Governance

AN END TO PRIVATISATION

We call on Labour to restore the duty of the Secretary of State to deliver a comprehensive, universal, publicly provided and managed NHS, meeting clinical need, free at the point of use and funded out of general taxation, provided by public bodies. This needs to be achieved with as little disruption as possible. 

The SHA wants to eliminate the private sector except in exceptional and transient circumstances. This needs to be achieved with as little disruption as possible.

The NHS Bill 2016-17 provides a model for legislation in the first weeks of a Labour Government. Legislation should include the relief of NHS bodies from PFI debt.

Commissioning will be replaced by planning, based on needs and assets assessment.  Wales and Scotland offer excellent examples. Planning must be separate from provision and free of any form of conflict of interest or undue influence. Planning functions must be democratically accountable and cannot be given to the private sector under any circumstances.

The NHS will no longer regard Foundation Trusts as free-standing competitive corporations. Foundation Trusts will be reintegrated into the NHS family.

New Models of Care

The NHS England Accountable Care System has created 44+ local health services to replace England’s NHS, bypassing Parliamentary debate. Accountable Care Systems will provide limited services on restricted budgets. We can already see the effects of such austerity, with the long term increase in life expectancy stalled since 2010.  These New Models of Care and the government’s NHS asset sell-off result directly from the 5 Year Forward View currently being implemented via ‘Sustainability and Transformation Partnerships’. We therefore call on the Party to reject the 5 Year Forward View in its totality.

SHA supports the commitment to restore our NHS by reversing privatisation and halting Sustainability and Transformation Partnerships. This demands more than amending the 2012 Health & Social Care Act; we must restore our fully-funded, comprehensive, universal, publicly-provided and owned NHS without user charges, using the NHS Bill (2016-17) as a legislative starting point.

Discussion document on Enduring Aims and Principles

ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH

Addressing the social determinants of health is the foundation for health and wellbeing. Access to clean water and safe waste disposal; social and affordable housing which provides enough space, affordable and efficient heating; clean air, indoors and outdoors; good education to achieve universal literacy and numeracy; jobs that protect health and ensure adequate income; and an environment which promotes healthy transport, green spaces and public amenities should all become elements in a holistic approach to public health.

We support the child poverty abolition target for 2020.

This has implications for the public health service:

  • Chief Medical Officers and District Directors of Public Health need to be professionally independent, reporting annually on the health and health inequalities of their populations and their recommendations on priorities.

  • Communities and our relationships with them and between them and the statutory sector are key to health protection and resilience. The SHA is committed to creating the conditions whereby communities can increasingly share decisions with the statutory sector, thereby increasing confidence and health.

SOCIAL CARE AND INDEPENDENCE

Savage cuts have resulted in about 40% fewer people receiving social care now than in 2009, with severe cuts in other local support services. The human rights of disabled and older people have been ignored. The current system is out-of-date in its assumptions about what disabled and older people want and need and tends to reinforce negative images. Instead of respecting people as contributing citizens and family members, the system has adopted a wasteful consumerist ideology. Too often, in an over-pressurised service, patients and service users are not being treated with sufficient respect and dignity. This requires an end to the 15 minute social care packages.

We call for a new kind of social care, not more of the same.

The key principles for any future system of long term care must include:

  1. Universal coverage – The need for long-term care is part of the normal public sector services and should be treated just as health and education.

  1. Maximum risk-pooling – The most efficient way of insuring ourselves against the costs of impairment or frailty is to all pool resources in order to cover that risk, as with the NHS.

  2. Equity – The system should be equitable and should not discriminate against people because of condition, age or geography.

  3. Entitlement – All citizens should benefit from the system and should not be disadvantaged by income or ability to pay. The system should be funded from general taxation and be free at the point of use, as with the NHS.

  4. Control – All citizens should be able to get the right flexible support to meet their needs, to be able take the level of control that is right for them and their families.

The three key elements of the proposal are:

  1. Fund a universal system and end means-testing – Social care on the same footing as healthcare, funded from general taxation, with resources distributed on the basis of need, free at the point of need.
  2. Invest in citizenship and community – Social care must offer support that people and families can shape to their circumstances, and that helps people contribute as citizens and strengthens family and community life.

  3. End privatisation and the complexity of the current system – Social care must be integrated into one national system that invests resources locally and ends the wasteful procurement systems that currently undermine human rights.

These principles are in line with current developments across OECD countries.

Discussion document – Policy Proposal for Social Care

PRIMARY AND COMMUNITY CARE

It is still true that the availability of good medical care tends to vary inversely with the population’s need for it and this is particularly true in primary care.

The SHA is concerned that general practice under the Tories may go the way of dentistry, pharmacy and optometry, with co-payments becoming the norm. The SHA wants to eliminate the private sector except in exceptional and transient circumstances.

The SHA does not support GPs being responsible for planning although they must be centrally involved, alongside other key stakeholders.

The SHA wants to see improved access to primary care, with continuing personal care. This will require more clinicians and more and better use of IT. We sympathise with GPs’ frustration and agree that the government’s proposals for primary care are too little too late. We need a comprehensive new set of arrangements to support, incentivise and energise primary care.

Independent Contractor status

There are advantages and disadvantages to the independent contractor status of GPs. The SHA recommends a trial of a mixed economy, where in some areas primary care is salaried and in others as it is now, evaluating comparative benefits and risks.

Planning Primary Care

Primary care must be planned and managed rather than just administered which is the present predominant model. We recommend primary care workforce planning and joint multi-disciplinary training.

Integration

We should have a large-scale trial with a fully integrated provider which covers delivery of all primary, secondary, mental health and social care free at the point of use, for a single County or City.

We also recommend:

  • investment in treatment and prevention of mental health problems in children and young people,
  • a long-term plan for health promotion,
  • community-based home care treatment and prevention. This requires more District Nurses and Health Visitors, better paid and supported ,
  • Informal carers need to be fully supported. We support an increase for all carers’

THE MYTH OF THE DEMOGRAPHIC TIME-BOMB

The SHA rejects the concept that an ageing population results in unacceptably high costs. We are proud to have an increasing number of older people whom we value. Older people have falling mortality, less morbidity, and are more economically active than before. Some forms of disability are postponed to later years. Increased life expectancy means more years lived in good health.

Older people contribute almost £40 billion more to the UK economy annually than they receive in state pensions, welfare and health services. It is not age but nearness to death that accounts for health expenditure. Most acute medical care costs occur in the final months of life, the age at which these occur having little effect. According  to European research, health expenditure on older age groups is high because a larger percentage of people in those age cohorts die within a short period of time.

The SHA therefore wishes to see an evidence-based discussion on policies for a healthy ageing population, as part of developing the National Health and Care Service.

Discussion document on Primary And Community Care And The Myth Of The Demographic Time-Bomb

MENTAL HEALTH

Mental Health services see demand increasing by 5-10% for adults over the last 3-4 years, and by 30-40% for children and young people. There are delays accessing care partly because of worsening shortages of staff.

The SHA recognises that societal factors impact on mental wellbeing and illness. These include social deprivation, debt, poor accommodation and security of tenure, inadequate community and family support networks. Socio-economic inequalities have independent impacts: being judged socially inferior has negative effects on physical and mental health, even for those illnesses with a genetic component. We need to promote a social model of care rather the narrow medical model which is particularly unsuited to mental health and addiction services.

The SHA supports implementation of the Five Year Forward View for Mental Health, including parity of funding for prevention and treatment, research into treatments and alternatives to medication, with funding for related social care. We support the Manifesto’s ring fenced mental health budget.

We also recommend:

  1. A National Service Framework for Mental Health provision, with an emphasis on talking therapies and advocacy.

  2. Enhanced mental health services for children and young people, including school-based prevention with more school nurses and health visitors, ready access to CAMHS and better and more inpatient provision.

  3. A strategy for reduction of excess mortality rates for people with serious mental illness including suicide prevention strategies, with improved provision for acute MH emergencies including supporting friends and families. 

  4. Reducing stigma with more information about mental illness,how to self help and early intervention.

Discussion document on Mental Health Policy

DEMOCRATIC, ACCOUNTABLE AND TRANSPARENT HEALTHCARE

The SHA recommends a commitment to responding not only to needs as defined by clinicians, but needs as defined by users, carers and citizens. We see the process as a meeting of experts: the NHS offers its clinical expertise, while the patient is an expert on their own strengths and the impact of ill-health.

Working with NHS users applies at a macro level (planning local and national NHS services in collaboration with citizens and users) and at an individual level in the consultation between patient and clinician with shared decision-making. The community can, with help, identify key issues that matter to them and work with the statutory sector to address those issues – this process protects health. Community development is one key mechanism.

We would like to see a totally independent patient- and public-led and adequately funded Community Health Council type system.

Discussion document on the Organisation Of Health And Care Services

BREXIT AND THE NHS AND CARE SERVICE

The NHS and social care are dependent on overseas labour. We would like to see recruitment and employment of staff from the EU and other countries allowed. We want Labour’s policy on Brexit to focus on the economy and free movement.

EU law includes measures to achieve equivalence of labour, health and safety standards in its trade agreements with countries such as Vietnam and Peru. The European Court of Justice has consistently emphasised a high level of human health in its judgements and it is notable that in its negotiating position on the Transatlantic Trade and Investment Partnership, the European Union was arguing for a judicial model of dispute resolution. There is a real danger that these protections will be lost through Brexit. Indeed, the main justification for many of those advocating Brexit is to remove these protections.

Discussion document on International Trade

2 Comments

We call for protection of women’s rights:

  • Guaranteeing family friendly employment terms and conditions affecting morale, recruitment retention of women including Lesbian, Gay, Bisexual and Transgender people.
  • Fertility control In Vitro Fertilisation, contraception and abortion access: thus protecting women’s mental health, finances and family stability
  • Safe childbirth for every woman. Risk assessment for home births (evidence of deaths increasing)
  • Reverse the outsourcing of maternity services.
  • Increased support for carers, to improve health and protect people from poverty.
  • Integrate the care system with the National Health Service to be free at the point of use, paid for by taxation.
  • Employ nurses in care homes and improve training and terms for care workers.

Equality:

We call for protection of women’s rights with respect to equality which addresses:

  • the long-term impact of domestic abuse, in the widest context, on health
  • the impact of gynaecological intervention that harms women internally e.g. mesh implants and externally e.g. Female Genital Mutilation.
  • the impact of caring on mothers of children who have specific and higher needs over their lifetime
  • the effect on women refugees and European Union migrants of the new United Kingdom Comprehensive Sickness Insurance regulations involving healthcare charging
  • the quality of and accessibility to women’s mental health services, including primary post-partum treatments.

This is to be presented to the Labour Party Women’s Conference 2017

Tagged | Leave a comment

This is a draft programme drawn up by the SHA. It remains under development and does not yet represent our final set of recommendations. However, it follows much work and consultation and we see this as a conversation with our members, the party and the public. We want and expect that such discussions will change aspects of this document and we welcome that debate. We shall be holding a workshop on Public Health which will feed in to this work.

We want to present conference with a challenging set of practical and theoretical ideas. They are summarised here, but there is further detail on our website.

Please respond by commenting below  or contact us directly at Conference:

Alex Scott-Samuel;  Brian FisherMartin Rathfelder;  Jean Hardiman Smith

INTRODUCTION

The SHA is committed to NHS care, free at the point of use and funded out of general taxation, provided by public bodies. We challenge austerity which we agree is a political choice not an economic necessity.

We recognise that the devolved nations make their own policies. These draft policies apply mainly to England.

This summary is divided into the following sections:

A NATIONAL HEALTH AND CARE SERVICE (NHCS)

Bringing together our separate health and social care systems to become one unified care system driven by the political values and professional / organisational principles that underpin the NHS. This can be achieved by a gradual, non-disruptive process.

The political values needed are:

  • a system with national standards;
  • funded from progressive taxation;
  • delivered by locally accountable bodies that rely on committed staff many of whom have professional training and professionally established responsibilities;
  • evidence based; relies on the notion of “co-production” between service users and professional staff – people playing an active role in their care and professionals welcoming, respecting and responding to that role.

We call on Labour to fund the NHCS to enable a comprehensive service, reaching the upper quartile of EU average spend.

More details can be found here

AN END TO PRIVATISATION

We call on Labour to restore the duty of the Secretary of State to deliver a comprehensive, universal, publicly provided and managed NHS, meeting clinical need, free at the point of use and funded out of general taxation, provided by public bodies. This needs to be achieved with as little disruption as possible. The NHS Bill 2016-17 provides a model for legislation in the first weeks of a Labour Government. Legislation should include the relief of NHS bodies from PFI debt.

This has implications for what is currently called commissioning.

Commissioning outside the market is called planning, based on needs and assets assessment. Wales and Scotland offer excellent examples. Commissioning/planning must be separate from provision and free of any form of conflict of interest or undue influence. Planning functions must be democratically accountable and cannot be given to the private sector under any circumstances.

It also has implications for Trust status:

The NHS will no longer regard Foundation Trusts as free-standing competitive corporations. Foundation Trusts will be reintegrated into the NHS family.

New Models of Care

The NHS England Accountable Care System creates 44+ local health services to replace England’s NHS, bypassing Parliamentary debate. Accountable Care Systems will provide limited services on restricted budgets, worsening health indicators like the long term increase in life expectancy, stalled since 2010. These New Models of Care and the government’s NHS asset sell-off result directly from the 5 Year Forward View currently being implemented via ‘Sustainability and Transformation Partnerships’.  

SHA supports the commitment to restore our NHS by reversing privatisation and halting Sustainability and Transformation Partnerships. We therefore call on the Party to reject the 5 Year Forward Viewin its totality. This demands more than amending the 2012 Health & Social Care Act; we must restore our fully-funded, comprehensive, universal, publicly-provided and owned NHS without user charges, as per the NHS Bill (2016-17).

More details can be found here.

ADDRESSING THE SOCIAL DETERMINANTS OF HEALTH

Addressing the social determinants of health is the foundation for health and wellbeing. Access to clean water and safe waste disposal; social and affordable housing which provides enough space, affordable and efficient heating; clean air, indoors and outdoors; good education to achieve universal literacy and numeracy; jobs that protect health and ensure adequate income; and an environment which promotes healthy transport, green spaces and public amenities should all become elements in a holistic approach to public health. We support the child poverty abolition target for 2020.

This has implications for the public health service:

  • Chief Medical Officers and District Directors of Public Health need to be professionally independent, reporting annually on the health and health inequalities of their populations and their recommendations on priorities.
  • Communities and our relationships with them and between them and the statutory sector are key to health protection and resilience. The SHA is committed to creating the conditions whereby communities can increasingly share decisions with the statutory sector, thereby increasing confidence and health.

More detail can be found here

SOCIAL CARE AND INDEPENDENCE

Savage cuts have resulted in about 40% fewer people receiving social care now than in 2009, with severe cuts in other local support services. The human rights of disabled and older people have been ignored. The current system is out-of-date in its assumptions about what disabled and older people want and need and tends to reinforce negative images. Instead of respecting people as contributing citizens and family members, the system has adopted a wasteful consumerist ideology. Too often, in an over-pressurised service, patients and service users are not being treated with sufficient respect and dignity. This should include an end to the 15 minute social care packages.

We call for a new kind of social care, not more of the same.

The key principles for any future system of long term care must include:

  1. Universal coverage – The need for long-term care is part of the normal public sector services and should be treated just as health and education.
  1. Maximum risk-pooling – The most efficient way of insuring ourselves against the costs of impairment or frailty is to all pool resources in order to cover that risk, as with the NHS.
  2. Equity – The system should be equitable and should not discriminate against people because of condition, age or geography.
  3. Entitlement – All citizens should benefit from the system and should not be disadvantaged by income or ability to pay. The system should be funded from general taxation and be free at the point of use, as with the NHS.
  4. Control – All citizens should be able to get the right flexible support to meet their needs, to be able take the level of control that is right for them and their families.

The three key elements of the proposal are:

  1. Fund a universal system and end means-testing – Social care on the same footing as healthcare, funded from general taxation, with resources distributed on the basis of need.
  2. Invest in citizenship and community – Social care must offer support that people and families can shape to their circumstances, and that helps people contribute as citizens and strengthens family and community life.
  3. End privatisation and the complexity of the current system – Social care must be integrated into one national system that invests resources locally and ends the wasteful procurement systems that currently undermine human rights.

These principles are in line with current developments across OECD countries. More detail can be found here.

PRIMARY AND COMMUNITY CARE

The SHA is concerned that general practice under the Tories may go the way of dentistry and optometry. The SHA wants to eliminate the private sector except in exceptional and transient circumstances.

The SHA does not support GPs being responsible for planning although they must be centrally involved, alongside other key stakeholders.

The SHA wants to see improved access to primary care, with continuing personal care. This will require more clinicians and more and better use of IT. We sympathise with GPs’ frustration and agree that the government’s proposals for primary care are too little too late. We need a comprehensive new set of arrangements to support, incentivise and energise primary care.

Independent Contractor status:

There are advantages and disadvantages to the independent contractor status. The SHA recommends a trial of a mixed economy, where in some areas primary care is salaried and in others as it is now, evaluating comparative benefits and risks.

Planning Primary Care

Primary care must be planned and managed rather than just administered which is the present predominant model. We recommend primary care workforce planning and joint multi-disciplinary training.

Integration

We should have a large-scale trial with a fully integrated provider which covers delivery of all primary, secondary, mental health and social care free at the point of use, for a single County or City.

We also recommend Investment in treatment and prevention of mental health problems in children and young people, a long-term plan for health promotion, community-based home care treatment and prevention. More District Nurses and Health Visitors, better paid and supported are essential, with Informal carers to be fully supported. We support an increase for all carers’ benefits.

The Myth Of The Demographic Time-Bomb

The SHA rejects the concept that an ageing population results in unacceptably high costs. We are proud to have an increasing number of older people whom we value. Older people have falling mortality, less morbidity, and are more economically active than before. Some forms of disability are postponed to later years. Increased life expectancy means more years lived in good health.

Older people contribute almost £40 billion more to the UK economy annually than they receive in state pensions, welfare and health services. It is not age but nearness to death that accounts for health expenditure. Most acute medical care costs occur in the final months of life, the age at which these occur having little effect. According to this hypothesis health expenditure on older age groups is high because a larger percentage of people in those age cohorts die within a short period of time.

More detail can be found here 

MENTAL HEALTH

Mental Health (MH) services are “overwhelmed” (NHS Providers July 2017, ref 1), with demand increasing by 5-10% over the last 3-4 years, and by 30-40% for children and young people, with delays accessing MH care, often with inadequate treatment, partly because of worsening shortages of MH staff.

The SHA recognises that societal factors impact on mental wellbeing and illness. These include social deprivation, debt, poor accommodation and security of tenure, community and family support networks. Socio-economic inequalities have independent impacts: being judged socially inferior has negative effects on physical and mental health, even for those illnesses with a genetic component.

We need to promote a social model of care rather the narrow medical model which is particularly unsuited to mental health and addiction services.

The SHA supports implementation of the ‘Five Year Forward View for Mental Health’ (Feb 2017), including parity of funding for prevention and treatment, research into treatments and alternatives to medication, with funding for related social care. We support the Manifesto’s ring fenced mental health budget.

We also recommend:

  1. A National Service Framework for Mental Health provision, with an emphasis on talking therapies and advocacy.
  2. Enhanced MH services for children and young people, including school-based prevention with more school nurses and health visitors, ready access to CAMHS and better and more inpatient provision.
  3. A strategy for reduction of excess mortality rates for people with serious mental illness including suicide prevention strategies, with improved provision for acute MH emergencies including supporting friends and families. 
  4. Reducing stigma with more information about mental illness / how to self help / early intervention.

More detail can be found here 

DEMOCRATIC, ACCOUNTABLE AND TRANSPARENT HEALTHCARE

The SHA recommends a commitment to responding not only to needs as defined by clinicians, but needs as defined by users, carers and citizens. We see the process as a meeting of experts: the NHS offers its clinical expertise, while the patient is an expert on their own strengths and the impact of ill-health.

Working with NHS users applies at a macro level (planning local and national NHS services in collaboration with citizens and users) and at an individual level in the consultation between patient and clinician with shared decision-making.

The community can, with help, identify key issues that matter to them and work with the statutory sector to address those issues – this process protects health. Community development is one key mechanism.

Ensure a totally independent patient and public led and adequately funded Community Health Council type system.

More detail can be found here 

BREXIT AND THE NHS AND CARE SERVICE

The NHS and social care are dependent on overseas labour. We would like to see recruitment and employment of staff from the EU and other countries allowed. We want Labour’s policy on Brexit to focus on the economy and free movement.

EU law includes measures to achieve equivalence of labour, health and safety standards in its trade agreements with countries such as Vietnam and Peru. The European Court of Justice has consistently emphasised a high level of human health in its judgements and it is notable that in its negotiating position on the Transatlantic Trade and Investment Partnership, the European Union was arguing for a judicial model of dispute resolution. There is a real danger that these protections will be lost through Brexit. Indeed, the main justification for many of those advocating Brexit is to remove these protections.

More detail can be found here

Acknowledgements

Thanks to all members of the SHA Policy Commission and many other members of the SHA who have worked so hard to put this document together. We look forward to continued discussion and change.

4 Comments

This is a discussion document not agreed policy.

All NHS bodies must be under clear obligations and duties:

  • To work to reduce inequality
  • To cooperate with other public bodies
  • To promote shared decision making and community development
  • To be open and transparent and to involve public and patients in all major decisions and plans.
  • Mergers and other organisational changes should be subject only to local agreement.
  • NHS bodies should have boards of directors with a majority of NEDs and governing bodies set up to reflect a balance between patients, public, staff and other local stakeholders.
  • The procurement and contract management of major assets should be the responsibility of the Secretary of State with NHS Bodies subject to an appropriate reasonable internal charge for use.
  • We require national standards, national service frameworks, national outcomes frameworks and inspection and regulation on a national basis; and national terms and conditions to allow staff to move easily within the NHS. We already have national systems for collection of data and an obligation on all providers to supply that information.

Accountability and Transparency

  • The SHA supports patient choice and greater involvement by patients in their own treatment. This is not choice as a market mechanism and there may be some limits in the interest of overall efficiency predicated on patients / citizens / public responsibility.
  • Co-production is the process of working with NHS users. This applies at a macro level, planning local and national NHS services in collaboration with citizens and users; it also applies at an individual level in the consultation between patient and clinician where shared decision-making takes place. Care must be delivered with as much participation in shared decision-making as the patient wishes at the time.
  • The NHS must commit, therefore, to both listening AND RESPONDING to citizens and using adequate mechanisms for this.
  • We therefore commit to responding not only to needs as defined by clinicians, but needs as defined by users and citizens. We see the process as a meeting of experts – the NHS offers its clinical expertise. The patient is an expert on their own strengths – and the impact of ill-health on them. The community can, with help, identify key issues that matter to them and work with the statutory sector to address those issues – evidence shows that this process protects health.
  • Ensure an independent and adequately funded Healthwatch and comparable bodies in Wales, Scotland and NI.
  • Community development and community development workers will be supported and funded to increase communities’ input into planning and to increase the responsiveness of NHS organisations.
  • Such a systematic approach at individual and collective levels will require the development of processes such as:
    • Decision Aids
    • Full Record Access to primary, secondary and social care
    • Group appointments
    • Rapid feedback of users’ views to health and care organisations
    • Community development
    • Patient and community views of responsiveness and experience of services should become routine outcome measures for NHS performance
    • NHS organisations must demonstrate the changes in planning that they have made in response to individual and community recommendations
  • There will be appropriate training and workforce delivery to ensure effective individual and community participation
  • There will be an NHS-wide volunteering policy with appropriate support and payment.
  • Values important to patients like dignity and respect should be demonstrated in every service provided.  This should be informed by widely available and meaningful information about the performance of and outcomes from health care services, local and national.

APPENDIX

The current NHS has three “domains” that have to work together. These are the political domain, the professional domain and the managerial domain. Some writers on management in the public services claim that these three domains are necessarily in a state of conflict with – at any one time – two domains aligned against the third. The political process decides which two challenge the third and on what.

The political domain mediates, through the political process, what the NHS is to deliver (and what is isn’t). It is expected to exercise political oversight of how it performs – both at the national levels (England Scotland and Wales) and at the local level through the Board / Trust machinery acting on behalf of the Minister (or the head of the NHS in England). The political domain is largely driven by a 4-5 year cycle linked to the electoral calendars in the three countries. Devolution has complicated the frequency of elections and hence shortened the time horizons available to politicians in devolved systems. Politicians justify their legitimacy by reference to their mandate. Their aim is usually to deliver what they believe they can persuade enough of the electorate ( sometimes their share of the electorate) to accept. This means they operate to a political rationality.

The professional domain – doctors nurses etc – claim their legitimacy from “their” patients, whose interests they seek to represent. The professional domain can be divided between the different professions and often within professions (e.g. GPs v Consultants, surgeons v physicians). Their time horizon is much longer as often they seek engagement over decades if they are pursuing a career. Their rationality is based on science and experience – that is, they claim to know what “works” – and this is a different approach to that of the politician. The professions guard their professional rights closely in maintaining standards of, and controlling entry to, the profession.

The managerial domain seeks to find a unifying set of aims around which their discrete organisation can gather – using such techniques of short and medium term plans, change management and quality improvement, etc. Often the managerial domain will relate to the public by simply seeking to keep services running in the hope that it will deliver the best it can for the most it can. It’s rationality is the wider public service.

(You will note that the three domains each see “the public” in different ways and there is little agreement as to how the three domains different views of “the public” may be reconciled. Indeed, part of the analysis underpinning domain theory assumes that each domain will seek to get “the public” on its side – e.g as in the junior doctors dispute). How “the public” itself fits into the domains isn’t clear.

Managing the NHS and the wider care system – politically, managerially, and professionally – has been recognised as the most demanding of tasks. The NHS does not conform to the usual management approaches that apply in “normal” businesses – in part because its ownership and the values that drive it are unlike any other, and in part because demand seems infinite and resources are limited. Our political processes have found it difficult to match investment in the NHS with what that process can make available. Evidence of “what works” is frequently contested and good practice is still not regularly and readily imbedded across the organisation.

SHA believes that the political domain has to set out more clearly what it expects the NHS to deliver in terms of volumes and range of services. Moreover, it must make explicit what the service is not able to do. The political choices – once made – have to be defended through the political process, and the expected service levels have to be matched by human and financial resources agreed by the wider service as necessary to deliver the services promised. The political domain must not set targets unilaterally or offer resource levels that are incompatible with wished for outputs / outcomes

Professional domains must update professional standards as new services and care methods become available. They must increase their efforts – jointly – to spread best practice and support professionals who need further training or other help. SHA believes that the professions should play a full part in overseeing the delivery of care, ensuring (again jointly) that poor practice is recognised and steps taken on professional levels to rectify matters. Each profession has a duty to advise managers, politicians and the public on the resources needed to deliver safe services – especially for new and emerging therapies. Such advice should be soundly based and will be open to challenge by competent others.

The managerial domain in the NHS should operate to the highest Nolan standards. It should be placed on a professional basis, with a code of conduct that offers protection to its members should they be instructed to manage the service in an unsafe way. It should have a duty of co-operation placed upon it insofar as working with other managers operating in the public sector is concerned. Recognised management posts, such as Chief Executives, Directors of Nursing, and equivalent posts, should have a legal duty to report to Boards (in public) any concerns that they have about service demands and resources. Such reports should be privileged – i.e. their content shall not give rise to legal action by either their employee or any private party mentioned in such a report. The managerial profession should renew the competence of staff in senior grades on a four-yearly basis.

Tagged | Leave a comment

This is a draft policy not yet agreed.

Addressing the social determinants of health is an important foundation for the health and wellbeing of our citizens. The fundamentals of life such as access to clean water and safe waste disposal; housing which provides enough space, clean air and efficient heating; education to achieve universal literacy and numeracy; jobs that protect health and ensure adequate income; and an environment which promotes healthy transport, green spaces and public amenities should all be assessed and developed as a holistic approach to public health.

Local and national democratically accountable governments need to hold these strategic responsibilities and be supported by public health officers at Chief Medical Officer level in national governments and District Directors of Public Health at local government level. These officials need to be professionally independent chief officers and be required to report annually on the health of their populations with reference to other populations and assessing health inequalities and their recommendations on priorities.

Communities and our relationships with them and between them and the statutory sector are key to health protection and resilience. The SHA is committed to creating the conditions whereby communities can increasingly share decisions with the statutory sector, thereby increasing confidence and health.

  • The nation’s Chief Medical Officers (CMOs) will be required to report annually on the health of their populations to their governments. The UK CMOs will be required to submit an annual report directly to Parliament charting progress in UK comparative performance in terms of population health, health inputs, care processes and patient outcomes (both patient and clinician reported). Such a report will need to consider the UK health outcomes in an international context.
  • Directors of Public Health within local authorities should be adequately resourced executive directors able to make recommendations which must be integral to decision-making by the council’s chief officers.
  • Social care and other local authority provision and relevant services and proposed developments should be included in public health plans.
  • All local authority policies and plans should be subject to an environmental and health impact assessment.
  • All policies in government will be subject to an assessment of their impact on the public’s health.
  • Strategies and plans for wellbeing should be agreed at local, sub-regional and regional level and should be used to guide decisions about service provision, major investments and reconfigurations.
  • Infectious diseases require attention to high uptakes of vaccination and immunisation and the promotion of hand hygiene and the reduction in the use of antibiotics to help prevent the growth in antimicrobial resistance.
  • The public health remit must include promoting health, protecting health as well as effective (evidence based) health and social care. All these three domains of practice require robust systems of appraisal of evidence, systematically collated knowledge and information.

ENVIRONMENT/CLIMATE CHANGE

  • The NHS must maximise environmental sustainability and engage with the strategy that protects and improves health within environmental and social resources now and for future generations.
  • Such sustainability strategies mean reducing carbon emissions, minimizing waste and pollution, building resilience to climate change and nurturing community strengths. See separate section on sustainability and planetary public health (in preparation with David Pencheon of the NHS Sustainability Unit).

AIR QUALITY

  • We will take urgent steps to reduce the air pollution caused by road traffic, particularly by diesel engines.
  • We will reconsider strengthening the regulation of vehicles, taxation of vehicles and motor fuel in the light of the evidence of damage to health caused by particulates.
  • All this in the context of decreasing coal fired electricity generation and proportionately increasing the use of renewables.

FOOD AND DRINK

  • We will remove the VAT exemption from sugar and raise tax on the simple sugar content of drinks and foods such as breakfast cereals. 
  • We will ensure that the quantity of sugar, salt and fat in manufactured food is easily apparent to customers by standardised information in the form of WHO recommended traffic lights and standard information wherever it is sold.
  • We will ban the use of trans fats in food products and push for the ban to be extended internationally.
  • We will introduce minimum unit pricing for alcohol and encourage lower alcohol products.  We will reduce the hours during which supermarkets are permitted to sell alcohol and make it more difficult to buy dangerous quantities of alcohol.
  • The sale of tobacco and alcohol in supermarkets should be regulated so separate areas are identified to display and pay ensuring better supervision and differentiating alcohol and tobacco from a normal family shopping basket.
  • Tax should be proportionate to alcohol strength

HOUSING

  • We will introduce minimum standards for healthy housing construction to ensure sustainable housing quality and reduce the risk of adverse impacts such as fuel poverty through inefficient heating/insulation.
  • Internal ventilation is also required to reduce the risk of house dust, fumes to ensure clean air.
  • Housing should be located near green spaces and close to play ground amenities for children.

WORKFORCE

  • In conjunction with a strengthened Health and Safety Commission, we will introduce measures to ensure that workers feel more in control of their own work. Workers and their trade unions should be represented on company boards?
  • Occupational health will become a responsibility of the NHS to provide a national service with local generalist and more specialist regional resources.
  • A healthy workplace must be the expectation and employers be held to account on best practice and minimum standards in line with health (both physical and mental) and safety legislation.

DRUGS AND TOBACCO

  • The taxation system will make healthier products like fresh fruit and vegetables more affordable while making less healthy processed food products better regulated and relatively more expensive.
  • We will progressively raise tobacco tax and the age below which it is unlawful to supply tobacco to young people.
  • Personal, social and health education (PSHE) will be compulsory in schools appropriate to the age of the child and directed to inform and empower children to look after themselves. 
  • We will bring forward proposals to reform the law on misuse of drugs to minimise risk which will include alcohol, tobacco and other drugs.

TRANSPORT/ SPORT.

  • The Active Travel (Wales) Act 2013 will be extended to England so every local authority will be required to publish details of expenditure on transport measures divided between walking, cycling, public transport and motor vehicles.  
  • We will rebalance the transport budget so that 10% is spent consistently over the length of the parliament on the needs of pedestrians and cyclists
  • We will remove VAT from bicycles and encourage cycle to work and other workplace incentives.
  • We will progressively ensure access for all to affordable public transport
  • Physical activity should be encouraged in schools with whole school activities, travel to school schemes as well as specialist sports teaching.
  • All local authorities must introduce 20mph speed limits on all residential roads so this speed becomes the urban road norm.
  • Transport policies need to be strengthened so that city centres are largely free of private cars with access ensured by efficient public transport, cycle and pedestrian access.
  • Overall transport policies should be biased towards walking and cycling, bus and trains and vehicles that are increasingly electric or other low carbon fuels.
  • We recommend that transport policy should accept a hierarchy of walking >cycling >public transport, to include good provisions for disabled people
  • Air transport needs to be increasingly regulated and air fuel tax applied. We must actively encourage more use of continental trains as an alternative to short haul flights.

CHILDREN

  • We will ensure children have received high quality PSHE through their school years so they are aware of gender and sexual and interpersonal relationships, understand the distortions of on line pornography and be empowered to say no.
  • We will ensure contraception and sexual health clinics are easily accessible to reduce the risk of sexually transmitted diseases and unwanted pregnancy
  • More investment in the training and employment of midwives and Health Visitorss to ensure that sufficient support from midwives and health visitors is available for women and babies, especially solo parents and young mothers,
  • We will increase benefit rates for pregnant women so that they can afford a healthy diet and suitable accommodation.
  • Every school must have a named school nurse and a school counsellor, for which more funding will be required
  • Children’s mental health services need to be improved and made adequate for the speedy identification and treatment of mental disorders in children in the least stigmatising way.
  • We will ensure that there is parity of treatment in health and social care services in respect of both youth and age. 
  • Services must be improved in transition from child to teenager and teenager to adult

HEALTH INEQUALITIES

  • Improving health requires addressing the social determinants of poor health based on the principle that there is a role for an interventionist state, for redistribution of wealth and power, and a role not just in planning and commissioning but in delivery. 
  • Labour’s long-term goal is to break the link between a person’s social class, their social situation and their health. We will work across government, using the power and influence of all government departments and agencies, to achieve this.
  • We recognize the importance of the early years (pregnancy and first 5 years of life) and there should be workplace benefits to enable generous maternity and paternity leave, state nursery provision and safeguarding along the lines of Scandinavian countries.
  • The establishment of an Office of Health Equity to promote and monitor the application of the Fair Society, Healthy Lives policies of giving every child the best start in life; enable all children, young people and adults to maximize their capabilities and have control over their lives; create fair employment and good work for all; ensure a healthy standard of living for all; create and develop healthy and sustainable places and communities and strengthen the role and impact of ill health prevention.
  • Health impact assessment of all government policy will be used to reduce inequalities in income and wealth and those caused by trade, foreign and defense policy

THE IMPORTANCE OF COMMUNITIES

  • NHS agencies and providers will ensure that every locality has a thriving third sector largely funded by grants rather than contracts.
  • NHS organisations will be expected to take an active part in neighbourhood partnerships and to encourage users and carers groups to do so.
  • Health agencies will play an active part in deploying community development to improve health protection through community empowerment, help tackle health inequalities and encourage responsive statutory agencies.
4 Comments

This is a discussion document not agreed policy.

The rationale for international trade is clear. No country can be self-sufficient in everything it requires, whether this is because of the geographical distribution of natural resources, climatic constraints on agriculture, or the benefits that come with concentration of particular types of expertise. However, it is important that this trade takes place in ways that bring benefits for all concerned. Unfortunately, this is not the case with many existing global and regional trade agreements. Too often, they are designed in ways that allow the powerful to exploit the powerless, whether by exploiting weak labour standards, damaging the environment, or preventing poor countries from adopting effective public health measures. In particular, many incorporate systems of investor state dispute settlement processes that enable global corporations to undermine public health, avoiding the protections provided by courts.[1]

There is now very extensive body of research on the health implications of international trade. For example, the removal of tariff and quota barriers can drive increasing consumption of unhealthy products.[2, 3] The following recommendations flow from this literature.

  1. All trade agreements should include an explicit commitment to safeguarding and promoting a high level of human health;
  2. Governments should be free to adopt evidence-based measures to protect health and the environment, which should not be considered to be non-tariff barriers to trade;
  3. International trade agreements should work towards the progressive realisation of equivalent standards of employment, health, and safety in those sectors included in the agreements in all of the countries participating;
  4. Disputes between parties should be addressed in a judicial setting, decided by judges selected by an independent body, meeting in public, with publication of all of the evidence being considered, and with provision for cases to be joined by other interested parties, including trade unions, non-governmental organisations, and professional associations;
  5. Independent monitoring systems should be established to ensure that international trade does not undermine health and the environment, drawing models such as the shadow reports produced by NGOs or the UN system of special rapporteurs.

Finally, there is a need to address the particular circumstances of the NHS. Neither European Union law other international trade agreements require the UK to open up its health services to competition. Health care, along with education, social services, and public services broadcasting among others is considered to be a service of general interest. Internal market rules apply to the services only to the extent that public authorities have opened them up to the market and “insofar as the application of such rules does not obstruct the performance, in law or in fact, of the particular tasks assigned to them” (Art 86(2). Thus, in the United Kingdom, Scotland, Wales, and Northern Ireland have avoided many of the problems that have arisen following the Health and Social Care Act in England.[4] Moreover, in its rulings, the European Court of Justice has consistently given a high priority to the sustainability of national health systems.[5] Thus, the opening up of public health systems to competition law is entirely a decision for national governments.

The recommendations above are already in place within the European Union (e.g. the Social Chapter). Thus, it includes measures to achieve equivalence of labour, health and safety standards in its trade agreements with countries such as Vietnam and Peru, the European Court of Justice has consistently emphasised a high level of human health in its judgements, and, it is notable, that in its negotiating position on the TTIP, the European Union was arguing for a judicial model of dispute resolution. Consequently, there is a real danger that these protections will be lost should the UK actually leave the European Union.[6] Indeed, it is apparent that the main justification for many of those advocating Brexit is to remove these protections.

References

1. Steele SL, Gilmore AB, McKee M, Stuckler D: The role of public law-based litigation in tobacco companies’ strategies in high-income, FCTC ratifying countries, 2004-14. Journal of public health (Oxford, England) 2016, 38(3):516-521.

2. Mendez Lopez A, Loopstra R, McKee M, Stuckler D: Is trade liberalisation a vector for the spread of sugar-sweetened beverages? A cross-national longitudinal analysis of 44 low- and middle-income countries. Social science & medicine (1982) 2017, 172:21-27.

3. Stuckler D, McKee M, Ebrahim S, Basu S: Manufacturing epidemics: the role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS medicine 2012, 9(6):e1001235.

4. Reynolds L, Attaran A, Hervey T, McKee M: Competition-based reform of the National Health Service in England: a one-way street? International journal of health services : planning, administration, evaluation 2012, 42(2):213-217.

5. Greer SL, Hervey TK, Mackenbach JP, McKee M: Health law and policy in the European Union. Lancet (London, England) 2013, 381(9872):1135-1144.

6. McKee M: Brexit: the NHS is far safer inside the European Union. BMJ (Clinical research ed) 2016, 353:i2489.

Tagged | Leave a comment

This is a discussion document not agreed policy.

  • A new unified care system that combines health and defined social care components and specialised housing, having local democratic input from the Local Authorities with the Public Health Director having that role in an expanded Public Health organization with the NHCS and in the LA, to ensure the tightest of possible joint working.
  • Social care will be offered on the basis of assessed need, free at the point of use, and funded from progressive taxation. Devolved administrations will have the freedom to develop their policies and approaches independently within this context.
  • Universities and their teaching and health research functions will be seen as part of the NHS and will be part of our staff development and R&D arm, including predicting future staffing and workload demands.
  • A care system in which prevention, assessment / diagnosis, intervention / treatment, and ongoing care support is evidence based and marked by co-production and cooperative joined up delivery with all core services delivered by health and social care providers.  Third sector providers, supported by grants, can be a positive addition.  Commercial providers will still be a part of the system supplying goods or equipment. Commercial providers of any patient care services will only be permitted in specified exceptional circumstances and should be subject to the same rules and guidelines as the Health and Care Service, and other public services in terms of responsibilities, accountability and transparency. Commercial Confidentiality is unlikely to be justified. In the longer term, we would aim for commercial providers of core services to be limited to exceptional cases, where it is in the best interests of service users and patients
  • Management of, and accountability for the National Health and Care Service would be the responsibility of each Minister of the four governments within the UK, with each once more responsible for ensuring the provision of the system as a whole, a national framework and national standards, including clinical, employment of staff, protections for staff, training of staff, patient safety, quality of services, and encompassing the duties of NICE etc.
  • Most planning and delivery would be on a local basis, but bound to a minimum by national standards and requirements.

 

 

1 Comment

This is a discussion document not agreed policy.

A Health and Care Service

  • The bringing together of our separate health and social care systems so that they become one unified care system driven by the political values and professional / organisational principles that underpin the NHS.
  • Organising resources to meet the medical and social needs of people so that organisational and professional barriers that might hinder the giving of care are kept to a minimum (or even removed totally). It sees the need for care as sitting within the wider social context which individuals and families inhabit.

Marketisation/privatisation

  • We support an NHS which is integrated, sensitive to patients’ needs and democratically accountable; founded on values of professionalism, cooperation and partnership not on marketisation: financially driven competition.
  • The NHS should be defined as a single national system set up on the basis of social solidarity and all relationships between commissions and NHS providers should be within the NHS and not the subject of legally enforceable contracts but be subject to best value. While there are no contracts there can be no intervention through competition law
  • Labour will restore the duty of the Secretary of State to deliver a comprehensive, universal NHS publicly provided and managed and will give the Secretary of State the power to give directions to any part of the NHS
  • The private sector will only be allowed to offer patient services as an alternative to the NHS by exception, in rare and clearly defined circumstances, for example:
    • with convincing evidence of necessary enhanced care
    • where these offer vital, novel services otherwise as yet unavailable,
    • as a temporary remedy for persisting inadequate standards,
    • or to meet peak service pressures when NHS capacity is not immediately available.
  • All providers to the NHS, including the private sector, must waive any rights to commercial confidentiality and must comply fully with all requirements for provision of information and be covered by NHS complaints procedures including the Ombudsman and regulation.
  • Any private providers should not be subsidised either directly or indirectly, and no NHS funds should be spent on any form of market development as this is a form of subsidy
  • The NHS will no longer pretend that Foundation Trusts are free-standing competitive corporations.

Funding:

  • Austerity must end and funding increase to at least the EU average.
  • Health, and eventually social care, should be free at the point of need and funded out of general taxation and should be provided by public bodies.

Private practice:

  • We see no place for private practice. That is, people paying clinicians for care and paying for facilities such as private hospital beds.

Cooperation

  • Labour will remove any legal or other barriers which prevent or deter cooperation. We shall create structures that facilitate and promote co-operation and partnership  
  • The SHA supports continuing development of the many non-market mechanisms

Planning/commissioning. Limit vested interests as much as possible

  • The SHA wants to exclude tendering and the private sector, except in very limited circumstances. Commissioning outside the market is called planning.
  • Commissioning/planning functions have to be done somewhere based on needs and assets assessment. 
  • Planning functions must be democratically accountable.
  • Commissioning/planning must be separate from provision and free of any form of conflict of interest such as undue influence by the dominant NHS acute providers.
  • Commissioning responsibility cannot be given to the private sector under any circumstances. Decisions about services and funding must be made through open and transparent democratically accountable processes.
  • Planning, rather than the market, is the basis of the healthcare system in Wales. Health boards, NHS trusts and their partners are required to work together to secure and deliver services for their populations, collaborating with partners at various levels to assess population need and to plan and deliver services, through the local health board, public services boards and 64 primary care clusters. They are expected to have a long-term view and to be clear about the actions they will take in the more immediate future to deliver high quality, accessible and sustainable services within the national policy context. NHS organisations are expected to collaborate in addressing strategic delivery issues that impact on the delivery of services for patients, and are encouraged to explore strategic alliances to resolve consistent challenges. Plans should make clear where issues are beyond the scope of an individual organisation, and should clearly set out an agreed response at an all-Wales, and / or regional and sub regional level. The collaborative arrangements across Wales should support the alignment of actions within individual organisational plans.

Cross-sector planning

The SHA regards it essential to include sectors like housing, education, air pollution, and the fire service which affect health but are not conventionally involved with NHS. good housing and planning are multipliers of health & well-being and significantly assist in improving the environment for people with particular needs, such as the homeless, those with learning difficulties and those with mental illness. Coordinated action with housing could challenge the national housing shortage, could improve hospital discharge and help with the knee-jerk reaction to austerity of many hospitals in selling off land inappropriately.

An example of cross-sector working is the Shepherd Cardiff work where linking data from A+E with policing interventions reduced crime and knife injuries. 

New Models of Care in England

The SHA is open to considering alternative models of organising the relationships between primary and secondary care. But the plans in the FYFV do not represent useful or effective alternative options. In the current climate of austerity, these are luxuries that distract from the real issues of underfunding. We do, however, support the current New Models of Care in respect of care homes where much improvement is needed.

The SHA does not wish to see Accountable Care Organisations. They do not appear to be accountable. It is not clear how they will improve care. They are a precursor to an insurance-based system.

Integration of Health and Social Care

  • Social care, physical and mental health services must work together in the patient’s interest, offering “integrated care”.
  • Tier 1 Local Authorities should have responsibility for the integrated commissioning of all care at least at the strategic level.
  • The SHA is aware of the risk that integration of care could, under a Tory government, lead to an NHS with co-payments, just like social care. The SHA wishes to see social care nationalized, free at the point of use, and would welcome a transitional approach which would take us there over time.
  • In the interim, we advocate close working, shared data with the patient’s consent.
  • Please also see our thinking about social care in section…….

STPs

The SHA observes that STPs are being forced as their prime purpose to focus on living within the financial constraints of austerity, almost to the exclusion of anything else. In addition, the financial plans of many of the STPs that we have seen appear to be based on poor evidence and flaky accounting.

The SHA also sees that any reorganisation of services in England, local or national, is likely to have to follow the tendering and privatisation demands of the HASCA. We see this is a real and present danger to the integrity and effectiveness of the NHS. We see a risk in the size of the footprints.

On the other hand, if STPs were to be removed from the demands of austerity, there is merit in bringing sectors together to jointly solve problems.

Devolution

The “market” approach is fragmenting provision and creating a hugely complex web of organisations linked by legal contracts, adding significantly to transaction costs. We should introduce incentives for joint appointments, joint budgets, collocation, information sharing, and shared services across the NHS and local authorities. An integrated plan for commissioning across all public services.

We should have a large scale trial with a fully integrated provider which covers delivery of all primary, secondary, mental health and social care, for a single County or City.

1 Comment

This is a discussion document not agreed policy.

1. Purpose

1.1.This paper supports the bringing together of our separate health and social care systems to become one unified care system driven by the political values and professional / organisational principles that underpin the NHS.

1.2. The political values are: a system with national standards; funded largely from progressive taxation1; delivered by locally accountable bodies that rely on committed staff many of whom have professional training and professionally established responsibilities; is evidence based; relies on the notion of “co-production” between service users and professional staff – people playing an active role in their care and professionals welcoming, respecting and responding to that role.

1.3. In summary, the organisational principles are:

  • a national (England, Scotland, NI and Wales) approach to defining the scope of what is to be provided, and at what standard, and which retains oversight of how local machinery (accountable too to local populations for this task) delivers the national aims2
  • a service that is paid for overwhelmingly out of progressive taxation –
  • a service where the duties, rights and responsibilities of professional people are recognised, respected, and supported by supportive managerial and professional machinery
  • a service that directly employs its own staff and owns its physical resources, and may operate through recognised third sector bodies where they are better placed to serve needs, or operates “franchises” operated by independent practitioners or commercial franchise holders. (3.1.5 below)
  • We see the 3rd sector primarily as offering innovation and user-centred approaches. The public sector needs to learn and integrate those insights into routine care.

1.4. The paper sketches out:

  1. what is meant by, and comprises, a unified care model
  2. some options for how such models can be created
  3. the issues that are raised by moving to such a model.

2. What is a unified care model?

Put simply, such a care model is a means of organising resources to meet the medical and social needs of people so that organisational and professional barriers that might hinder the giving of care are kept to a minimum (or even removed totally). It sees the need for care as sitting within the wider social context which individuals and families inhabit.

The exact components of such a care model will always be contested – especially in respect of the wider social determinants of health status which impact upon individuals or groups of individuals – but below are listed at 2.1. those components that the author suggests sit within the care model and at 2.2. those which complement it from outside the model.

2.1. Within the model

2.1.1. Primary care resources

  1. GP, Dental, Pharmaceutical, and Ophthalmic screening, diagnostic, and referral services – 24 hour service for GP cover
  2. Sheltered / supported “own home” provision including adapted housing
  3. Residential and Nursing home care, district nursing and Health Visiting including palliative care
  4. Non-acute hospital “care and watchful waiting” capacity
  5. 24 hour community immediate response teams of carers, district nurses with “admitting rights” to ii) iii) and iv) if necessary
  6. Mobile 24 hour paramedic and social care diagnostic / assessment and treatment capability with “admitting rights” to ii) iii) iv) and v) if necessary
  7. “Fixed site” 24 hour major diagnostic / assessment capability commensurate with suspected and urgent social, surgical, medical, obstetric, traumatic, paediatric and psychiatric episodes also able to access radiology, pathology, ECG, and EEG clinical support, and senior social work expertise3.
  8. Home delivered rehabilitation skills.
  9. Domiciliary care services with complementary day care services
  10. Respite care for carers with significant carer loads
  11. Resources and approaches to build social capital, such as community development

2.1.2. Secondary/tertiary care resources

i) Fixed site ongoing (inpatient / day patient) diagnostic / assessment capability as in vii) above with added skills of physiotherapy, speech therapy and occupational therapy

ii) Fixed site treatment / intervention skills across the range of needs as in a vii)

iii) Fixed site rehabilitation skills

iv) Specialist physical and mental treatment and recovery services operating on a regional basis.

2.2. Outside of, but complementary to, the model

i) Accessible transport arrangements

ii) An effective and fair benefits system

iii) Good occupational health services (and fair employment terms)

iv) Effective primary, secondary, higher, and further / life long learning educational opportunities regarding healthy living

v) A quality “public realm” for social intercourse

vi) adequate housing.

3. How might the unified model be achieved?

Two different options for moving from where we are now to the intended service shape are briefly described below.

3.1. Option 1 : A fully unified planning and delivery vehicle

3.1.1. This option requires legal changes to bring a unified health and care service into being over time – probably over a decade. In simple terms it would create a new public body from the separate components parts of the English health and social care system to replace NHS and local government bodies that currently plan and/ or deliver health and social care services.4

3.1.2. There are variants upon this model but essentially, and subject to local variations because of geography, one all purpose health and social care authority that both plans services and oversees their delivery to ensure the population served receives the level of service promised by Government is suggested for populations of up to 500,000 people.

3.1.3. The governance arrangements need to ensure that:

a) the wishes of Government in terms of the range and volume of services to be provided are realistically matched to the resources available

b) the planning and delivery tasks each iteratively inform the other (the predictive (planning) capability indicating the challenges ahead, and the frontline knowledge feeding back into the planning process about possible means of delivery and service change).

c) managerial, professional and democratic inputs properly feature in the governance arrangements so that the right accountabilities are discharged

d) knowledge about best practice is gained and disseminated with the planning process enabled to embed best practice in local delivery.

3.1.5. Commercial contracts are seen as an inadequate way of seeking to manage dynamically the different components parts of a care “system”; however, the notion of franchised operations is an alternative option in selected situations as a means of moving from the current reliance on privately owned providers towards a publicly owned set of assets.

3.2. Option 2 – non-structural (organic) change

This option would still see the legal basis for the two services being altered so that both were provided on the same terms as the NHS – i.e. free at the point of use on the basis of need, paid for mainly by taxation and / or additional graded national insurance. However existing planning and delivery models would remain in place initially and “softer tools” of increasing managerial and professional collaboration – within a new corporate identity of a National Care Service – would allow a slower pace of organisational change to occur that is driven from below.

1 The paper does not seek to address in detail the many issues surrounding the funding needed to enable the new model to be resourced. It is recognised that work needs to be done to assess the service load that Government wishes to see made available and to provide the necessary financial, human and capital resources. An early decision would be how current co payments are to be phased out and alternative funding (or service reductions) effected. The assumed starting position is that any unified service will inherit the current range and volume of services and cost envelope but would move to the new model over time. Some of the current benefits paid to those r eceiving care might need to be added to the budget for the new National Care Service

2 Here, it is recognised that. since 1999, UK wide machinery for certain functions has to, or ought to be, retained – for example planning of human resources and sensible UK wide location of super specialist clinical care.

3 This capability, whilst physically situated within acute hospital settings, culturally and organisationally should be seen as sitting within, and serving primary care. Only when a decision has been taken to “admit” a citizen to an acute hospital does the secondary care component of the care model come into play.

4 The scale of the changes needed would vary in each devolved administration and the major change would be in England which is furthest away from the intended model. Depending on which approach is used, the financial effects operating through the Barnett formula would shape the pace and nature of the reponses in Wales and Scotland.

Tagged | Leave a comment

This is a discussion document not agreed policy.

The SHA is concerned that general practice under the Tories may go the way of dentistry and optometry. The SHA aims to eliminate the private sector except in exceptional and transient circumstances.

The SHA wants to see improved access to primary care for both acute and chronic care. We are keen to maintain continuing personal care. This will require significant increased funding for clinicians in primary care. The government’s proposals are too little, too late. They have resulted in immense frustration with GPs threatening industrial action for the first time. The SHA recommends reassessing many aspects of the current arrangements for general practice to reassure and energise primary care. This should include boosting numbers of clinicians and making the most of opportunities afforded by information technology.

The SHA does not support GPs being responsible for planning although they must be centrally involved, alongside other key stakeholders, in local planning decisions.

Independent Contractor status:

There are advantages and disadvantages to the independent contractor status. The SHA would recommend a trial of a mixed economy, where in some areas, primary care is salaried and in others as it is now, the benefits and risks to be evaluated. One option should include one of the current New Models of Care (NMC), that under which hospitals run some general practices. It is unclear whether this will lead to improvements or more problems and such a move needs evaluation before any decision about permanence.

In some areas where there are difficulties in sustaining general practice, we may need a directly operated model, employed by the NHS. The franchising arrangements for primary care must always include clear national standards.

Planning Primary Care

The SHA sees that primary care must be planned and managed rather than just administering it which is the present predominant model.. One of the outcomes should be a more consistent quality of primary care. How to best manage primary care must be discussed with primary care, but as with the rest of the NHS, we would expect national standards with local delivery.

The SHA recommends primary care workforce planning and joint multi-disciplinary training where appropriate.

We should have a large-scale trial with a fully integrated provider which covers delivery of all primary, secondary, mental health and social care, for a single County or City. This should include social care free at the point of use. This could include GP practices collocated with other services, including hospital services; a strong focus on intervening in the social determinants of health. All to be under national standards.

Clinical developments

Care plans for all patients, jointly written and jointly carried out.

The SHA notes the connection between psychological problems in children and young adults and mental ill-health in later life, and supports investment in

  1. community-based programmes to identify and support children and young adults with depression, anxiety and other psychological disorders, and
  2. research efforts to identify the best approaches to reducing psychological distress in this age group.

The SHA understands the difficulties of changing the health of the population and so encourages Labour to commit to a long-term plan for health promotion, preferably coordinated by a national arm’s length health promotion agency. This needs to include ways of engaging ‘hard to hear” groups and approaches to healthy community development.

We would like to see Labour commit to:

  • promoting specialist medical and nursing care closer to home.
  • prioritising innovative ways of running ‘Hospitals without Walls’, where specialists and generalists work alongside each other in community settings to improve outcomes for patients, enhance generalists’ skills and contribute to specialist training.
  • prioritising the development of 24/7 ‘Hospital at Home’ services for admission avoidance, early discharge and rehabilitation, in parallel with all acute Trust hospitals.
  • investing in the expansion of community nursing services and other community-based specialist services to create stable ‘Hospital at Home’ services. Also investing in social services’ input to ‘Hospital at Home’. Decisions about clinical responsibility for ‘Hospital at Home’ services to be made at local level, but a budget to be provided for an expansion in the numbers of community geriatricians

The SHA notes the underdeveloped and underperforming state of falls prevention services in hospitals as well as in the community, and recommends investment in community-based programmes to identify people at risk of falling and encourage them to take up preventive services (like exercise promotion classes).Community care

The SHA wishes to see community care in both the health and social care sectors adequately funded and skilled.

The SHA does not recommend wholesale focus on community care as a means to avoid acute hospital admission. The evidence is weak. In the current climate of austerity, it becomes a way of cutting hospital beds even further. However, there may be a case in those areas where particular pathways make it particularly appropriate to shift hospital work into primary care.

We want to see resilient out-of-hospital solutions for the care of older people, including increased recruitment of GPs, District Nurses and Health Visitors. One example that needs evaluation are Older People’s Assessment Units and extended primary care.

THE MYTH OF THE DEMOGRAPHIC TIME BOMB

The SHA rejects the concept that an ageing population results in unacceptably high costs. On the contrary, we are proud that we have an increasing number of older people whom we value.

Older people have falling mortality, less morbidity, and are more economically active than before. Some forms of disability are postponed to later years. Increased life expectancy means more years lived in good health.

Older people contribute almost £40 billion more to the UK economy annually than they receive in state pensions, welfare and health services.

It is not age but nearness to death that accounts for health expenditure. Most acute medical care costs occur in the final months of life, with the age at which these occur having little effect. According to this hypothesis health expenditure on older age groups is high, not so much because their morbidity or disability rates are higher, but because a larger percentage of the persons in those age cohorts die within a short period of time.

It is those dying between the ages of 50 and 60 who cost the most.

Old age dependency has fallen substantially in the UK and elsewhere, when measured using remaining life expectancy. It is likely to stabilise in the UK close to its current level.

Similar findings have been reported in other European countries where by 2008 it was shown that ‘contrary to popular belief, ageing is not an inevitable and unmanageable drain on health care resources.’ Indeed one study suggested that the cost of death declines with age because older ‘people tend to be treated less intensively as they near death.’ If the cost of death declines with age then an ageing society could lead to lower health care costs.

Wanless concluded: ‘Despite this significant ageing of the population, demographic changes have so far accounted for a relatively small proportion of the increase in spending on health care in the UK. While overall spending (between 1965 and 1999) grew by 3.8 per cent a year in real terms, the demographic changes alone required annual real terms growth of just 0.5 per cent a year. Less than 15 per cent of the growth in health care spending over the past 35 years can therefore be attributed to the cost of meeting the needs of an ageing population. This is in keeping with findings from other countries.’

2 Comments

This is a draft policy not yet agreed.

Social care policy has been subject to much muddle, tinkering and the perpetual promise of a fairer funding system – a promise which is never fulfilled. Now is the time to end the confusion and create a social care system that is fit for the 21st century and which is in harmony with the socialist principles which underpin the NHS.

This policy proposal offers a solution which is fair, sustainable and which would be hugely beneficial to all citizens and families across the country.

The three key elements of the proposal are:

  1. Fund a universal system and end means-testing – Social care must be put on the same footing as healthcare, funded from general taxation, with resources distributed fairly, only on the basis of need.
  2. Invest in citizenship and community – Social care must offer support that people and families can shape to their circumstances, and that helps people contribute as citizens and strengthens family and community life.
  3. End privatisation and the complexity of the current system – Social care must be integrated into one national system that invests resources locally and ends the wasteful procurement systems that currently undermine human rights.

The problems in social care grow ever deeper as the case for reform grows stronger:

  • Deep cuts in funding mean that 40% fewer adults are supported than in 2009.
  • Cuts to children’s social care are combined with growing numbers going into ‘care’.
  • Vicious means-testing systems push people into poverty in order to get care.
  • Funding for local government (council tax and business rates) is not a sustainable base for social care.
  • Individualised funding has become a confused mess of competing schemes, like personal health budgets.
  • People are not offered flexible support, instead they are encouraged to take their budgets as cash and employ your own staff, even when this is burdensome.
  • The regulatory system doesn’t work, rarely spotting abuse and undermining good practice.
  • Procurement rules push privatisation and discourage local community investment.
  • The system treats people as consumers, not citizens, undermining solidarity.
  • The system fails to respect the demands of the UN Convention on the Rights of Persons with Disabilities.

Background

The distinction between health and social care was created by the Thatcher reforms of the early 1990s and the term ‘social care’ is now commonplace, however it is rarely found in other countries and it can be more confusing. It may be more useful to think instead about the overall system to support disabled and older people who need on-going support and assistance and to call this Long Term Care.

Confused leadership

If we examine the organisation of Long Term Care in the UK we find it is confused, weak and fragmented. Not every country in the UK is exactly the same, but in England responsibility is divided between 5 different government departments:

  • Department for Communities and Local GovernmentDCLG – local government and housing related support
  • Department of Health – DH – adult social care
  • Department for Education – DfE – children’s social care
  • Department for Work & Pensions – DWP – disability benefits
  • Office for Disability Issues – cross department leadership (in practice junior to DWP)

Since the introduction of austerity leadership has deteriorated further as responsibility for policy problems has been pushed onto local authorities or NHS organisations.

Fragmented funding

Furthermore these departments oversee a variety of funding streams for Long Term Care, managed in a number of different ways:

  • Children’s social carestatutory responsibility, managed by local government
  • Adult social care for working age disabled peoplealso a statutory responsibility, managed by local government, but subject to different legislation
  • Adult social care for older peoplealso managed by local government
  • Continuing Health Care for people with chronic health conditions – managed by the NHS
  • Mental health services – managed by mixture of NHS and local government
  • Palliative and other long-term care and nursing services – managed by the NHS
  • Supporting People funding – managed by DCLG via local government
  • Independent Living Fund – The coalition Government closed down this national scheme that allowed some disabled people to get a budget for personal assistance but the scheme has been maintained in Scotland and Northern Ireland.

The overall level of public funding available for Long Term Care is certainly much higher than the £19 billion currently spent via local government. However the precise level will depend on which NHS or other services are treated as part of the Long Term Care.

Ongoing crisis

Local government, particularly in England, has had its funding savagely cut since 2010. This has led to deep cuts to adult social care, with about 40% fewer people receiving social care now than in 2009.) There have also been severe cuts in other local support services.

The severe cuts in social care have not gained the attention of the media nor the general public. Although the 2017 budget saw talk of additional funding for social care for the first time since 2010. Instead of genuine funding reform there has been much talk of theintegrationof health and social care for over 30 years. However much of this appears to be a policy smokescreen. These Better Care Fund arrangements seem to be an inadequate cross-subsidy from the NHS to social care and there is no evidence that they have led to any significant innovations or meaningful reform.

The human rights of disabled and older people have been persistently ignored and the system has been treated as of marginal relevance to mainstream political debate. In fact the current system is also out-of-date in its assumptions about what people want and need and it tends to reinforce negative images and assumptions about disabled and older people:

  • On-going heavy investment in private and charitable residential care, despite the fact that this is not the support most people want.
  • The problems in social care are seen as causing problems for the NHS rather than being treated as problems in their own right.
  • While there is much talk of ‘personalisation’ mostly people are forced either to accept inflexible services ‘commissioned’ by statutory bodies or to take on the often onerous responsibilities of managing a ‘direct payment’ (receiving their budget as a cash payment and often employing their own support staff).
  • There is minimal innovation, inclusion or accessibility for disabled and older people in our local communities.
  • Confusion in central government is mirrored by confusion at the local level with responsibilities unclear and fragmented.
  • Instead of respecting people as citizens and family members, with something to contribute, the system has adopted a consumerist ideology which is misplaced and wasteful.

The following proposals provide a framework for leaving behind this ineffective, and often toxic, legacy, and redesigning the welfare system so that it properly respects our human rights and the unique value of all human beings, no matter their age or impairment

Key principles

In the future policy must reflects the need for the UK to create a system which is consistent with its responsibilities as a signatory to the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) which includes a universal right to the support necessary to enable independent living (Article 19).

If the UK Government took seriously its human rights responsibilities this would revolutionise our approach to long term care.

The key principles for any future system of long term care must include:

  1. Universal coverage – The need for Long Term Care is part of the normal risk of life and should be treated just as health and education.
  2. Maximum risk-pooling – The most efficient way of insuring ourselves against the costs of impairment or frailty is to all pool resources in order to cover that risk, as with the NHS.
  3. Equity – The system should be equitable and should not discriminate against people because of condition, age or geography.
  4. Entitlement – All citizens should benefit from the system and should not be disadvantaged by income or ability to pay. The system should be funded from general taxation and be free at the point of use, as with the NHS.
  5. Control – All citizens should be able to get the right flexible support to meet their needs, to be able take the level of control that is right for them and their families.

In addition, If the UK were to apply these principles then it would be more in line with current developments across OECD countries:

On equity and efficiency grounds, a majority of OECD governments have set up collectively financed schemes for personal and nursing care costs. Many are also moving towards universal entitlements to coverage of Long Term Care costs.” [OECD (2011) Help Wanted?: Providing and Paying for Long-Term Care. OECD.]

Similarly the UK would also be in line with an international trend from Canada, the USA, Australia, Scandinavia and Eastern Europe to shift more power and control to citizens themselves, rather than to merely place people within services, minimising control and the opportunity to exercise citizenship.

long term care

Proposals in more detail

1. Partnership

Any future policy should be developed in partnership with and with support of disabled and older people themselves. In particular the National Pensioners Convention (NPC) and other groups led by disabled people must be central to the definition of any detailed proposal.

2. Human rights

Future policy must be based on human rights and the UN Convention on Rights of Persons with Disabilities (UNCRPD). The Convention confirms that all disabled and older people, no matter their age, condition or impairment, have full human rights and must be supported to be independent and contributing members of society – equal citizens.

Currently the UK is a signatory to the Convention but since 2010 it has been extremely negligent in meeting its international human rights responsibilities. For instance, in 2016, the UN Committee on the Rights of Persons with Disabilities reviewed the UK Government’s policies and stated:

“…there is reliable evidence that the threshold of grave or systematic violations of the rights of persons with disabilities has been met in the State partyThe core elements of the rights to independent living and being included in the community, an adequate standard of living and social protection and their right to employment have been affectedfreedom of choice and control over their daily activities restricted, the extra cost of disability has been set aside and income protection has been curtailed as a result of benefit cuts, while the expected policy goal of achieving decent and stable employment is far from being attained.

Any future policy for Long Term Care must make commitment to clear and enforceable human rights central to its strategy.

The foundation stone for this policy must be full social commitment to the creation of a robust, enforceable, universal entitlement to the support necessary for independent living. This right would exist for people of all ages. In effective the whole of society would guarantee to set aside the resources necessary to make sure that any of its members who needed extra support to participate as an equal would receive that support.

3. Universal scope

This right would extend to all people needing on-going support. It would include support for disabled people regardless of age or impairment (people with physical, sensory or cognitive impairments). It would include all people needing on-going support because of their mental health or chronic health conditions. It would include childrens social care and support for people who are at the end of life.

The purpose would be to create one single, universal and flexible system to replace much of current social care provision, and also to include only those elements of NHS funded services that would genuinely benefit from being converted into flexible entitlements (e.g. Continuing Healthcare, and some mental health provision). This system would end the system of Personal Health Budgets and make clear that means-testing, charging and private insurance has no place in the modern welfare state.

There would also need to be in place an infrastructure of services to support people with information, advocacy, social work and nursing expertise and support to manage their entitlements. Local community support would need to be established to ensure that any individual entitlements were convertible into effective support.

4. Means-testing

There is no moral case for applying means-testing to social care and the impact of the vicious levels of means-testing in the current system are highly toxic:

  • People with higher incomes or assets get no benefit from social care and have no interest in supporting it through the ballot box or by taxation.
  • People on modest incomes or with assets are tempted to give away what they have to family or to spend their resources in order to become eligible for social care.
  • People who are eligible for support are discouraged from earning additional income if they can, as this means they will lose their social care support.
  • Means-testing is carried out using an expensive and cumbersome ‘charging system’ often raising no more money that the system costs to implement.

Already the system is confused. Children and families are not means-tested, but adults are means-tested. People needing adult social care are means-tested, but if their needs are re-assessed as ‘health’ needs then they stop being means-tested. None of this makes any sense and it often undermines the possibility of effective joint-working or integration between health and social care.

Self-funders currently spend about £10 billion on care, which is 0.5% of GDP. In essence this policy can be funded by asking people to pay a very small tax increase in order to cover themselves against the risk of having to pay for their care privately and potentially losing all their assets. A similar policy change in Australia involved the introduction of a hypothecated tax in order to pay for all fully funded universal system for working age adults. It was introduced by the recent Australian Labour government and was so popular that the incoming Liberal government was not able to touch it.

5. Delivery

The right to personalised support to achieve independent living would be delivered through a balance of individual entitlements and community-based support, made up of the following elements:

  • Flexible and individualised services, provided by statutory and local community organisations
  • People being able to manage their own budget or choose their own support if they want
  • Peer support and community-led systems of support
  • Independent advocacy and information services
  • Social work and professional advice

Support arrangements, in a healthy system, will not be static. They will change over time as citizens, communities and local leaders innovate, identify and share best practice.

This system would also end the use of procurement and tendering systems, which have had a very damaging impact on local statutory and community services. Currently services for disabled people are put out to tender and people are sold offto the lowest possible bidder.

The only way to avoid being part of this inflexible system is take your budget as a direct payment and about 25% of adult social care is organised in this way. But this is often neither feasible nor advisable, and it can bring many additional burdens. In practice there are IT systems available which could replace the current mess of contracting, invoicing and payment systems and which could make flexible services possible for everyone. In fact the NHS currently owns 50% of PHB Choices, and it (or some similar system) could easily be developed to provide a coherent solution for the whole system – giving people choice and control but not forcing people to use direct payments.

6. Organisation

A renewed system for Long Term Care needs to have clear and coordinated leadership at a national level, combined with the right kinds of being decisions being made at an individual, practitioner or local level. There are a number of ways this could be achieved and much would depend on the details of how any further devolution of powers in the UK might work, however an outline proposal is as follows:

  • Overall national leadership for Long Term Care could move to DCLG
  • Local communities would receive a ring-fenced Long Term Care budget calculated on the basis of need
  • Local community support systems would be organised through local government, in partnership with NHS agencies
  • Assessment of entitlement and setting of budgets would be organised locally
  • Individual budgets for people would be portable, flexible and clear

This system would combine fairness with good governance and positive incentives.

7. Advocacy

One of the major failings of the current system is the fragility of individual and collective rights. Within local communities people have only the weakest notion of their entitlements and as the cuts programme began most charities, now highly dependent on central or local government funding, failed to mount any defence of peoples human or legal rights. Any new system must be underpinned by legal and advocacy systems that protect people form this kind of systemic abuse.

8. Economics

There have been a wave of failed initiatives to calculate the cost of ‘social care’ and to determine suitable systems of funding. It is vital to create a sustainable system of funding to underpin rights created by the new system. Instead of building on a failed system and the assumption that residential or nursing care is the default model for support we need a fundamentally different approach to the economics of independent living:

  • Focus on the costs of exclusion versus the benefits of inclusion and contribution
  • Avoid the crisis and cost inflation caused by high eligibility thresholds
  • Support families, who already provide over 80% of care in practice
  • Minimise the bureaucracy and regulation built into the current system
  • Avoid the direct and indirect costs of means-testing
  • Build on current investments within the NHS and local government

This issue is also important to the definition of eligibility. Currently the system has made it very easy for people to be deemed ineligible for support, however significant their needs. A new system will seek to enhance contribution and connection by all citizens. Systems like local area coordination, or a renewed focus on community social work, would provide a better basis for building a sustainable system than the current care management system, that was imposed on local government by Mrs Thatcher.

9. Wider policy change

These changes need to be considered in the context of wider changes in policy. In particular it is clear that if communities become more welcoming places and if all citizens benefit from the right balance of rights and responsibilities then the whole system becomes stronger and more sustainable. Here are some examples of beneficial changes that would make independent living a reality:

  • Housing policy – more accessible properties and robust and flexible housing entitlements
  • Social security policy – more income equality, lower benefit reduction (marginal tax) rates (or even better, a basic income) and greater acknowledgement of the increased living costs for disabled people and families
  • Education policy – more inclusion innovation at every level of education
  • Health policy – protection from eugenic or prejudicial end of lifepolicies and a commitment to the equality of all
  • Employment policy – greater protections and support for disabled employees to achieve and maintain jobs, greater support for families who take on caring responsibilities

Conclusion

What is outlined above is a reasonable policy for a wealthy society in the early years of the 21st Century. The fact that it may seem ambitiousis that we have not yet created the necessary conditions to make it seem reasonable. To do this we will need to see:

  • More opportunities for disabled and older people to lead the way in making the case for change
  • An effective alliance, led by disabled and older people, but embracing families and professionals
  • Clear communication of the key messages and universal benefits of this new approach
  • Support from and for politicians with the vision to back these changes

None of this is impossible. These kinds of changes were achieved by the Every Australian Counts campaign and are leading to the most substantial international effort to support the human rights of disabled people. There is no reason why the UK could not do something similar.

This paper was produced by Dr Simon Duffy on behalf of the Socialist Health Association on 21st April 2017

Tagged | Leave a comment

This is a discussion document not agreed policy.

Mental Health services are “overwhelmed” by soaring demand according to a report by the body representing community, ambulance and hospital service providers, NHS Providers (July 2017, ref 1). Demand has increased by 5-10% over the last 3-4 years, but by 30-40% for children and young people. Patients are facing long delays to access mental health care, and people too often receive inadequate treatment. The numbers of people in need of specialist post-trauma mental health services has escalated dramatically following recent terrorist and civilian disasters. These intractable problems are the result of the Conservative Government’s unremitting policy of economic austerity, the prolonged real terms reduction of NHS funding over the past 7 years, and worsening shortages of key mental health staff such as nurses and psychiatrists.

The Socialist Health Association is committed to ensuring fulfilment of repeated high level commitments to ‘parity of esteem’ for mental health, and urgent implementation of proposals set out in the cross-agency Five Year Forward View for Mental Health (February 2016, ref 2) and Five Year Forward View for Mental Health: one year on’ (February 2017, ref 3). This must be combined with the future freedom from political interference of NHS policy making and delivery.

mental health

The origins of mental wellbeing and good mental health

The SHA policy on mental wellbeing is founded on the recognition that societal factors impact significantly on the whole spectrum of mental wellbeing to mental ill-health. The effects on individuals and families of social deprivation impacting on income, debt, access to appropriate accommodation, rewarding employment and security of tenure, community and family support networks, the availability and content of education, and other factors all play their part. The physiological reactions to stress of an expectant mother with pressing social difficulties affect the developing brain of her child. Experiencing or witnessing abuse and violence in the domestic setting at an early age can have severe lifelong effects on mental wellbeing and health.

In addition to the effects of absolute deprivation, living with extreme socio-economic inequalities has an independent impact: the experience of being judged socially inferior is a chronic cause of stress with negative effects on physical and mental health. Even severe mental illnesses with a genetic component are influenced by such social factors.

‘’.. . although genetic vulnerability may underlie some mental illness, this can’t by itself explain the huge rises in illness in recent decades – our genes can’t change that fast.’ Richard Wilkinson and Kate Pickett – The Spirit Level.

Virtually every aspect of policy – economic, housing, education and training, environment, equalities, health and social care – impacts on mental wellbeing, and should be seen clearly and addressed collaboratively to serve the promotion of good mental health, personal autonomy, and full access to civil society. At the same time, responsibility for determining and delivering health and social care must be freed from the highly disruptive cycle of repeated organisational change and political interference in NHS management.

Promoting knowledge, support, and care

A general understanding of the promotion of mental wellbeing, and the way mental health problems are manifest should be promoted at all levels in society through ante-natal care, children’s centres, school and further / higher education, to places of employment, and this should be a central facet of a National Strategy for Public Health.

The vast majority of people with mental health problems, including those who need highly specialised inputs to their management, will rely on primary and community care for diagnosis and ongoing care and support. For the large number of people who have both physical health and mental health problems these are managed together in primary care. Access to social support and integrated resources can best be managed by community based mental wellbeing collaboratives bringing together service users and carers, community groups including ‘Being Well’ projects (Plunkett Foundation: https://www.plunkett.co.uk/community-controlled-care ) commissioners, voluntary sector organisations, local authority services, and primary and secondary health services.

To make these effective,

  1. The severe reduction in funding for primary care, and in particular general practice, must be reversed urgently
  2. Community based mental wellbeing collaboratives (see above) should be established in all areas, with appropriate public health support.
  3. The progressive and continuing erosion of funding for mental health services, itself the product in part of continuing real-terms reduction in funding for the NHS more widely, must also be reversed urgently and in line with ongoing rhetoric about ‘parity of esteem’ for mental health. Parity should not mean a race to the bottom for mental, physical and social health funding.

Specific SHA policy recommendations include:

  1. Parity of funding for the prevention of, treatment services and related social care for, and research into mental ill-health; and for treatments including psychological alternatives to medication; and funding to ensure research findings are applied in clinical practice more quickly. To reflect the accepted burden of disease, 23% of NHS spend should be committed to secondary mental health service provision rather than the present 13%. Funding must be ring-fenced.
  2. An integrated cross-party, cross-government National Strategy for Mental Health including public education, universal support, and clear policies for tackling the societal determinants of poor mental health, ie poverty, debt, housing need, low educational attainment, low employment aspiration and community disintegration.
  3. A new National Service Framework for Mental Health drawing on the ‘Five Year Forward View for Mental Health’ and linked to the National Strategy for Mental Health, incorporating urgent review and reinstatement of national standards for mental health service provision, including for illness prevention and improved access to services.
  4. Establishment of an Independent National Health and Social Care Service Commission to oversee the rapid integration of health and social care, and to govern a new National Health and Social Care Service in future free from party political interference.
  5. Confrontation and breaking down of stigma should be a fundamental part of mental health strategy – this requires more public information and education about mental illness, the building of community cohesion, how to help oneself, and about the principles of early intervention.
  1. Improved and better resources including mental health services in Primary Care / General Practice, funded in addition to and not at the expense of more specialised secondary mental health services
  2. Continued development of integrated services which jointly and holistically address mental, physical and social needs, especially for children, women in the perinatal period, people with learning disabilities and associated mental ill-health, people with serious mental illness, people suffering comorbid physical and mental illness, and older people with multiple physical and mental conditions and related social needs.
  3. Review and possible reversal of the ill-considered and austerity-driven dismantling of specialist mental health teams (eg for people in crisis, people with complex needs and personality disorders, assertive outreach for people with psychotic illnesses), or greatly enhanced resourcing of integrated Community Mental Health Teams.
  4. Further extension of psychological therapy services to provide more alternatives to medication, including increased provision of longer term psychotherapies for those with more complex and enduring mental health problems.
  5. Greatly enhanced services for children and young people with mental health problems (anxiety, depression, self-harm and eating disorders are increasingly prevalent), including collaborative mental health & wellbeing provision in schools and colleges, increased numbers of health visitors and school nurses, ready access to specialised mental health services (CAMHS), an increase in inpatient provision to avoid children and young people being admitted to hospital far from family and home, and specialist provision for eating disorders, post sexual abuse and other post-traumatic disorders, autistic spectrum disorders, Attention Deficit Hyperactivity Disorder, and drug abuse.
  6. Service development and further research for the identification and treatment of ill-health, and provision of integrated social care for older people with mental disorders or dementias, in domestic, community and residential (care and nursing home) settings.
  7. Substantial additional funding and improvement in health and social care services for children and adults with learning disabilities, including for autistic spectrum disorders.
  8. Urgent research and clinical intervention to reduce mortality rates for people with serious mental illness who still die 15-20 years before those without SMI.
  9. Urgent review of the escalating incidence of suicide and attempted suicide, urgent updating of suicide prevention strategies, and resources for rapid intervention and inter-agency collaboration following suicide attempts.
  10. Greatly improved cross-agency provision for people with acute mental health emergencies, including mental health / police interface services and crisis intervention services – including helping friends and families to cope. We should treat mental health crises with the same urgency and import as other medical crises.
  11. Reduction in the number of patients who are subject to Compulsory Treatment Orders, which have not been shown to benefit patients. This will require increased and improved in-patient treatment provision.
  12. Reversal of austerity-driven and counter-productive reductions in psychiatric in-patient bed numbers, including for children and young people.
  13. Comprehensive provision of integrated health and social care services for adults and children who have been exposed to significant traumatic experiences recently or in the past, including specialised psychological treatment services for those suffering from post-traumatic and related disorders.
  14. Urgent and rapid enhancement of mental illness diagnostic and treatment provision in the criminal justice system, especially in prisons for both adults and young people.
  15. Provision of comprehensive, country-wide mental health facilities with essential translation services for refugees and migrants, both in mainstream community services and in detention / removal centres.
  16. More research and sensitive provision for people who experience mental health problems as a result of exposure to stress in the workplace.
  17. Research on and more systematic approaches to evaluating the outcomes of treatments for the full range of mental health problems, including both common, episodic ill-health (eg anxiety and depressive disorders) and severe, enduring mental illnesses (eg schizophrenia, bipolar disorder).
  18. Resources for mental health services have been stretched to the point of dangerousness, so substantial additional funding, imaginative development of more integrated services, and persistent determination will be required to bring about the improvements and changes that are so urgently needed. Only a robust policy framework, freedom from repeated political interference, and ruthless commitment to delivery will achieve true ‘parity’ of esteem and funding for mental health.

References:

  1. NHS Providers (2017) ‘The State of the NHS Provider Sector’

  2. NHS England (2016) ‘The Five Year Forward View for Mental Health’

  3. NHS England (2017) ‘Five Year Forward View for Mental Health: one year on’

Tagged | 5 Comments
%d bloggers like this: