Dog buying not leg chopping

Follow the money. Long term conditions take 75% of the NHS budget. 18m people have one long term condition. Many have more. If you are over 60 it is likely you have a long term condition. If over 85 you will likely have more than one. And the numbers of elderly continue to rise. And the numbers of long term conditions rise. So where coronary heart disease and cancer would once carry you off , they now often represent a long term condition.

So if I were looking at reform and how our NHS will survive on limited budgets and rising demand I would start here.

But we are not.

Why is this?

One reason is the pre dominance of hospitals in all the debates. The medical model is paramount and yet we know perfectly well what works; integrated models of health and social care.

Let's take an example; diabetes; 2,5 million people. And growing. How does the NHS tackle this? At one level, for Diabetes type 1 it's good. It chops off peoples legs effectively and efficiently. Does it do well in work to prevent obesity? No. Does it do well in working with people who have diabetes type 2 to prevent progression ? No.

And how do we commission services? We prioritise leg cutting when dog buying or kite flying may be the way forward. So we need to be working with organisations like Diabetes UK encouraging them through commissioning to develop integrated systems of care for those with diabetes where they work with the private sector ( eg high street opticians ) local government ,other providers of support services in the third sector and hospitals and GPs to develop the integrated offer or offers.

Offers that build in control and choice for the citizen so that they can be more in charge of their condition.

Offers that develop personal budgets for thr consumer?

Already on the ground there are innovative integrated approaches being developed. They are led by organisations like BTCV ( the conservation volunteer body ), MIND , Diabetes UK, Natural England etc which are developing ways to support people with diabetes to get more exercise , support and advice. Why is the DH not promoting and encouraging all this from the front?

So how , in the futue , will the NHS Commissioning Board promote this? A number of pointers are already emerging.

Appointments to the Board should reflect where the money is spent. So over half might come from social care,long term conditions for example . So all the usual suspects from the acute world need to give way.

There needs to be a strong element of external challenge to established DH thinking in appointments. Brendan Barber for example rather than yet another CEO of a large teaching hospital , Barbara Young, Clare Fox of the Ideas Institute, Matthew Taylor. Allison Ogden- Newton. Just to name a few.

In many other organisations that are looking to cut the cost base and increase productivity you would start with where your biggest spend is. But not in the DH. The attention and focus on hospital spend is very noticeable. Many of the comments on competition have been around the effect on hospitals, not on how competition might open up new solutions in long term care or promote integrated care approaches and personal budgets.

I've just emerged from No 10 and another breakfast meeting: though this time it's a bacon roll in the cafe rather than one of those grand roundtable affairs in the State rooms. I push the message above with force but I'm under no illusion that as far as many in the health world are concerned these are the cinderella services. But I'm convinced this is a top priority for health.




The " Pause Room " at DH. My attic abode!