Sir Stephen Bubb

Sir Stephen Bubb

Friday, 19 April 2013

Winds of change? Radical reform for health needed




In retrospect, Danny Boyle may not have done us a favour? Do politicians need to stop the rhetoric about how the NHS is a national treasure (which it is)and get to grips with the crying need for radical reform? Yes- in many ways it is a national treasure but that may sometimes justify a woolly approach to a growing crisis in our health service. As Norman Lamb, the Health Minister said at a recent ACEVO health conference the NHS is often described as a national religion so any proposal for change can be seen as heresy. We must not avoid a sensible debate on radical options for change. Many of us would argue that the resource problems are no so great that without reform the treasure of a free universal service will come under threat.

This is the message of ACEVO's Taskforce on Prevention in Health, chaired by Sir Hugh Taylor, which launched its report on Wednesday at our Health and Social Care Conference. The Prevention Revolution: Transforming Health and Social Care sets out some key recommendations aimed at shifting resources from reactive, clinical services to integrated, preventative services, which support better self-management of conditions, more home and community-based care, and better support to address the social determinants of health. It emphasis's the need for new, innovative providers from the voluntary sector to pioneer new ways of working and achieve real cultural change.

I would argue for a radical look at our 1948 health model, which builds on the advances in medical care and great hospitals but now starts the shift of resources to community care and prevention.  Health and wellbeing has changed dramatically over the last 65 years. Now even cancer is increasingly a long-term condition. But our resources continue to be dominated by acute care, not prevention or community care.

I've watched the debate on health develop since that big listening exercise in 2011 where I played a somewhat controversial role in arguing for more choice for patients. I remember people telling me patients don't want choice. Well, since then that patronising and damaging claim has been shot away. With the continuing exposure of poor to sometimes criminal neglect in some hospitals, who can now doubt that choice is important. I doubt the relatives of those who died at Mid Staffs were worried about the colour of the uniform of the staff - whether that was an NHS, private or charity uniform.

It's not just Francis. The recent report from the CQC, which states that older people in nearly a fifth of hospitals are not being treated with dignity or afforded the respect they need, is damning. Then there is the independent report by Bristol University on a 3 year study about the handling of the care of those most vulnerable; people with learning disabilities. Such patients are dying on average more than 16 years sooner than anyone else and it shows catastrophic failings in care contributed to this.

We know there is also huge professionalism and dedication in our health service at all levels; innovation and medical advances that benefit us all. We know of dedicated doctors and nurses who go the extra mile. We should avoid the trap that assumes, post Francis, all NHS hospitals neglect patients. But the reality is that the case for radical change is strong and getting stronger.

The financial problems of the service are masked by the supposed Treasury decision to protect spending. In fact, as health inflation rises more than general inflation each year resources for health (and of course council resources for care) decline. And medical advances and an ageing population with growing chronic illness add further pressure.

The Nuffield Trust predicts that an ageing population in an unchanged NHS will cost an extra £54bn from 2011 to 2022. And that ageing population will be living with a range of long term conditions that will sometimes require medical intervention but more often will need care and support in the community.

Increasingly citizens are getting ahead of the politicians in understanding there are good hospitals, excellent hospitals and bad ones. Good doctors and surgeons and bad ones. And they want to choose the good ones, but our producer-dominated system often either denies them that choice or does not provide the information needed to enable it .

A recent poll by ICM asked people what they thought of this statement:

“It shouldn’t matter whether hospitals or surgeries are run by the government, not-for-profit organisations or the private sector, provided that everyone including the least well-off has access to care”.

83% agreed with this – 56% strongly, while only 14% disagreed, 10% strongly.

Yet the political parties are frightened to embrace the obvious: that what matters is what works, not who provides the service. If a private hospital cares for its patients better, then people should be able to choose it. If one NHS hospital is better than another then let people choose it. If people at the end of life want to be supported at home or in a hospice why do we deny then that choice. And at the beginning of life why do we so often deny mothers the right to a home birth?

To give you a very practical problem, some 7,000 people a year have their foot or toe amputated as a result of their diabetes, but we know proper advice and support and practical assistance for people with diabetes could dramatically reduce that figure.

So we need to move resources from hospitals to community. Just as in the 80s, we started the revolution in the care of mental health by closing asylums and developing care in the community, we now need to close and reorganise hospitals, reshape their services and move resources to prevention, to integrated care usually provided in communities and where charities are in the lead. This does not necessarily mean we should close a hospital. We should equally be considering how we change and adapt these assets in a different way. Reshaping the services they provide to acknowledge the changes brought about by a growing elderly population and chronic illness. Developing Community or cottage hospitals. Centres for integrated care.  Contracting for partnerships to run such hospitals between the private, third and public sectors.

Indeed by ensuring more frail elderly people receive proper care and appropriate medical support in the community will enable hospitals to concentrate their skill in tackling the more difficult and problematic diseases and advancing the boundaries of medical science.

So who needs to do what?

There are hundreds of well resourced, professional charities. World leaders. Masters of innovation. Close to their members and communities. Advocates and champions of patients. Experts and repositories of knowledge. We need to commission them more.  It is by growing the charity and social enterprise sector that we can help to start that shift in resources to prevention and community support.

It will require the new CCGs to actively revise their commissioning policies and strategy. To contract differently.  To look at what is being spent on the frail elderly and on dementia, and demand that it is done better. To review spend on long-term conditions and to seek alternative approaches. To work with local councils to develop public health strategies that promote wellbeing.

We need the 19 commissioning support units to actively promote the third sector and to provide practical support to CCGs who want to engage with that sector.

And the new National Commissioning Board could be key to encouraging a culture of change and innovation, rather than rules adherence and risk avoidance. Will it?

I think that local councils could play a significant role in demanding change. We need the new Health and Well Being boards to flex their muscles. Few in the health system have understood that a determined HWB could be an engine for change and a powerful push to challenge complacency. They need to challenge and take on the power of vested interests in favour of their communities.

And what of the politicians? Both parties are showing a timidity of approach and a lack of courage in confronting challenges. Competition is not a disease. Well managed and regulated competition opens up choices. It delivers better for citizens and taxpayers. So let's encourage people to exercise choice and encourage challenge from patients and citizens. That means being open to different sectors and using competition as a force to promote choice. I don't believe in competition being forced on the health service but I do believe in citizens demanding that when they see bad provision they secure change. If that means charities or the independent sector provide more, then so be it. It's bottom-up reform. It's the power of challenge to entrenched interests that could see reform and the Parties need to promote and encourage that. We cannot support notions of the NHS as a "preferred provider" in the wake of Francis. That would be to assume  the interest of the provider is more important than that of the citizen and patient. It is that culture we must change.

In the choice and competition report of the listening exercise we recommended a statutory right to challenge (as enshrined in local government law). We need that done now.
  But this also means the third sector needs to reflect on whether its own organisation and structures meet the new commissioning world. We need to do more to promote consortia working and alliances amongst charities and social enterprises. That might be amongst like charities at national and at local level. Or with private and public sector providers, including direct work with hospitals.

That is the work ACEVO will be doing; with our members and with partners like the NHS Alliance, NAPC, the Foundation Trust Network and colleagues in our sector.

Is there a “wind of change" in the NHS? We can see the signs. But now we need Government and Opposition to wake up to their leadership role in being radical for reform.

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