Wednesday 22 February 2012

Catherine the Great and Health!

Today's Times carries an article from me making a plea for politicians to realise the real challenges on health and social care, and make use of the imagination and innovation of our sector. Members who were at our AGM will have to forgive me for using the Catherine the Great quote!

When facing great political turmoil, Catherine the Great once said, "a great wind is blowing and that gives you either a headache or imagination". The current debate on the Health Bill has certainly given the Government a headache. But is our political class responding to the challenges facing our health and social care system with sufficient imagination?

When I was writing the report for the Government on choice and competition as part of the Health Bill's listening exercise, I was struck by the fact that there is a great deal more consensus on the challenges facing health and social care provision in this country than the furore over the Health Bill would suggest.

Crucially, there remains common acceptance by all major political parties of the basic principle of a universal national health service, provided free at the point of use. Furthermore, there is also growing agreement that the current system cannot cope with the growing health needs of a changing population.

There are now 18 million people suffering from long-term health conditions in the UK. That number is growing. 21% of the population are now aged over 60. That proportion is growing. Medical advances, lifestyle changes and demographic shifts are growing demand for NHS services, but financial resources are limited.

Almost everyone agrees we have a problem when over 70 % of NHS funding is spent on treating long term conditions, usually in the most inefficient way there is: in hospital. And almost everyone agrees that if the NHS is to cope with these pressures it must shift resources towards preventative, patient led community based services which treat chronic conditions far more effectively and which act to pre-empt acute crises of ill health.

Might I also suggest that the majority of observers agree that to carry out this change effectively, the NHS must allow new providers with new ideas to break the bureaucratic stranglehold on service delivery. When in government, Labour's Andy Burnham- now shadow health secretary- spoke of his vision for a preventative and people-centred NHS which would allow the maximum freedom for local innovation. Much the same thing can be heard from Health Secretary Andrew Lansley today. And yet, to judge by the reaction that his bill has provoked, one would think that a centralised, bureaucratic and too often inefficient model of healthcare delivery is politically sacred and permanently untouchable.

Similar challenges face our increasingly broken system of social care provision; a problem which, as I suggested at the Health Summit at No. 10 on Monday, we have yet to tackle effectively. Successive governments have failed to address the issue of the growing numbers of frail elderly who are increasingly being treated (often badly) in hospital beds, when they should be receiving care at home or in high-quality residential homes. Due to the growing proportion of elderly members of the population, the system is creaking at the seams. We desperately need a political consensus to reform our social care system, and the current acrimonious debate on health is distracting attention from that necessity, as well as from the way forward proposed by the independent Dilnot Commission on social care provision.

What frustrates many of my members, the leaders of the country's charities and social enterprises, is that despite the consensus on both problems and solutions, the debate over reform focuses on the phantom of "privatisation".

We know that the majority of people who die in hospital want to be cared for at home or in a hospice, yet we fail to commission the charities that provide that care. This is a shocking waste. Many of the country's charities have a deep understanding of the problems that people and communities face, and do a superb job of providing vital community-based health care and much-needed assistance for patients in their homes. They know how to help patients to manage their own conditions. In such cases, supporting patients to manage their conditions through lifestyle, diet and exercise, is just as valuable as the work that clinicians do. Yet we continually fail to commission those charities that have the ability and drive to support patients in this way.

I fervently hope that our politicians can build on the common ground that exists on the need for health and social care reform, and find a way to take it forward. The positions of the Coalition and the Opposition differ more in emphasis than in substance. The Government is right to stress the importance of an open public service environment in which new providers can compete, innovate and offer users a real choice. However, it should place more emphasis on the end to which competition is the means: meaningful patient choice and user-led, community-based services that focus on effective intervention and prevention. The opposition, for its part, is right to emphasise the need for integrated, preventative services, but has forgotten that competition is a necessary first step to making that possible.

When we face the toxic combination of dramatic increases in demand for health care and dwindling resources, we must ask that the political parties focus on how the existing model can change to deliver effective health and social care that is based in the community rather than the hospital, is focused on prevention rather than cure, and places power and choice in the hands of citizens rather than providers. The change we need will never be achieved by leaving the current bureaucratic centralised systems in place. So how do we encourage the innovators with the imagination to do things differently?

An early start today. Off to Leeds for another silver jubilee meeting with members, but first off to early morning Mass for Ash Wednesday. I'm giving up alcohol for Lent...I wondered if I should mention on Blog in case I fall from grace and am caught by a member slurping a white wine...

1 comment:

Dan Filson said...

High quality residential homes. What a good idea. I was for several years chairman of trustees of a charity that had supplemented a set of almshouses (read, sheltered housing) with a home for frail elderly (not, note, a nursing home), with the original intent of housing almshouse residents who could no longer live on their own but open to direct admissions too.

The care given for residents, mostly not very mobile but able to spend their days in a well appointed day room if they chose to leave their own rooms (or were not bed-bound) was good. The food was good and there were superb gardens adjacent to the day room.

Arguably the trustees made an error (the home was opened before I became a trustee) in not going for economies of scale as a care home is labour-intensive and labour in inner London is not cheap, especially if, by choice, you do not pay the rock-bottom wages paid in the private sector, nor the higher ones paid in the local authority sector, but in between.

What became apparent in recent years was the sheer market forces of bad care driving out good, and cost-driven considerations driving out care-quality considerations. Put simply, the local authority who for the most part were increasingly the purchasers of our places chose to first fill their own homes - middling in quality, frankly - to keep them viable, despite the weekly cost per resident being a couple of hundred pounds a week higher. Then they shopped around in the private sector for the cheapest weekly cost, often well away from the borough in places where nobody familiar would visit the resident. Only if they could not find a place thus did they turn to us, even though the quality of care was recognisably better than that in either their own homes or the private sector's (at least at the market end we were covering - no doubt somewhere there were very high quality private sector homes at over £1,000 a week), though a leading councillor's mother was found a place. Faced with an absence of placements from the council, the charity for a period accepted pure private sector residents whose absence of poverty or anything approaching it sat uneasily with our charitable terms of reference. Eventually the trustees, after I retired from their number, decided the financial risks and subsidy could not be justified and closed the home, and are now converting the premises into further almshouse accommodation with minimal staff presence.

So there goes another place where those who should not be in hospital, but are too frail to live alone in their own homes, could have gone. By the time the authorities wake up, there will be no voluntary sector presence in London - and possibly increasingly more of southern England - for this type of resident, and even the for-profit sector frankly finds it too hairy given the quirks and roller-coaster policies of placement purchasers.