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.
