Thursday 27 March 2014

The ACEVO Health and Social Care Conference

ACEVO’s Health and Social Care Conference on Tuesday was a resounding success, with some really stimulating presentations from Duncan Selbie (CEO of Public Health England), David Behan (CEO of CQC), Sandie Keene (President of ADASS) and Sir Bruce Keogh (Medical Director of NHS England),  as well as some fantastic panel discussions.  The focus of the day was how to deliver the ‘Prevention Revolution’  called for by the ACEVO Prevention Taskforce.

All our speakers were in agreement that health and social care must urgently move towards preventative care that takes place in the community and in people’s own homes, ending the current over-reliance on reactive, high-cost treatment in hospital settings. 

Andy Burnham, Labour’s Shadow Secretary of State for Health, gave the keynote speech and outlined his party’s plans for ‘whole person care,’ which include the merging of health, social and mental health care into a single budget. 

I said that I would make my opening introduction to the keynote speech available on my blog, as I didn’t have time to get through it all, so here it is:

Within 2 years half of all hospitals may be in deficit. Meanwhile over 40% of our population with long term conditions account for 70% of the entire NHS budget. The budget for such conditions continues to grow, as do the number of us living longer.

The overwhelming majority of people with long-term or age-related conditions are treated in hospital. My local clinical commissioning group in Oxfordshire spends around 40% of its budget on the local over-65 population. As many as a third of all older people in hospital beds do not need to be there on medical grounds. There, their condition often deteriorates.

Why do we do this? The evidence suggests that we could spend a smaller proportion on elder care were more elderly people treated in the community. The irony? This precisely is what many elderly people want. And it is those same people who the institutions and processes of the NHS are at present designed to ignore.

In 2011, I was asked by the Government to chair the ‘choice and competition’ strand of the consultation exercise in advance of the Health Bill. This was highly contentious in the health service and highly contentious politically. The conclusion that I and my fellow NHS Future Forum members reached was that competition can provide greater choice for patients - but only in certain circumstances. Our report emphasised that competition must always serve "the interests
of citizens and the choices they wish to make.” For example we argued that the legal provisions in the Localism Act that give citizens a “Right to Challenge" be extended to the health service. Why, we asked, can citizens challenge social care providers but not the health service?  We said that competition must always be bottom up, driven by citizen rights not top down imposed by Government or Monitor. And there have been some perverse decisions made in the name of competition. This policy is clearly not working and we need to move the debate on. A competition framework that believes there is a fair playing field between the private sector and charities is nonsense. The NHS is based on the ethos of public service and the general good. That is what charities also believe. We can all understand why people do not like the notion of private profit in the NHS. But that should not stop our sector being able to expand because we offer the delivery, research, campaigning and advocacy that the NHS needs.

There is little sign that the health service, configured as it is, is currently capable of translating the changes we need; moving resources from acute care into community and prevention and this closing hospitals. Day by day, the barriers to alternative approaches have become more insuperable. The Government argued that the new, localised clinical commissioning groups would be able to engage closely with their local communities to commission better-targeted, better-designed services. Yet their implementation of much new localised commissioning has seen less money spent in the community with more services moving back into hospitals to protect their budgets. There are specific examples of perverse practice. Consider: much chemotherapy and end of life care can be provided at home. However, home-based support is often not commissioned because it undermines the hospital providing this service.

A radical change is needed: a new vision for NHS commissioning and a new set of incentives to take on vested interests within the NHS.

Within the charity and social enterprise sector there exists a huge range of providers developing innovative approaches to managing long-term conditions that reduce the demand on hospitals. When a patient's diabetes has deteriorated their feet are chopped off. The conservation trust charity runs a “green gym" which takes referrals from doctors of unemployed people with type 2 diabetes and gets them out in parks and mediates their condition. Charities like the Red Cross and RVS can work on elderly wards and in A&E to support older people getting home and getting the care they need their , as they are already doing in some hospitals now.

Citizens should always have the opportunity to choose such approaches over hospital-based provision. I would argue that 'citizen’s rights' and their “right to challenge” must now be entrenched in legislation. With such rights in place, citizens' choice would drive reform, rather government-imposed competition policies. Such rights are already part of the Government's rhetoric but after a promising start they have fallen by the wayside. The regulator Monitor has still not produced its long-awaited Choice and Competition Framework, which is intended to help commissioners and providers understand where change may deliver improved outcomes for patients.  The Government have a policy to encourage the "right to provide ", encouraging staff in the NHS to spin out, yet this has not been pursued.

A good example of the problem we now have is the fact that most people, given the choice, would choose to die at home, supported and cared for medically and in a caring environment. Yet most die in a hospital bed. So Andy Burnham's proposal to entrench the right to choice at end of life is an excellent example of this rights based approach. Entrenching rights in the NHS Constitution will give confidence that the NHS does truly belong to the people.

Change will not only involve entrenching social rights; it will also involve realigning the NHS' perverse incentives. For example,  when acute hospitals are paid according to volume of activity, they have no incentive to reduce admissions - quite the reverse. As ACEVO articulated in a 2013 report entitled The Prevention Revolution, there is an urgent need to develop outcomes-based funding schemes that will reward reductions in admissions and incentivise the growth of preventative care and support.

The key to delivering on these aims is robust political leadership. There has been criticism that   the rhetoric on competition has become muted, but actually that is no bad thing. Competition is a means to a better NHS, not an end in itself, and any Government must focus on the key strategic tasks: tackling long term conditions, prevention and community solutions for the elderly. Rather than talk about competition, we need our politicians of all parties to provide the cultural and systemic leadership for better commissioning to move resources from hospitals in order to increase the diversity of providers and approaches available to our citizens.

Andy Burnham has been brave in arguing for radical changes to provide integrated care. The Oldham report is marking out a radical path for change. This is essential.

Successive governments have failed to understand commissioning, and have failed create a system in which a diversity of health providers can flourish. The impact on our hospitals continues to be
grave. A  Government post 2015 has a chance to change this; and the politician that leads on this agenda will be the key to saving our NHS.

Over to you Andy!

Monday 24 March 2014

Oxford, the Lister and...

A big family occasion at the weekend; my nephew Alexander getting married. The ceremony was in the Chapel at Wadham College, then lunch at Exeter College, finishing with Indian dancing in Oxford Town Hall. No, I did not partake of the dancing

I read a lesson at the wedding- a favourite piece from T S Eliot, the last section of the final part of the four quartets (Little Gidding).

"We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time"

But as this marks a beginning I was also reminded of the end (Eliot’s poem is centred on the notion of “in my beginning is my end”) as rather sadly I had to visit my great Aunt in the Lister hospital in Stevenage. She is 101 and taken into hospital on Friday with an infection. But I have to say when I visited she was showing signs that premature expectations of end of life may be confounded. She has a strong and determined spirit. I was also much impressed with the care being given by the doctor and nursing team there.  You hear and read many stories of poor care for the elderly but no signs here. Rather the opposite. 101 is a fine age.

And finally, you might be amused by the following piece from "Civil Society".

 “The culture of celebrity comes to Regent’s Wharf

Congratulations to Leeanne Graham, personal assistant to Sir Stephen Bubb, chief executive of Acevo, who has joined the board of the Association of Celebrity Assistants, a not-for-profit membership organisation for, well, people who assist celebrities.

Congratulations to Sir Stephen, too. Any lingering doubt about your own celebrity has now been expunged."

Friday 21 March 2014

Soho and Glasgow

If you are ever in Soho Square, look up at the elegant Georgian town house in the SE corner. Emblazoned across the front is “House of Charity". This is the House of St Barnabas, a long standing charity providing help and support to young people, particularly to get them back into work through their academy and support schemes.

I have blogged about the wonderful developments here before. I went to see this place as it was transformed from a girl’s hostel into a club for social leaders. An inspirational CEO, Sandra Schembri (ACEVO member naturally) had the idea of turning the elegant " hostel" into a club that then provides income to support their work with deprived young people. The hostel had become outdated and inadequate for proper care and they wanted to focus on support for young people into work.

I was there hosting a dinner wearing my Social Investment Business hat. We were celebrating the new partnership we have formed with the Social and Sustainable Capital group, formed by 2 brilliant ex City lads who wanted to turn their huge financial acumen to further the reach of social finance. SIB and BSC have put capital behind 2 new funds they have established with a 20m pot for third sector organisations to apply for simple straightforward investment. It’s what the sector needs; not a lot of talk about equity and complicated social impact bonds. 

Amusing to bump into Peter Holbrook (CEO of SEUK) in the bar. He is a frequent visitor here he tells me!  ACEVO members can join St Barnabas at a reduced membership fee. I recommend it.

They even have a smart garden and Chapel (good place to marry!).

I also had a great meeting with CiarĂ¡n Devane, the CEO of Macmillan Cancer Care to talk about where we are in getting a reformed NHS. He also sits as a non-exec on NHS England so in a powerful position to influence the debate on shifting resources from hospital to community. Amusingly I flew up to Scotland afterwards to Chair some interviews for the Government and popped into the new Museum of Modern Art. In the cafe and library there I spotted this magnificent display from them. I know from personal experience that the advice and support they give to people with cancer is second to none.

Thursday 20 March 2014

Charity Safety Net Stretched to Breaking Point cont..

The Financial Times last Friday published an article on the voluntary sector filling in the gaps of austerity in which I was quoted.  Having recently blogged about ACEVO's new research that warned the charity safety net is a breaking point, I wrote to the FT in response. 

Here is the letter, which also appeared in the Times

Sir, As you report, charities are increasingly acting as the “safety net” for the most vulnerable in our society. A new survey released by the Association of Chief Executives of Voluntary Organisations (Acevo) this week shows that this role is coming under increasing pressure; 88 per cent of charities have seen an increase in demand for services over the past year, and 89 per cent expect further increases in the year to come.
However, fewer than a third of charities feel confident that they will be able to meet this demand. In an environment of spiralling costs and diminishing funds, the government must intervene to ensure that charities retain the capacity and capability to support our most disadvantaged communities.