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!