Health and care matters

ACEVO has a strong membership in charites and social enterprises in social care, health and disability, so we hold an annual national conference to debate issues of concern and hear from key people in the sector.

We had a bumper crop this year. All the main parties set out their stalls. Paul Burstow MP, Jeremy Hunt MP and Andy Burnham MP spoke, but perhaps the most interesting session was when Simon Stevens (head of NHS England) set out some of the issues he faces leading NHS England, and asked for our views.

Inevitably, since the emergence of the disgraceful new grant conditions to be imposed by DCLG to snuff out advocacy in our sector (that morning's Times) there were questions on this. Paul Burstow from the Lib Dems was quick to denounce what he called "the Pickles gag" and Jeremy Hunt, though he would not comment directly on the Pickles move, was clear about charities' right to campaign.

We launched our Alliance Contracting report at the conference. There's more details here.

Alliance Contracting is a new way to promote more collaboration in health and care settings - a post-competition approach that builds on more collaborative approaches and consortia-building. Current government procurement is so often costly and overly bureaucratic. It has favoured private sector bodies too much because we don't operate on a fair playing field. Andy Burnham was particularly supportive of this approach.

Indeed his policies of entrenched rights for the third sector in delivering services, and 5 to 20 year contracts were music to the ears of our members. In fact, as I observed to David Brindle of the Guardian, I think this is the most radical approach to the sector of any politician in any party. Much to be supported and perhaps a benchmark to encourage others to follow. We shall pursue at out forthcoming third sector hustings on 24 March - everyone very welcome!

And let me leave you with some photos of our speakers yesterday.

Charities and A&E – quiz the ministers!

Well today’s been good for drawing attention to charities’ work in A&E. We’ve announced a new programme with Red Cross, Age UK and RVS, funded by the Cabinet Office. 700 charity volunteers to work in the 29 most under-pressure A&E departments around the country, and help reduce demand on A&E over the next 12 weeks. See today’s Telegraph for an excellent roundup by Chris Hope.

Naturally, this is the precursor to bigger things. I’m making sure that government collect evidence of how charities can reduce the load on A&E. It’ll be a good evidence base for a wider national intervention in future years. Charities need to be integral to A&E strategic planning in future. This programme will help make that happen.

But what of the parties’ thoughts on the third sector’s role across social care + health? At election time this is the important question.

On 3 March ACEVO’s Health and Social Care Conference is the biggest such third sector event. In central London (and in front of the BBC + other cameras!) we’ll have not only Jeremy Hunt but also Labour’s Andy Burnham and the Lib Dems’ Paul Burstow to put their respective pitches to third sector leaders. With lots of time for questions. And in the morning we have a session with Simon Stevens of NHS England – an excellent chance to discuss progress on his five year forward view.

I highly recommend you come along, whether you’re third sector leader or anyone else. Tickets here: https://www.acevo.org.uk/event/spring-health-social-care-conference-2015. See you there!

Choice and integration

The third sector leads the way in joining social care and health. My recent work on winter pressure in A&E departments has reminded me just how effective we are at reducing demand for hospital services. More news on that to come later in the week...

I've written a piece for the New Statesman today, looking at Labour's plans for a 'National Health and Care Service'. Here it is:

Government NHS reforms adviser: Burnham's plan for patient choice is the right way

Last week, the former Health Secretary Alan Milburn said it would be a "fatal mistake" for Labour to fight the election by spending on, but not reforming, the NHS. He was joined by another Labour luminary – Lord Darzi – on Friday, as a clear group appeared to line up against the shadow health secretary Andy Burnham’s agenda.

These attacks are not just unseemly, but wrong as well. Look behind the headlines and Burnham’s agenda is the right one: to reenvision the National Health Service as a National Health and Care Service. Now we need more detail on how this is to be done.

It’s clear the NHS can’t survive without fundamental reform. As an adviser to this government during the passage of the Health and Social Care Act in 2012, and more recently on care for people with learning disabilities and on winter pressures in Accident and Emergency, I’ve seen the gravity of the situation first hand.

I’ve also seen there are no easy cuts to make. Cuts without strategic thinking have fragmented not only healthcare but also social care across the country. This directly harms our most vulnerable citizens. It means more people falling through the cracks of a breaking structure. We are on borrowed time and on the cusp of a reality where crises like the one we are living through in A&E this winter will become the norm. And it is largely our legislators’ fault.

Poor social care causes more damage every day. Cuts to council budgets have trimmed care for the elderly to the bone. Charity CEOs tell me of reverse auctions for local health contracts being won by the very cheapest service, whatever form it may take. Some private operators – though they are often very effective – may bid so low that they make a loss on social care and recoup the money elsewhere.

In A&E, these cuts send more older people into hospital for preventable problems. Often 20 per cent of beds are filled by elderly people who aren't ill, but end up in hospital because no one else can help. They can't be discharged because there's no social care to help them at home. Cutting costs money; when we run out of beds it can also cost lives.

Burnham's plan is to price in these very real externalities of running a health service. The vision is to change the NHS by replacing competition with integration. When Burnham talks about integrating the work of public, private and third sector providers, he is indicating a situation in which new services are created by new kinds of collaboration.

Collaboration rather than competition becomes the driver of patient choice. This is not merely theoretical. This winter I have chaired an NHS taskforce to get charities in to 29 emergency departments that are under pressure to tackle the immediate problem. We hope to get the charities into action early next week. We will be giving vulnerable patients a choice to receive community care that the market has failed to provide.

No doubt market liberals of the left and right will sniff at this vision of a world of choice beyond how they define it. But politicians of all parties must keep their nerve. The idea of a health service rescued by cuts and efficiencies is debunked. Now they must scale up the radical approach into a sustained plan of action. 

They can build on pilots like the charity intervention into Accident and Emergency, on innovations such as the coalition’s attempts to pilot bringing together budgets for health and social care at a local level, and they can create a new, integrated plan for health and care. The Burnham plan may not be easy to digest or to do – but it is needed.

NHS and charities!

Two weeks ago Simon Stevens published the NHS Five Year Forward View, a high-level strategy document on the future of the NHS. A couple of days later Andy Burnham reiterated his stance that the NHS should be the ‘preferred provider’ of health services, in an interview with HSJ.

Both positions mention the voluntary sector and profess its value. But there’s little hard policy to say how exactly we’ll establish good partnerships with heath commissioners. Enter ACEVO and our new ‘Working in Partnership’ report, published with the Central Southern Commissioning Support Unit.

Our report sets out seven principles to break down the barriers to partnership working between health and social care commissioners and the voluntary sector:

1. Sustainability - Organisations should seek to build partnerships through jointly committing leadership time and resource to understanding each other’s operating environments and contexts.

2. Transparency - Organisations should be open with each other and clear about the purpose and benefits of the partnership for partners, patients and the public.

3. Joint Vision - Organisations should share their vision and plans as early as possible so that they can identify synergies and opportunities to develop a joint partnership vision.

4. Joint Capability - Organisations should seek to enhance each other’s capability through, for example, knowledge transfer or the joint provision of services.

5. Proportionality - Both partners should be equal in the partnership but should be proportionate in their requirements of each other.

6. Innovation and improvement - Organisations should seek to share, develop and implement innovative solutions.

7. Accountability and governance - Be clear about how decisions are taken within each organisation and within the partnership. Agree how you will hold each other to account.

This is excellent progress. Now we need health commissioning units across the country to take these principles on board. ACEVO’s 2015 Election Manifesto - which we publish very shortly - devotes much attention to this area and will give the political parties food for thought. I’ll have more on this next week...

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!