Friday 27 June 2014

Lord Norman Warner argues that the NHS, as currently constituted, is well past its sell-by date and in acute need of reform. Based on a recent report co-written with Jack O’Sullivan, he puts a forthright case for radical and fundamental reimagining the way the health service works in the community

Recently, a Commonwealth Fund expert panel rated the NHS as the world’s best healthcare system. It certainly does score very well on universal coverage and relative cheapness. However as the same report showed it comes tenth out of eleven advanced counties in terms of `healthy lives’ – a score which includes deaths among infants and adults who would have survived if they had received timely and effective healthcare.

This seems a hefty downside for a health care system. The reality is that the NHS is now on a path of inevitable decline without radical reform, write Lord Norman Warner.

Despite spending £130 billion a year of public money on health and social care – more than education, defence and police combined -  these services increasingly fail to meet the needs of the frail elderly; people with long term conditions; those with cancer, and the preventative requirements of younger people with obesity, diabetes, mental health and addiction problems.

We fail to look after people in the community at the right time, casually neglect social care and have a half-hearted engagement with public health. Demand and need both continue to rise with the changing demography and disease profiles. Adult social care is now in a parlous state as budget cut follows budget cut, with more to come. 

Meanwhile we go on propping up expensive acute hospitals to look after people who shouldn't be there – 25 per cent or so of the occupants of acute medical beds. While most people want to die in their own  home we force many to die in the most unsuitable and expensive alternative – the acute medical wards.  We are increasingly aware of how unsafe some of our hospitals have become because they cannot provide 24/7 consultant medical cover for many specialities. You are much more likely to die in an acute hospital if you are admitted at weekends or even in some days of the week. 

Our current inappropriate care delivery model, largely unreformed since 1948, inflates NHS costs and limits many people’s potential to live longer and healthier lives. Yet we and our politicians go on worshipping at the shrine of an NHS created 65 years ago in very different social circumstances, as though criticising it or radically changing it will somehow destroy our national identity.

But now a major affordability gap is opening up of at least £30 billion a year by 2020, with a £2 billion gap in prospect by the May 2015 Election. The status quo is unsustainable – given our tax base; the state of the public finances; changing population needs, and scientific advances. As public expectations rise and public resources shrink we face a perfect financial storm but nobody standing for election, across the political spectrum, wants to talk about how to fill the gap.

This is not just a health and care crisis. By 2015 the NHS will account for nearly a third of government department expenditure (excluding social security). The great unspoken truth of British politics is that the NHS, as it is run and funded, risks seriously damaging other public services. Pouring more of our limited public money into an unreformed health and care system can only jeopardise other public services, already more harshly treated than an over-protected NHS. A good example is social care - seriously damaged by 30 per cent cuts in local authority budgets. Do we really want to cut other services like early years’ children’s services, social housing and support, disability services, vocational training and education to protect an NHS poorly designed to meet modern needs?

So what to do? We need a reform programme that tackles both the care and cash issues together. However well-intentioned, simply pouring more public money into an unreformed health and care system represents poor value for taxpayers’ money and will ultimately lead to public disappointment and anger. Change will take time and we need to start re-imagining the NHS and thinking about a reform programme that will take the next Parliament and beyond to complete. And beware those who suggest there is a silver bullet like a one-off tax or national insurance hike – both a tax on jobs. 

First we must rebalance the NHS so that it provides more effective community-based services, closer to where people live. This means converting many existing hospital sites to fully-fledged community hubs providing a wide range of community-based integrated services available 24/7 and funded from an integrated budget. 

These new community hospitals should include improved urgent care; physiotherapy and rehabilitation; outpatient specialist appointments; minor surgery; access to integrated health and social care; pharmacy; dentistry and optical services; palliative and end of life care; nursing homes with on-site medical cover; health and care information and advice. They would have few acute beds and more limited diagnostic services. 

Alongside, or as part of them, there should be consolidation or federation of enhanced general practices to ensure better 24/7 primary and urgent care. Hubs should have new consultant general physicians with expertise in chronic disease management and the care of frail elderly people with multiple co-morbidities.

Second we should commit to creating a new “National Health and Care Service” with full integration of community health and social care budgets at national and local levels to secure more personalised whole person health and wellbeing. This means a bigger role for local government, with Health and Wellbeing Boards gradually becoming the budget-holders for social care, local public health funding, and community health services (including mental health); and services delivered by community hubs and elsewhere in the community.

These budgets should be allocated on a weighted capitation basis and shared with CCGs who would continue commissioning services in cooperation with HWBs. Over time the two bodies might be merged by agreement but without any `sudden death’ reorganisation. NHS England would be responsible for monitoring the performance of HWBs and holding them to account for public monies, and retain responsibility for the provision and supply of family doctors.

Third, we have to strengthen hospital specialist services because too many acute hospitals are trying to deliver an inappropriate range of service lines and jeopardising patient safety. Over no more than two Parliaments, these services should be consolidated on fewer sites, better staffed and better equipped for 24/7 access with guaranteed 7-day consultant cover for their services. These changes should be clinically led and overseen by NHS England using their specialist commission powers. This change would save lives as well as money, as was demonstrated by the consolidation of stroke services in London from 32 centres to 8.  

Fourth we must increase local discretion over the pattern of services and who provides them. The over-centralisation of the NHS has limited experimentation, innovation and the use of new technology, usually to the detriment of patients. We need more patient choice and we should end the phoney arguments about who is best to provide services. The great achievement of the NHS is its universal coverage of financial and clinical risks, not monopoly public service provision: there was no such monopoly prior to 1948. 

We still need some central guidance drawing on evidence of good practice and what provides good value for money. But this should be kept to the minimum with local people able to take more responsibility for the way services are provided within their local community health and social care allocations and within a new slimmed down NHCS constitution of rights.

Fifth there should be a new partnership between the State and with individuals for co-producing health and wellbeing, with more emphasis than now on individual self care and preventative healthcare. There should be a new local NHCS membership scheme with a monthly subscription for those not exempted, such as children, of £10 a month collected through council tax and devoted to locally determined prevention schemes.

Finally we need new funding streams for a new NHCS. To kick start change a £15 billion Service Transition Fund should be established using the resources identified by Monitor in their October 2013 report Closing the NHS funding gap. Although the health part of the new NHCS should be largely funded from general taxation, more use should be made of hypothecated taxes that promote healthy living (eg taxes on alcohol, tobacco and unhealthy foods and drinks) and more related to care consumption eg compulsory social care insurance – as in Japan – and inheritance tax) We should look at means-testing continuing care under the Dilnot-capped costs regime and extending charging for prescriptions, travel vaccinations and for hospital hotel costs, as in France and Germany.

These changes will be highly controversial but we have to engage with these issues as a society if we want a health and care system fit for the 21st century.

Lord Warner was formerly director of social services for Kent County Council, a senior civil servant,the first Chair of the Youth Justice Board, Chair of the National Council for Voluntary Organisations and member of the Dilnot Commission. He was Minister ofHealth from 2005-2007 and the author of a number of seminal reports. He iscurrently Commissioner for Birmingham City Council’s children’s services.

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