A visit to an old people’s home in Croydon for the launch of a new St Christopher’s project, bringing together social care and end-of-life care. I just had to go because the topic is such a direct hit on the subject matter of this blog.

For some time now, St Christopher’s has been focusing on all the people in our community who don’t get and don’t need a hospice service – the majority of people who die at home and in care homes. Too many of them, as the National End-of-life Care Programme says, end up in hospital, often because of anxiety by staff in a care home about whether they can cope with someone whose condition seems to be getting suddenly worse. Or, to be honest, whether the management of the care home have got anxious because too many people are dying and they don’t want to get the reputation for that. The problem with this is that, even if people think care homes are God’s waiting room, the managements mainly act as though everyone’s going to live forever with this wonderful care they’re getting. Of course, older people themselves realise that the reason why they’ve moved out of their own home is that they’re going to die soon and we have to recognise that better in health and social care.  As it is, we can all remember the Fawlty Towers episode in which a resident dies and John Cleese has difficulty in smuggling the body out of the hotel; that’s another example of the ‘nobody dies’ syndrome. Some hospitals and hospices are also set up to get the bodies out the back way (the John Cleese way, but probably not that incompetently), and in reality most people do not want to be involved with someone’s death unless they have to be. So it’s not surprising that people, even health and social care people, back away a bit when the prospect comes up. You can feel confident in your professional or interpersonal skills and still not think that you want to be involved in the death of someone that you’ve got to know.

So the National End-of-life Care Programme in its document: ‘The route to success in end-of-life care – achieving quality in care homes’ is keen to get care homes to be more prepared to take on people who are dying in their care home.

That is what the St Christopher’s project is all about. Pre-project statistics in Croydon showed that above the national and regional average of people (more than 50%) died in hospital and below the national and regional average died at home or in a care home – the place where they live. So, for some time, they’ve been working with nursing homes there, using the Gold Standards Framework (GSF), which improves training and commitment to good quality care at the end of life. They’ve massively improved the proportion of people dying in the nursing home rather than being blue-lighted to hospitals from  55% to 76% over a  year period. Obviously that means people dying where they are surrounded by things and people that they know rather than being in an alienating hospital. So now they’re going to repeat the trick with ordinary care homes starting with the four that are taking part in this project. Fewer people die there, but it’s still a big issue.

How do they do it? It’s mainly about supporting and developing staff so that they feel they can make a real contribution to making it better for their patients. At the launch, Veronica McCleary from Sanctuary Care in South Norwood, talked about the very real difference the preparation for the project made to her staff. She spoke about the increased confidence and a feeling of achievement that she and staff who attended the training had felt. They are now going to use this new project to help to improve the infrastructure in the organisation to support them. And you can’t change practice just by giving people training: you have to back that up by showing people in the care home how you can do things better and supporting them while they practice until the point where they feel able to do it on their own.

The St Christopher’s people are using the ‘six steps’ of the route to success document materials: you can see the St  Christopher’s document on their website: http://www.stchristophers.org.uk/sixsteps.

But some of this is greyed out because the Croydon project moves through the six steps in order. If you want to see a more complex document about six steps, you can look at the document prepared by a similar project in the North-West (but that seems to enjoy complicated forms more, although the overview guide is comprehensive):

http://www.endoflifecumbriaandlancashire.org.uk/six_steps.php

Or you can keep coming back to the St Christopher’s website as things get ungreyed over the next year:  http://www.stchristophers.org.uk/sixsteps. They also give you the email address of Jo Hockley to write to. She’s leading the show.

All this is a bit nursey and toolified (see below). The level of disability of people in care homes has grown and the consequent need for help and care has become more complex over the years, so skills with physical care have become more and more important. It’s a pity that this means that we concentrate on this, because a bit more skill on people’s social needs and personal development would also be a good idea (hence the St Christopher’s work on taking arts activities to care homes that I’ve talked about before). But the main point is that it’s quality of care that will help to move social care forward, and less concern about the financial and commissioning models which at best re-arrange the recliner chairs on decking of the Titanic care home

To go back and read up on the whole thing: the route to success document (the basis of the St Christopher’s and North-west projects) here: http://www.endoflifecareforadults.nhs.uk/assets/downloads/RtS_Care_Homes___Final__20100804.pdf

And if you;re interested in Gold Standards Framework for nursing homes (it’s also done with GPs), go here: http://www.goldstandardsframework.org.uk/.

Actually there are other route to success documents, for example on prisons, but more to the point there are many resources on the route to success website (now gnomically called RTS, so you might not have realised what it was about. Indeed, you might not have realised that route to success was about improving practice in end-of-life care. Obviously someone thought this was a cool title and it’s become a National Eol Care Programme brand. Unfortunately, it’s a brand that hasn’t had the advertising heft of Heinz, so while old hands may realise it’s end of life care baked beans, newcomers won’t know what it’s all about).

Anyway, you can get shedloads of useful documents, together with hammers and chisels to use on the coalface of end-of-life care. (Regular readers will know that I think there’s too much of a tendency in the NHS to conceal the reality that our job is mainly to fill in lots of forms, by calling forms tools – it seems so practical and sounds so professional and focused when you mention them to politicians. We might almost be as useful as plumbers).

Sorry about that, there is a website with lots of RTS tools to download. (There you are: if I’d just said that would you know what I was going on about?)

Useful stuff for helping people at the end of life: http://www.endoflifecareforadults.nhs.uk/tools/core-tools/rtsresourcepage

With all the talk about personalisation and direct payments, you might find it useful to look at a House of Commons Library report on the legal basis for direct payments, the things local authorities have discretion over (for example, employing relatives to help someone who is receiving direct payments), who is eligible, how much you can get and so on. It also (on the last page) has good links to further information. It’s only eight pages long. Presumably they write these things because MPs need help to deal with them.

It’s on the web, here: http://www.parliament.uk/briefing-papers/SN03735

The government is thinking of introducing a ‘duty of candour’ in the NHS. If it does, social care cannot be far behind: why would you have candour in health and not in social care?

The consultation  document is interesting because it makes clear that the professional advice is to be open, explain and apologise when things go wrong and the legal advice is that explaining and apologising does not admit liability. So, the jumpiness among managers about admitting anything is inappropriate.

As a beginning social worker in local government, I was always told never to say what was going to happen on the grounds that it very well might not, local government and regulations being what they are. I believe this attitude is the main source of the complaints that well-meaning commentators make about local government officials. As with bumping my car against someone else’s, you are always taught never to say anything. And what with the addition of the pressures of the past twenty years of businessification in public services to market your organisation and say how good it is at all times, it’s not surprising that candour is rarely to be seen.

But how can you enforce candour, when most professionals are trained to be elegantly non-committal and most employees not to drop the organisation in it?

Here’s what’s proposed:

There must be an appropriate investigation undertaken to establish the facts of the incident. This should be consistent with published guidance

Then there should be a communication with patients, carers and families with:

An apology – a sincere expression of sorrow or regret for the harm caused during the treatment or care. Saying sorry is not an admission of liability and is the right thing to do.

A step-by-step explanation of what happened, in plain English, based on the facts known at the time, as soon as is practicable after the incident is identified. By this, we mean as soon as practicable after the incident is reported to local risk management systems, and within 5 working days at most. If necessary any meetings with patients or their representatives can take place after the 5 working day period provided the offer of a meeting occurs within 5 days.

Both written and face-to-face explanations and apologies, unless the patients and their families/carers explicitly decline an offer of a meeting. This must be clearly recorded and open to audit.

Full written documentation of any meetings, according to the principles in the Being Open guidance, with these records filed separately from medical records and copies shared with the patient and their family/carer. These records will form the audit trail for use in cases of possible breach of the contractual openness requirement.

The consultation notes that since, under the proposed Health and Social Care Bill, clinicians will be involved in everything, they are likely to be tainted by or aware of incidents that should be apologised for. The document proposes that they should report failures to be open to the local clinical commissioning group.  There is also the problem that it is sometimes hard to find out when things have gone wrong.

The difficult I see with this is that, aside from the business and marketing pressures in a competitive system to seek to close down complaints or concerns, people are not good at openly admitting they were wrong, and it is not a good move to snitch on others, unless the failure is gross, when you have to continue to work with them.

Moreover I don’t think a big investigation followed by a formal letter and meetings is about being candid. That’s about standing up and saying that you got it wrong. The problem is that most of us also want to be able to say that we tried, that we did our best, that it seemed reasonable at the time. My wife never accepts that as an excuse for making a mess at home and I suspect that people would rather not hear all that when they say they want a simple apology and a statement that it’ll never happen again.

And that’s another thing, what with the pressures all services are under, it probably will happen again so that promise will not work either.

No, I think a duty of candour is unlikely to be a success, due to human nature rather than anything else. It’s another of those things that politicians should have thought twice about before promising.

Anyway, whenever was a government candid about something that went wrong? Who are they to tell us? And isn’t this whole business of apologising for the unfortunate acts and thoughts of a while ago getting a bit out of hand?

The consultation document: Department of Health (2011) Implementing a ‘Duty of Candour’; a new contractual requirement on providers: Proposals for consultation. London: DH. http://www.dh.gov.uk/dr_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_130443.pdf

I’m back after working abroad for a few weeks, and I notice that the Department of Health website now has a tag cloud: see the picture:

So you see ’social care’, let alone ’social work’ there? Or ‘palliative care’? Or ‘end-of-life care’? Or ‘older people’? Clearly none of that bothers the DH.

Two crucial reports have come out before and after last weekend. I started writing about them, but it got so long, I’m breaking up the posts: this one mainly gives you the links.

The first is the report on funding palliative care:

The report here: http://palliativecarefunding.org.uk/wp-content/uploads/2011/06/PCFRFinal%20Report.pdf

Palliative care Funding Review (2011) Funding the Right Care and Support for Everyone: Creating a Fair and Transparent Funding System; the Final Report of the Palliative Care Funding Review. London: Palliative Care Funding Review.

This report, commissioned by the Department of Health aims to arrive at a funding mechanism for palliative care. The Review has a website: http://palliativecarefunding.org.uk

The second, and more important one, is the much-awaited Dilnot review of social care funding.

The Dilnot Report here: https://www.wp.dh.gov.uk/carecommission/files/2011/07/Fairer-Care-Funding-Report.pdf

Commission on Funding of Care and Support (2011) Fairer Care Funding: The Report of the Commission on Funding of Care and Support. London: Commission on Funding of Care and Support.

This was also commissioned by the Department of Health and, it seems, the Chancellor of the Exchequer.

It connects with the Department’s social care policy statement:

Policy statement here: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_121971.pdf

Department of Health (2010) A Vision for Adult Social Care: Capable Communities and Active Citizens. London: Department of Health.

It also connects with the Law Commission report on social care law, because the government will have to decide how it is going to implement the social care report, and then how the law is going to be shaped to support it.

Law Commission report here: http://www.justice.gov.uk/lawcommission/docs/lc326_adult_social_care.pdf

The Law Commission (2011) Adult Social Care (Law Com 326)(HC 941) London TSO.

Isn’t it interesting that nowadays all these reviews, which are supposed to be independent, have their own logos and websites, instead of being clearly being clearly the product of the Department that commissioned them? Actually The Dilnot review has a heartening message telling you how wonderful its results are, which at one time would have been addressed to the Secretary of State and pointed out how it answered the questions he asked. Now, it is a breezy personal statement from the three important people in the review to us, the public. All this, I think, is designed to say how independent these people are, suggest that they invented what they want to say, in spite of the fact that the Secretary of State actually specified their terms of reference and so had a strong influence on the answers they have come up with. Except for the Law Commission which reports to Parliament, and so its reports have a gravitas that the others don’t: they are a serious bunch don’t have to sell their report to the public.

Of course, you can’t make rules against people behaving stupidly, but it seems surprising that most health and social care professionals would fail to be aware that this was a no-no, but apparently not, and the Information Commissioner has started getting strict about people breaching confidentiality. A legal report tells us about a fine for an employee of a private injury claims service who got his nurse girlfriend to give him names of patients who were recently injured – he followed them up to try to get personal injury claims. The nurse’s PCT found out about it when patients complained about being contacted. The report ends:

in a statement released by the ICO last week, the Information Commissioner Christopher Graham said that “the ICO will always pursue prosecutions where individuals breach both their duty of confidentiality and the Data Protection Act. Those whose responsibilities include the custodianship of sensitive personal data should take note.”

http://www.macroberts.com/content/content_1484.html#page=1

I now return to my plan for a comprehensive look at the present position of the health and care scene with special relevance to end-of-life care; I stopped in mid-track a little while ago when real life intervened and the government announced its pause for listening on the Health and Social Care Bill.

I thought I needed to resume by a review of how the Bill has been getting along.

Good briefings and information

As I’ve said before, the King’s Fund has a good briefing website:

http://www.kingsfund.org.uk/current_projects/the_health_and_social_care_bill/

The advantage of looking at them is that they are more savvy on competition and management and don’t particularly have an interest on behalf of staff. The general briefing is very good.

Summaries

For a good summary of the issues, you can’t do better than the BBC. Its Q&A about the proposed reforms is good (although it deals only with the NHS, not with social care):

http://www.bbc.co.uk/news/health-12177084

There is also a bit more explanation on another page:

http://www.bbc.co.uk/news/health-12750695

and a section on the issues that have been most in contention:

http://www.bbc.co.uk/news/health-12971361

This summarises the main problems as:

-                     pace of change – they are trying to go too quickly and do too much of a comprehensive change.

-                     promotion of competition – the main purpose seems to be to encourage many more providers or services, particularly in the private sector, which may destabilise NHS providers, and let in too much of the private sector.

-                     accountability – trying to make the NHS less secretive (for example, as compared with local government).

Parliamentary information

You can see the progress of the Bill through Parliament on the Parliament website:

http://services.parliament.uk/bills/2010-11/healthandsocialcare.html (click on ‘All previous stages of the Bill’). This gives you access to Hansard for the sessions that discussed the Bill, so you can see what people said.

The second reading has the Secretary of State’s introduction to the Bill. At the Committee stage, there were witnesses to explain things in the early stages. You can see who they were and what they said on the following dates:

Tuesday 8 February 2011 (Morning)

Sir David Nicholson, Chief Executive, National Health Service (and NHS Commissioning Board)

Stephen Thornton, CBE, Chief Executive, the Health Foundation

Dr Jennifer Dixon, Director, the Nuffield Trust

Professor Julian Le Grand, Richard Titmuss Professor of Social Policy, London School of Economics

Tim Gilling, Deputy Executive Director, Centre for Public Scrutiny

Chris Ham, Chief Executive, King’s Fund

Dr Hamish Meldrum, Chairman, BMA Council, British Medical Association

Tuesday 8 February 2011 (Afternoon)

Michael Sobanja, Chief Executive, NHS Alliance

Dr James Kingsland, President, National Association of Primary Care

Dr Clare Gerada, Chair, Royal College of General Practitioners

Councillor Mike Roberts, Rushmoor Borough Council and a member of the Community Wellbeing Board, Local Government Association

Andrew Cozens, Strategic Director of Children, Health and Adult Services, Local Government Association

Nigel Edwards, Acting Chief Executive, NHS Confederation

Karen Jennings, Assistant General Secretary, Unison

Nick Parrott, Health Policy Specialist, Unite

Rehana Azam, National Officer, GMB

Thursday 10 February 2011 (Morning)

David Bennett, Chief Executive, Monitor

Sonia Brown, Chief Economist, Monitor

Sue Slipman, Director, Foundation Trust Network

Sir Stephen Bubb, Chief Executive, Association of Chief Executives of Voluntary Organisations

Sir Andrew Dillon, Chief Executive, National Institute for Health and Clinical Excellence

Richard Douglas, Director General of Policy, Strategy and Finance, Department of Health

Thursday 10 February 2011 (Afternoon)

Don Redding, Policy Consultant, National Voices

Paul Farmer, Chief Executive, Mind

Steve Ford, Chief Executive, Parkinson’s UK

Sarah Woolnough, Head of Policy, Cancer Research UK

Annwen Jones, Chief Executive, Target Ovarian Cancer

Jenny Bogle, Target Ovarian Cancer

Paul Jenkins, Chief Executive, Rethink

Cynthia Bower, Chief Executive, Care Quality Commission

Jill Finney, Director, Care Quality Commission

Sir Richard Thompson, President, Royal College of Physicians

Dr Peter Carter, Chief Executive and General Secretary, Royal College of Nursing

John Black, President, Royal College of Surgeons

Matt Jameson Evans, Co-Chair, Remedy UK

Right hon. Mr Andrew Lansley CBE MP, Secretary of State for Health, Department of Health

Right hon. Mr Simon Burns MP, Minister of State for Health, Department of Health

Paul Burstow MP, Minister of State for Care Services, Department of Health

The rest of the meetings are debates.

Organisations with an interest

Many organisations who have an interest have briefing papers etc. Just look up organisations on the internet and search for ‘health and social care bill’ or ‘NHS reforms’. Most are weak on social care.

The most recent report, and an authoritative but well-balanced one, has come form the Royal College of General Practitioners:

http://www.rcgp.org.uk/pdf/Government%20Health%20Reforms%20Analysis.pdf

You can also see her comments when she gave evidence to the Parliamentary Committee (above), and a video of her being interviewed by the BBC:

http://www.bbc.co.uk/news/health-13329031

However, the BMA has the most comprehensive site, with lots of information you can use for lobbying:

http://www.bma.org.uk/lobbying_campaigning/healthsocbilltoolkit.jsp

Their briefing papers for their main meeting on the subject a few weeks ago are very comprehensive:

http://www.bma.org.uk/images/srm2011healthbillbriefingpapers_tcm41-204671.pdf

The summary of its main points at the second reading stage of the Bill in Parliament are as follows:

• The autonomy of the NHS Commissioning Board and commissioning consortia is not undermined by unnecessary political interference;
• Consortia should involve practising senior hospital doctors, medical academics, public health medicine doctors and patients in the development of clinical pathways;
• Consortia are not forced to promote competition between providers and instead are able to work collaboratively across primary and secondary care boundaries in order to improve services for patients, without being subject to challenge;
• There is flexibility in the pace of change for the winding down of primary care trusts (PCTs) and strategic health authorities (SHAs), in order to address the disparity in the capability of local health economies to take on the commissioning role;
• National oversight of medical education and training is maintained;
• The management and planning of the medical workforce is carried out at minimum at a national level and preferably, at a UK level;
• Price competition, with the associated likelihood of a decline in quality, is explicitly precluded. Tariffs (prices for services) should encourage high-quality care and value for money rather than competition based on price;
• Economic regulation and financial accountability are considered within the framework of the stability of the local health economy, with commissioning decisions driven by clinical need, quality, sustainability and local priorities, as well as best value;
• Patient safety and quality are not undermined as a result of an artificial timetable to make all NHS trusts achieve foundation trust status by 1 April 2014;
• Any changes to the current arrangement of a cap on the amount of income foundation trusts can earn from other, non-NHS sources are not at the expense of NHS patients’ ability to access services. A re-examination of the basis for calculating the cap may be appropriate, however conducting this exercise via the legislative process is inappropriate;
• Strong safeguards are in place to ensure that patient confidentiality is not undermined by the Information Revolution.

You see that most of these are about the competition issue.

The Royal College of Nursing also has a Parliamentary briefing, also strongly about competition:

http://www.rcn.org.uk/__data/assets/pdf_file/0005/359726/RCN_Parliamentary_Briefing_on_the_Health_and_Social_Care_Bill.pdf

Knowing that many of my readers are not involved in higher education, I thought it useful if you had some links to teaching materials about a wide range of things that are freely available on the internet, and have recently been listed by SWAP, the Social Work and Policy bit of the Higher Education Academy. In many sites, you search for social work or whatever else you’re interested in. Some of these are only available to higher education organisations, but others offer part of their wares under a ‘Creative Commons’ licence or with other requirements. Also at the beginning some national resources that have useful materials, but you sometimes need permission to sue them:

BBC Learning – http://www.bbc.co.uk/learningoverview/index.shtml

Resources from the BBC for teachers and learners. A lot of it is focused on school curricula, but you can find useful images and videos to use.

British Library – http://www.bl.uk/

Extensive online gallery and sound recordings.

HEAL http://www.healcentral.org/healapp/browse?action=browse&pid=M&page=1&display=25

Health Education Assets Library – more health oriented, but some psychosocial materials. Has lots of photos.

Intute  - http://www.intute.ac.uk

Extensive, multi-subject listing, good on all social science and healthcare resources.

IRISS – http://www.iriss.org.uk

The Institute for Research and Innovation in Social Services, is the Scottish SCIE. Click on resources: there are videos, many, many podcasts, blogs, documents.

Jorum (Jorum means ‘collecting bowl’) – http://www.jorum.ac.uk

Part of this site is available to non-HE/FE colleges; there are a range of social work, social science and healthcare resources, including videos, teaching packs and information sheets.

MERLOT –  http://www.merlot.org/merlot/index.htm

The Multimedia Educational Resource for Learning and Online Teaching is based in California, but gives access to a wide range of materials.

National Archives – http://www.nationalarchives.gov.uk/education/default.htm

This is the Education site – extensive historical material on social issues, including a huge number of podcasts.

SCIE – http://www.scie.org.uk/

The Social Care Institute for Excellence is mainly known for its database of publications, but there are extensive resources relevant to social care and to some health care; also look at Social Care TV.

SWAP – http://www.swap.ac.uk/resources/index.shtml

The resources bit of the main site contains links to many available teaching resources on the internet, and its focus on social work and policy makes it very helpful.

Paul Edwards e-learning resources – http://sites.google.com/site/technologyenhancedlearning/system/app/pages/sitemap/hierarchy

Lists all sorts of programs and information about using the web and other e-learning tools.

The mostly comes from a recent SWAP newaletter, but the comments are mine.

Remember, that unless it’s clear on the site that you get the information from, you have to get permission to show videos and images.

And now, the Health and Social Care Bill and end-of-life and palliative care.

First, there is no specific coverage of end-of-life or palliative care, so we have to surmise what the issues might be for us.

Second, there is a focus on greater integration between health and social care systems, and this is given particular force by the role of local authorities in keeping an eye on healthcare services in their area and supporting advocacy and policy advice for healthcare providers and commissioners. There are no more guarantees of reducing health-think blindness than in the present system, and the strong role of GPs in the new system, many of whom are ignorant and want to remain ignorant and moralistic about social issues does not give much hope either. However, not all GPs are totally hidebound, and some are positively thoughtful, so this coordinated commentary and advisory local authority role offers some hope in more imaginative local authorities (as opposed to the Neanderthal ‘we do care management assessments – duh’ places; local authorities can be as, if not more, hidebound than GPs) that social care services and social thinking might have a greater impact on the inward-looking tendency in health services. Also the removal of the PCTs and even more the arrogant SHAs (‘oh, we’re so much more important than you pygmies’) has some hope of removing some of the more blighted buro-think in the NHS; most of them are in PCTs. The impact assessments say that perhaps 40% of PCT and SHA staff will transfer to consortia: let’s hope it’s the imaginatve ones.

The combined impact assessments here: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_123635.pdf

Therefore, we might hope for better influence in social care on end-of-life issues and better understanding of social care from GPs. And social work thinking might infiltrate at least some of the commissioning consortia.

Third, since a lot of palliative care in the UK is in the voluntary sector, existing non-NHS palliative care providers will have a clearer role of being licensed providers and will be able to compete. They are likely to be more experienced in getting in on the act than nursing and social care staff setting up social enterprises, and they have a track record.

The problem is gauging what the attitude of consortia will be. You can imagine that GPs will want to do as much end-of-life care as they can themselves, gearing up their own nurses to doing it. This would probably be cheaper, nearer to the community and liked by patients, who of course don’t know how much better it might be with their local hospice. Because patients and families will have a higher degree of choice, assuming a hospice provider is not too expensive, marketing the quality of hospice provision will become more important. However, the local reputation of many hospices and the fact that many GPs and community nurses like the help and support that home care services offer might encourage them to do a deal.

Fourth, however, there is the matter of the tariff, which will set the levels that consortia can pay for a service, unless there are specific arrangements. There is no national tariff at the moment, and previous efforts to create one descended into disorder. But we might move into the American situation in which there may be limits on what the consortia will agree is palliative care, and set requirements for admission, as the American insurance companies do.

Fifth, will private providers come into this? It’s hard to imagine the private hospitals aiming for this sort of thing, they will focus initially on providing predictable elective surgery. But you may well get private nursing homes and residential care homes competing to do end-of-life and palliative care on the cheap compared with the multi-talented hospices. After all, we’ve been working hard to train them to do this better, so they’ve been upping their skills in this area. And you might get private community care agencies moving into end-of-life homecare; it would be a natural extension of their domestic and domiciliary care markets.

One of the worrying things this points to is the advantage, in a competitive system, of not sharing knowledge and expertise. We would perhaps do a lot better not to train hospital and care home staff in palliative care, then they would have to come to us for services. Or are we going to focus on being training and development agencies? That would go against the Cicely Saunders principle of gaining the expertise to train and develop from actually doing the job.

Sixth, I think one of the important developments of recent years is hospital palliative care. To me, it is really important that end-of-life care in hospitals is the best quality, because so many people come to the end of their treatment or are admitted in emergencies and need good end-of-life care because they cannot be moved elsewhere. Are GP consortia going to be prepared to pay for this? They will want quick cure and out into cheaper accommodation. Perhaps the aim for hospices is to get themselves seen as cheaper providers of high-end end-of-life care to get people out of hospitals to cut costs. Here, the nursing home market will be strong competitors.

Finally, there is the general aura of competition in the Bill. Reading the Bill gives you a very clear impression that it is setting up the system to be strongly competitive; the arrangements for competition are there in every section, and priority is given to it wherever they can achieve this.

What is going to be the unique selling proposition of hospices? And how are they going to market themselves?

I have set out below the twelve main parts of the Bill at the end of the post and left in some of the subheadings that might interest readers of this blog; you can go to the Bill to see what it says on particular topics of interest, although you’ll have to know a lot about the previous legislation ot make sense of it. There are also a lot of schedules setting out details. There are no summaries of what every detail might mean; we will get some idea of this as it goes through Parliament and as specialist interests get to grips with it.

On the web: http://www.publications.parliament.uk/pa/cm201011/cmbills/132/11132.i-v.html

This is html; if you want to download and print out the whole thing, go here:

http://www.pulsetoday.co.uk/Journals/Medical/Pulse/2011_January_12/attachments/Health%20and%20Social%20Care%20Bill.pdf

The main pointers

Part 1 sets out the change in management structures, as follows.

The aim is claimed to be to remove the structures that regulated the New Labour system in which the Secretary of State has wide delegated powers to set targets or detailed arrangements across the NHS. Also, the system has been ‘delayered’ with the removal of strategic and primary care trusts. An NHS Commissioning Board would make operational management decisions; the Secretary of State is to be mainly concerned with setting a legislative framework, and would be required to act in the interests of the health service; failure to act on this requirement could be challenged in court.

Commissioning consortia will be statutory bodies consisting of representatives GP practices, who will have to participate. They will commission services for patients of the practices in the consortium (and some other local people) and will have a duty to commission services if this is not reserved to the NHS Commissioning Board (which will provide for things that need a national remit). There are various detailed changes, for example who exercises emergency and mental health powers.

Part 2 deals with public health, where currently both the NHS and local government have responsibilities. The aim is local joint working, led by local authorities. Local authorities would have responsibilities for health improvement (e.g. smoking and obesity) and must appoint a Director of Public Health; the Secretary of State retains responsibilities for health protection (e.g. flu jabs and epidemics).

Part 3 sets out how the system of economic regulation: the Foundation Trust regulator, Monitor, will have increased powers. Interestingly, its role will be (52.1) to protect and promote the interests of people who use health care services – (a) by promoting competition where appropriate, and (b) through regulation where necessary. The main aim is then, we can see, to control through competition not through regulation.

It also makes provision later for Monitor to regulate social care as well as health care (but not children’s services), but it does not seem to be bringing this in yet. You may wonder about a chapter on competition: this is to set out the various functions of Monitor in relation to the Office of Fair Trading, a sign that there is going to be a much stronger focus on competition in the service in the future. There are systems for Monitor licensing all NHS providers and for designating essential local services to ensure that they are protected from the competition requirements. Providers have to provide services within the national tariff, if there is one, or if not, agrees an amount according to specified rules. There are consultation arrangements for setting the national tariff. There are arrangements for in insolvency of providers.

Part 4 makes provision for all hospitals to become Foundation Trusts, that is independent free-standing bodies that can compete for custom from the commissioning consortia; other providers are also free-standing, and there has been talk about commssioning consortia begin able to use any licensed and willing provider. Together, the establishment of the consortia and these Trusts sets up the freer competitive system in which it is hoped a wider range of providers may be used by the consortia – they will not be so tied to a limited range of providers, through ongoing contracts, as under the present system.

Part 5 is about public involvement. There will be a national organisation ‘Healthwatch’ which sets up local healthwatches to provide both national and local feedback by people about their needs and wishes and for local authorities to provide advocacy on behalf of patients. These are bodies rather like the community health councils that we were familiar with in the 1970s. Local authorities are to take part in joint local needs assessments and create strategies to achieve appropriate outcomes with commissioning consortia. Through new Health and Wellbeing Committees will have overall responsibility for promoting a coordinated view of and action on local health and social care needs. This part gives a strong responsibility to the local authority for keeping an eye on local health services. It’s part of the checks and balances associated with a relatively fragmented market system of provision.

Part 6 deals with primary care services. These are relatively minor provisions for primary care, for example dental and pharmaceutical services.

Part 7 abolishes the GSCC and merges its functions with the new Health and Care Professions Council, of which I understand social work will be by far the largest profession. The Council for Healthcare Regulatory Excellence also has its functions extended to social and work and social care. Throughout, the Bill distinguishes between social care workers and social workers. There is provision for further voluntary registers for social care (and other unregulated) workers. The Office of the Health Professions Adjudicator is abolished.

Part 8 extends the role of NICE to become the National Institute for Health and Care Excellence. This, together with 5, 7 and 9 starts to include social care within the orbit of healthcare planning, but it might offer the opportunity of influencing healthcare planning with some social care priorities, particularly if the local authorities use their new health and wellbeing responsibilities well.

Part 9 formalises still further the role of information gathering and governance through the National Health and Social Care Information Centre. If you are going to have a competitive market, you need to have good information about all the providers. It also provides for setting and ‘information standard’ controlling how information in processed in health and social care.

Part 10 abolishes a number of health and social care quangos, as presaged in previous announcements.

Part 11 tells everyone they have to cooperate with one another. The focus is on the regulators, but of course cooperation will be essential in a much more fragmented market. It also makes provision for cooperation with Northern Ireland, Scotland and Wales.

Part 12 is odds and sods.

Offical headings (heavily edited)

PART 1 THE HEALTH SERVICE IN ENGLAND The health service: overview; Arrangements for provision of health services; Further provision about local authorities’ role in the health service; Abolition of Strategic Health Authorities and Primary Care Trusts; Functions relating to mental health matters; Emergency powers

PART 2 FURTHER PROVISION ABOUT PUBLIC HEALTH

PART 3 ECONOMIC REGULATION OF HEALTH AND ADULT SOCIAL CARE SERVICES

MONITOR; COMPETITION; DESIGNATED SERVICES; LICENSING; PRICING; INSOLVENCY AND HEALTH SPECIAL ADMINISTRATION; FINANCIAL ASSISTANCE IN HEALTH SPECIAL ADMINISTRATION CASES.

PART 4 NHS FOUNDATION TRUSTS & NHS TRUSTS

PART 5 PUBLIC INVOLVEMENT AND LOCAL GOVERNMENT

PUBLIC INVOLVEMENT; Healthwatch England; Local Healthwatch organisations; LOCAL GOVERNMENT; Scrutiny functions of local authorities; Joint strategic needs assessments and strategies; Health and Wellbeing Boards: establishment; Health and Wellbeing Boards: functions; Health and Wellbeing Boards: Care Trusts; THE HEALTH SERVICE COMMISSIONER FOR ENGLAND

PART 6 PRIMARY CARE SERVICES

PART 7 REGULATION OF HEALTH AND SOCIAL CARE WORKERS

Orders under section 60 of the Health Act 1999; The General Social Care Council; The Health and Care Professions Council; Role of the Secretary of State; The Professional Standards Authority for Health and Social Care; The Office of the Health Professions Adjudicator.

PART 8 THE NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE

PART 9 HEALTH AND ADULT SOCIAL CARE SERVICES: INFORMATION

INFORMATION STANDARDS; THE HEALTH AND SOCIAL CARE INFORMATION CENTRE;

PART 10 ABOLITION OF CERTAIN PUBLIC BODIES ETC

The Alcohol Education and Research Council; The Appointments Commission; The National Information Governance Board for Health and Social Care; The National Patient Safety Agency; The NHS Institute for Innovation and Improvement; Standing advisory committees

PART 11 MISCELLANEOUS

Duties to co-operate Monitor: duty to co-operate with Care Quality Commission; Care Quality Commission: duty to co-operate with Monitor; Other duties to co-operate

Breaches of duties to co-operate; The Care Quality Commission

Arrangements with devolved authorities etc Arrangements between the Board and Northern Ireland Ministers; Arrangements between the Board and Scottish Ministers etc. Relationships between the health services; Advice or assistance to public authorities in the Isle of Man or Channel Islands; Supervised community treatment; Transfer schemes;

PART 12 FINAL PROVISIONS