And remember, this was only about Scotland: what must be the level of complaint across the UK? And this is not only relevant to the unmourned Southern Cross: there are of course many other care home chains and other smaller-scale providers. Are there complaint statistics about each home provider? I’ve never seen any. If not why not? And who is analysing them for the qualitative information that they could provide? Obviously not the regulators, since it seems the Scottish regulator was not collating the complaints about this particular provider, so how can they really be regulating these providers?

If I were making an analogy, it looks very much to me like News International and the Metropolitan Police. An investigator of complaints collects up loads of data about bad practice, and then chooses to lose it in its filing cabinets. How is this information not relevant to assessing quality standards in social care?

The Press Gazette report here: http://www.pressgazette.co.uk/story.asp?sectioncode=1&storycode=47486&c=1

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.

There’s been a flurry of activity on the NHS Reforms, which have been becalmed by a listening exercise after a lot of political and professional protest. Of course, it’s a Health and Social Care Bill that’s been held up, and is apparently going to be reconsidered in House of Commons Committee in (probably) July, but the concern about social care has been sotto voce; the main social care element is to get rid of the GSCC. However, do not be deceived: all this has considerable significance for the political position of social care, and probably also of palliative care.

Let’s start from a social care/palliative care view of the issues. The big client group in both areas is older people; and it’s a growing client group. Not growing quickly, but by 2030 the post-war baby boomers will be well into the age range that uses health and social care in a big way (myself among them if I last that long – I’m planning to be a charmingly dotty old social care client – this is the best personality style to get people to provide services for you). As we saw when looking at the Nuffield study last week, typical usage of social care in the last year of life grows slowly in the latter phase of your old age, and in the last few months you become very expensive because you get lots of in-patient treatments. So it is cheap to provide for most people until they get near the end, although there will be some hips, knees, heart bypasses and boomps-a-daisy (injuries through falls) to be coped with in the meantime, but that can be a bit more planned and strung out. Then if you do the end of life well (look back at my posts on the end-of-life social care framework) you can stop a lot of emergency admissions to hospital care and cut down the costs of healthcare substantially and everyone would still think the care was wonderful.

Unfortunately, although voters would doubtless be very pleased to see improved social care, the political problem there is that people have to contribute to the cost of it and don’t like whittling away their family’s wealth in doing so. They much prefer an NHS model of free care, but are realising that this is not possible. So they don’t like to think about the government spending the money on social care, even though this would be the best option for most people. they want to have as much through the NHS as possible. The political problem has pushed back genuine integration of social care into this legislation because we are waiting for the Dilnot report in the next few months, which is going to have yet another go at suggesting how to get round the social care costs issue. Until that one is sorted out, you cannot have a rational discussion about where we’re going with NHS care, because the only rational way to think about it is in tandem with social care for older people, particularly those who are nearing the end of life.

But even so, the reality is that for the NHS, as well as social care, the big client group of odler people will mainly need community and primary healthcare from their GPs and a modicum of social care for a minority. Also, a lot of mentally ill, learning and physically disabled people have long-term care needs, which are relatively expensive because they’re long-term but are fairly predictable and do not cost a lot per person. These are the groups of people who the NHS should be concentrating on. However because the voters think that what they need to worry about is the hi-tech care they get if they are in a road accident or have a heart attack or some other serious illness when young, and they want to be sure that all the drugs and clever doctor things are available pronto from their local hospital, we are getting all this suspicion about these plans. It is clear that it would be fine it they got them more efficiently from a less local hospital that has properly geared up emergency department to do the skilled job of dealing with these occasional problems, but that feels a bit less certain, and the picture of the local place closing raises insecurity.

It may seem impossibly romantic to hanker after your local NHS hospital, but actually I wonder if people who think this way are reflecting a genuine preference that we should be thinking about. Lord Darzi (remember him? a doctor recruited as a minister to support New Labour’s attempt to promote local care) had an idea of community-based polyclinics for London and beyond which does reflect the need for a well-planned system of local care. My friends in European countries are not so worried about local general hospitals, happily accepting the regional specialist provision, because they have access to nearly everything but the seriously hi-tech quite locally.

Look at the mortality statistics: mostly people don’t die between 1 and 65. And, looking at the budgets, mostly they cost the NHS very little until they are in their upper 70s. So, it is a reasonable aim to save money by putting the clever doctor things a bit further away, getting us fitter and giving us all statins so that we don’t have heart attacks. Unfortunately, the voting public seems to think this is all a trick to take away the comfort blanket of their local NHS hospital. We should go back to Lord Darzi, because local general-purpose treatment and investigation provision would be genuinely welcomed, even though the hi-tech doctors don’t like it – it’s not whizzy enough for them. But my two recent cataract operations did not, I fancy, need to be done within the boundary of a large general hospital. A polyclinic would have been ideal.

So, the main problems that lead Lansley, the Secretary of State for Health, the coalition and people such as Alan Milburn (the former New Labour Health Secretary who emphasised competition when he was in power) to want substantial reforms are to deal with the real issues of:

-         demographic change (a growing population of older people making more extensive demands on the NHS), and

-         medical advance (the demand for ever more costly medical interventions as the doctors get cleverer at managing more serious illness).

There are some doubts about the importance of these. For a start, the big increases in the older population are a decade or more away, although o courfse, we have to work up to them. More important, if community care and end-of-life services for older people were really made to work, the demand on hospitals would be much lessened. And research that allowed doctors to manage older people’s many physical conditions better over the long-term are likely to reduce the cost of long-term conditions to the NHS, because most of it would be done in the community or in care homes. So what the Bill should actually be about is improving social care, including a good dollop of effective advance care planning for the end of life, with a little bit of NHS fiddling around the edges. But the political commitment to the NHS means a focus on convincing people that the nasty Tories not going to take away the beloved local hospital, that most people are probably not going to use much. As well as that, their eneds could probably be met by specilaised regional centres and better local investigation and treatment.

Substantial increases in much cheaper age-proofing of general public and commercial services, so that older people could carry on under their own steam for much longer than they can now would delay and reduce demand for expensive social and health care. Really effective social care provision would also reduce the demand on expensive hospital provision. The reason for the focus on GP control in the NHS reforms was that the GPs are the centre of providing for the massive number of people needing long-term care, most of which can be provided in the community, and a lot more of which could be provided if we stopped sending people to expensive hospitals. Incentivising GPs to provide community health care for older people would hold back the rising costs of NHS hospitals. It was just this that the hospital doctors and nurses feared: their status, and some of the elite status of medicine over the denigrated social care comes from the scientific status of constant medical advance. We should be spending some of this research money finding out how we can improve community provision for long-term care.

So what’s been going on? There have been three events within the last week or so:

- The Prime Minister made a speech confirming the political support for rowing back on the complained-about aspects of the reforms

- The NHS Future Forum reported on the ‘listening’ exercise, in which views on how to adjust the reforms were collected

- The government responded officially to these, accepting the main import of them. Of course, we don’t know the detail of how they’ll change the Bill to take account of them. Also, there have been some more individual reactions from Lansley and from Alan Milburn.

Cameron accepting the main changes

Cameron’s speech confirming the acceptance of the main points of the proposed changes, given on 7^th June 2011, in advance of the Report of the Future Commission being published, is at:

http://www.conservatives.com/News/Speeches/2011/06/David_Cameron_Protecting_the_NHS_for_tomorrow.aspx

His argument is for getting the best possible value for money and big variations in quality across the country. These current problems are forerunners of significant difficulties of over-stretch if we don’t plan for larger demands from older people and medical advance in the future. As people have thought about it, there is a lot of support for these plans, but we need to get them right…’our vision of an NHS that is more productive, more patient-friendly, more professionally-driven and more diverse is clear’.

On competition: I do believe competition is a good thing. But not as an end in itself. It is a means to give doctors more choice to get the best possible care for their patients, and for patients to have that choice too. It is a means of bringing in fresh thinking, new ideas, different ways of doing things that deliver better and better value for money. Put simply: competition is one way we can make things work better for patients.

On the pace of change: We will make sure local commissioning only goes ahead when groups of GPs are good and ready, and we will give them the help they need to get there.

On integrated care: patients…are keen to make sure that whatever happens their care is joined up, that they don’t have to put up with the frustrations they have today – with different appointments in different places, with different people, all to discuss the same thing…professionals who have dedicated their lives to the NHS who are desperate that clinical decision making should replace bureaucratic decision making …but worry that only GPs will have responsibility and that will lead to a fundamental break and juncture between primary and secondary care…

Hospital doctors and nurses will be involved in clinical commissioning. We will also introduce clinical senates where groups of doctors and healthcare professionals come together to take an overview of the integration of care across a wide area. And of course, where effective networks of clinicians already exist, we will support them, not reinvent the wheel…Monitor will now have a new duty to support the integration of services – whether that’s between primary and secondary care, mental and physical care, or health and social care.

On waiting times: Patients tell me just how big an impact the time they wait for their healthcare can have on their well-being, and how they worry that by scrapping the old targets we might lose control of waiting times…The whole reason why transparency and choice are so important is so that patients can hold the health service to account and get the care they demand, where they want, when they want. That’s why we’re releasing a whole raft of information so you can compare and contrast different providers within the NHS – and make your decisions based no real solid evidence. And that includes evidence and information on waiting times. But we’re not going to leave anything to chance, especially as our changes are working their way through the system. So we’re keeping the 18 week limit…And we’re not going to lose control of waiting times in A&E either.

On NHS budgets: There will be no cuts in NHS spending…This year, and the year after, and the year after that, the money going into the NHS will actually increase in real terms with £11.5 billion more in cash for the NHS in 2015 than in 2010.

But…every year without modernisation the costs escalate. Demand pressures increase, driven by an ageing population and drug and alcohol abuse. At the same time, there are supply-side pressures too, driven by new and expensive drugs and technologies. We can’t pretend that the extra money we are putting in will be enough to meet the challenges. We need modernization of the NHS to do that.

The listening exercise

The NHS Future Forum reports and documents are at:

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127443

There is also a website that offers some criticisms of the Future Forum proposals:

http://healthandcare.dh.gov.uk/category/conversations/future-forum

The introductory material mentions voluntary organisations and hospices as having a clear role:

To provide this choice for people at the end of life will require an integrated approach in health and social care with greater involvement of the third sector, including the hospice movement. (p 8: Summary; Chair’s letter to the Secretary of State)

There’s also a comment on integration with social care, using the Health and Well-being Boards (p 12):

Local government and NHS staff see huge potential in health and wellbeing boards becoming the generators of health and social care integration and in ensuring the needs of local populations and vulnerable people are met. The legislation should strengthen the role and influence of health and wellbeing boards in this respect, giving them stronger powers to require commissioners of both local NHS and social care services to account if their commissioning plans are not in line with the joint health and wellbeing strategy.

Avoiding boundary disputes is also included (p 12):

Better integration of commissioning across health and social care should be the ambition for all local areas. To support the system to make progress towards this, the boundaries of local commissioning consortia should not normally cross those of local authorities, with any departure needing to be clearly justified. The Government and the NHS Commissioning Board should enable a set of joint commissioning demonstration sites between health, social care and public health and evaluate their effectiveness.

There are five main areas of discussion:

Choice and competition – broadly it promotes the availability of choice, in the context of patients’ and public security that local services are good. Since in an emergency, you have to go to the local provision and most people do not want to travel massively, choice about where to go is not so relevant as being able to influence the quality and style of the provision you experience. For me, it is a relief to see this point made, when the private sector commentators are all keen to get you to go to their local private hospital. Most people are perfectly well aware than in an emergency, the best place is the NHS. Of course the attitude is different for residential social care – people have got used to private sector provdiers there. Rather than the finance watchdog, Monitor, encouraging competition, the Future Forum says it should ensure that people should have the right to challenge commissioners if they are not getting adequate choice about how they are being provided for. Cherry-picking by private providers that would mean that integrated local services are not viable should be unacceptable.

Patient involvement and public accountability – it argues for integration as the main objective, delivered by patients having a strong say in how they are cared for, and stronger public accountability for the quality of provision at local and national level. Doubters think that health and wellbeing boards and local government generally are being cut so much there is little chance of htis happening.

Clinical advice and leadership – it should be wider, thus allowing the hospital doctors and nurses (no mention of social care) to stymie seriously community-oriented priorities.

Education and training – this is included to respond to problems about how the system will integrate with medical education; the comment is really ‘don’t know, we’ll have to work on it’. No attempt of course to connect this with training needs in social care.

The pace of change – set up the NHS Commissioning Board to give clear leadership, but don’t press too hard to get everything done by deadlines.

Government acceptance of the Future Forum recommendations and afterwards…

You can read the positive announcement (and a statement that the Future Forum is going to carry on listening) here:

http://www.conservatives.com/News/News_stories/2011/06/Government_accepts_recommendations_for_NHS_reforms.aspx

As usual, the King’s Fund has a good analysis of the announcements:

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

and Anna Dixon on their blog makes some useful comments:

http://www.kingsfund.org.uk/blog/nhs_privatisation.html

They also have a chunky report on the role of the voluntary sector in the reforms, done with NCVO. I’m going to return to this:

http://www.kingsfund.org.uk/publications/voluntary_sector.html

The Financial Times has a good in-depth briefing (but be careful how many times you click on the FT website; after a while their paywall looms up to hit you).

http://www.ft.com/indepth/nhs-reform

A useful briefing by the NHS Confederation (the health organisations’ organisation) on the government response and what they thought. Generally, they were pleased by the government’s report.

http://www.nhsconfed.org/Documents/110614%20member%20briefing%20govt%20response%20to%20FF%20-%20FINAL%20FOR%20WEBSITE.pdf

A video of Lansley addressing GPs yesterday, carried by the Telegraph from ITN, makes clear that GPs are going to be well on the way to their commissioning role by 2013, even if they’re not quite there yet. Clinical commissioning groups will cover all England by the due date, even if they’re not fully functioning. This was probably inevitable anyway before the pause for listening. So the claimed slowing up of the process until people are good and ready is largely non-existent.

Link to the Lansley video: http://www.telegraph.co.uk/health/healthnews/8576849/Andrew-Lansley-NHS-reform-consultation-not-a-PR-exercise.html

Alan Milburn’s Daily Telegraph article attacking the government’s proposed changes to the reforms is at:

http://www.telegraph.co.uk/news/politics/8578226/This-NHS-debacle-sets-us-back-a-generation.html

Milburn’s analysis is that quietly going ahead on the present track would have delivered many of the improvements, but that Lansley was inept in claiming that there would be a revolution in competition and a ‘free-for-all’ in who was allowed to provide NHS care, encouraging private providers. If we accept this judgment, it is easy to guess that Lansley might have done this to promote his position politically in the right-wing of the Conservative Party. More important, probably he actually believes that this would be a better way of running the NHS; lots of people do.

For people who are doubtful about how the private sector is going to react to the possible loss of opportunities for profit, I also like this Spinwatch diagram, which shows how people with political influence and private sector organisations favouring private sector involvement in the NHS are connected:

http://www.powerbase.info/index.php/File:Private_Healthcare_Network_SpinWatch.jpg

Conclusion

Actually, I don’t think the private sector has much to worry about. I don’t think competition red in tooth and claw was ever going to operate, and I think Lansley was ramping this up for political reasons, and has come a cropper as a result. There will continue to be steady increases in competition where it makes sense and in some places where it doesn’t. It is clear that the proposed changes are going to make the commissioning groups more difficult to manage, but it is clear that the process of reorganising is going ahead apace. I recently gave a talk to some pct managers, some of whom could remember their new job title, some of whom had been made redundant and some of whom had new jobs but didn’t know what they were going to be doing. Already, we’re beyond the point where the present system can carry on, so the question really is: how can we make the new system work well?

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

It is clear that the government proposals on NHS and (to some degree) social care reform are in trouble. What will this mean and what will it mean for end-of-life care?

I did some detailed stuff on the proposals and what’s in the Bill in previous posts: search for ‘Health and Social Care Bill’; there are several posts in January 2011.

However, if you want a good summary of the characteristics and political impact of the proposals, look at the BBC news website, in its Q&A on the reforms:

http://www.bbc.co.uk/news/health-12177084 (this also has a nice diagram of the changes).

and its summary of views for and against them:

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

A more complex account of the issues may be found on the King’s Fund website:

http://www.kingsfund.org.uk/topics/governance_regulation_and_accountability/index.html#keypoints (start at the keypoints, then go on the background tab and the comment and analysis. Anna Dixon’s blog post on the ‘paradoxes’ in the reforms is worth a read, and so are some of the comments: the readers of the Fund’s blogs are better informed than a lot of comments in newspapers).

Are the reforms in trouble? Why?

The fact that the Health Secretary, Andrew Lansley has said that there is still room to amend the reforms suggests that they are: the Telegraph report on that here (I use the Telegraph to report on government views because it is a broadly government-supporting newspaper, so I can’t be accused of selecting press that might put a negative slant on things):

http://www.telegraph.co.uk/news/politics/conservative/8379284/Andrew-Lansley-signals-retreat-over-NHS-reforms.html

The reforms are in trouble for three main reasons.

It’s not privatisation

One of the reasons is not privatisation through marketisation (that is, reducing the public sector element of NHS provision, by strengthening that aspect of NHS care that is provided through a managed market). Of course, the usual suspects have said ‘Tories – get your thieving private sector friends’ mitts off our NHS’. The two main suspicions are (1) that American and other big healthcare companies hope to get in on running local commissioning and (2) that the ‘any willing provider’ policy integral to the reforms is likely to increase private sector participation.

The main concern there is cherry-picking. Private sector providers like nice cheap easy, repeatable procedures to carry out (hip and knee replacements, cataract operations like the two I have just had, and so on). If you take these out of the NHS, you leave the more difficult stuff for the NHS to do. As a consequence, they have to deal with the more complicated and expensive stuff and over time can be made to look even more unrealistically expensive than they are now. Also, they cannot train up their surgeons on the easy stuff, so they are going to be less skilled on the difficult stuff. Faced with these criticisms, the government has introduced some concessions to meet these concerns. Lansley says in an interview (link below) that this means any willing qualified provider, so the local commissioners will decide; they can choose to avoid excessive private sector provision if they want to maintain their local hospitals.

Also, patients can say they want their local hospital and I expect a lot of them will. After all, we all know that if there is any problem in a private hospital, they can’t cope and the patient is blue-lighted to the nearest NHS hospital. It’s only really naive believers in the private sector that are unaware of this. Also, things like palliative care just don’t happen in the private sector and since the main increases in service demands are going to be among older people with long-term problems, they’re not going to find really good care in the private sector of healthcare. Private sector domiciliary and community care is far more likely to stay directly commissioned from the public sector, even if providers are increasingly private or social enterprise organisations.

Is there any evidence that private sector companies are trying use the reforms to get into the NHS? Yes, of course; any private sector organisation is going to look for expansion opportunities, just like any energetic public sector manager. Try having a look at the website of the private sector consultants, Binley’s: they’re charging a lot of money for people who want to get up-to-date news on changes, NHS changes are the top of their list of ‘products’ enabling private sector organisations to ‘track’ the NHS reforms; they say they have 30 researchers doing nothing else. Yes, there is big money in prospect for the private sector:

http://www.binleys.com/Products.asp?CatID=13

It is a broad spectrum of important opposition

Not including, it has to be said, the official opposition, Labour. As with the cuts campaigning that I covered yesterday, they are somewhat stymied by the reality that many of the reforms explicitly build on their own policies, and they might well have wanted to do something similar.

No, the three main reasons why the reforms are in trouble are mainly other professional and political opposition.

The first is that the people who are intended to be major players in the reforms, the GPs, have turned out to be mostly opposed to it. There are supporters in the GP camp, mainly people who have been making GP involvement in commissioning work in, mainly rural, areas where the Conservative MPs come from. A few of these people can be (and have been) characterised as venal doctors keen on supporting a privatised NHS so that they can get rich(er); possibly because some of them really are like that. Consultants have also called for the Bill to be withdrawn, it seems because it may endanger the importance of the major local hospitals through fragmentation and privatisation, and therefore their influence. They have been trying to whip up concern about local hospital closures. See the Telegraph report of their concerns, for example. This presents a mish-mash of claimed concern for the NHS and their patients and complaints that they are not respected by politicians, who promised to leave the NHS alone: http://www.telegraph.co.uk/health/healthnews/8400872/Doctors-call-for-industrial-action-over-devastating-NHS-reforms.html

However, they are still negotiating on pay and conditions (like other public sector employees, their pay has been frozen, fancy the consultants being treated like the lower orders), so perhaps the government will be able to buy them off. Governments have been doing that since Aneurin Bevan, the Labour health minister in the 1940s.

Also, lots of people concerned about the management of the NHS are doubtful that GP consortia being responsible for commissioning the majority of services can be made to work. This is partly because GPs are considered to be mainly interested in treating their patients (although GPs I know are also scathing about the management of commissioning on behalf of their patients and it’s important to recognise that being able to refer your patients to the right treatment is an really important aspect of the role of GPs), but also because this will lead to further fragmentation in planning and management. Some others are concerned that it will let private sector healthcare companies in to help them manage it. If you think pct bureaucrats are the worst kind of management to have, wait until you see a management consultant: incompetence is miles better than financially motivated rapacity.

The second major reason for the trouble that the reforms are in is that the LibDem party, in coalition with the Conservatives who have dreamed up the plans, have now come out opposed to them. There will have to be concessions. The Telegraph report contains a video of Nick Clegg, the LibDem leader, distancing himself from the reforms:

http://www.telegraph.co.uk/health/8378143/Nick-Clegg-faces-crisis-over-NHS-reforms.html

Another account of the LibDem debate here:

http://www.telegraph.co.uk/news/politics/nick-clegg/8378236/Nick-Clegg-in-climb-down-on-NHS-reforms.html

An important influence in this has been the intervention by Lady Williams, Shirley Williams an ageing national political treasure on the left: interviewed by Simon Hattenstone in the Guardian, she said:

“I’m very worried about health. I’m a passionate believer in the health service, I’ve never used private medicine in my whole life.” She believes the NHS is “by and large wonderful” and the proposed restructuring is as unnecessary as it is dangerous. “We looked at [Andrew] Lansley’s white paper, and it’s got a lot of holes in it. For example, what happens if a foundation hospital has a deficit or a surplus, where does the money go, to whom is it accountable? There’s no system of accountability of a democratic kind, except for the bit the Liberal Democrats have put in, which is not very strong, but all credit to our guy for doing it.”

Williams is aware that critics argue this is a preliminary step towards privatisation of the NHS. And yes, she is fearful. “What I do know is that if there was any sign we were moving towards privatisation of the NHS, a lot of Liberal Democrats would not put up with that.” Would Nick Clegg? After all, power is pretty intoxicating, isn’t it? “Oh to be fair to the man, I think he would feel this was a red line.”

The full interview at: http://www.guardian.co.uk/theguardian/2010/aug/14/shirely-williams-saturday-interview

The third major reason, also political, is that while the reforms are likely to get through the House of Commons, they will be under much more pressure in the House of Lords. Lady Williams and her friends are clearly calling up a storm. Again, probably some more concessions.

There’s a good LibDem document which is perhaps the best available political statement in favour of the reforms – it’s significant that Appleby, providing a critique in the British Medical Journal, cites this, rather than the white paper or any Conservative statement; it’s just such a good explanation of the political case:

http://www.libdems.org.uk/latest_news_detail.aspx?title=Modernising_the_NHS%3a_the_Health_and_Social_Care_Bill&pPK=e73493ce-b0f0-46f8-b83f-c94ffac3ed63

This is worth reading to get an idea of the arguments against the ‘Tories red in tooth and claw’ critique you get from left-leaning sources.

Is there a real concern?

The government makes two main points. It argues, first, that reform is needed because UK health outcomes are not as good as in Europe. This point has been subjected to a statistical analysis in the British Medical Journal by Professor John Appleby of the authoritative King’s Fund: http://www.bmj.com/content/342/bmj.d566.full

He argues that UK outcomes on cancer and heart deaths are worse than some countries in Europe, but are coming down faster, so we’ll be better soon, that in other illnesses the UK does better and that much of the difference is down to how the data are collected and analysed, rather than actual differences.

In a later article, Appleby points to the British Social Attitudes survey results, which show increasing public support for the NHS, and evidence that the public thinks it’s improving. A link to Appleby’s article: http://www.bmj.com/content/342/bmj.d1836.full

And to a summary of the British Attitudes survey (actually co-authored by Appleby, so it appears his BMJ article is in the nature of an advert for his work – what an academic would call effective dissemination):

http://www.natcen.ac.uk/media/606952/nat%20british%20social%20attitudes%20survey%20summary%204.pdf

This report says:

The largest increases [in positive views of the NHS] have been among those with traditionally low levels of satisfaction. These include 18-34 year olds (up 32 percentage points since 1996, compared with an increase of 24 points among those aged 65 and over) and better-off households in the top two income quartiles (up 31 and 36 percentage points respectively since 1996, compared with an increase of 25 points among the lowest income quartile).

While satisfaction with the NHS among Conservative supporters fell initially when Labour came to power, it rose 12 percentage points between 1996 and 2009, reaching a high of 61% in 2009.

So actually it seems that people mainly like the NHS as it is. We know this, of course, because satisfaction surveys are not the most sophisticated way of measuring effective healthcare outcomes and most people could not imagine how it might be better if they’ve had (or they’ve heard that other people they know had) a broadly good experience. But all this does not add up to an overwhelming case for a very disruptive reform in most people’s eyes.

The second, and more important, point the government makes is that the NHS will have to cope with escalating demand and need and these reforms empower people in the NHS to transform the way they work to meet that demand.

You can of course go back to the horse’s mouth. Andrew Lansley gives an extended 42-minute interview on a doctor’s website at:

http://healthandcare.dh.gov.uk/andrew-lansley-talks-to-doctors-net-about-modernisation

(unfortunately, you have to sign up for other things – make sure you set your preferences); if you think 42 minutes is too long, set it going and do other things on your computer while it’s running; don’t do this at night, it’s very soporific. For example, he argues that cherry-picking will not be possible because if GPs set up an integrated care pathway, private sector companies can’t pick off individual procedures. The journo who interviews him puts serious criticisms (from doctors) to him, for example from specialist doctors who say they have studied to acquire the knowledge about what is effective, so how can GPs make these decisions, and, for example again, if things don’t work out, what are they going to do? He, of course, sounds eminently reasonable, and the interview doesn’t really put him under Paxman-like pressure, but it does give you a picture of what he thinks.

Overall, the picture is that it’s future population and medical cost pressures on the NHS that he has to reorganise to cope with, and if there’s not going to be much money, it’s clear that doing things better is the major way of dealing with those problems. The critics would say, of course, stop spending the money on silly things like maintaining an unrealistically significant place on the international scene,  settle for being a little country with not much international power but a really good lifestyle for citizens. Then you might have more money again, and you might give priority to citizens’ healthcare.

Will GP commissioning work?

The Department of Health is keen to say that GP involvement in commissioning has been very effective. If so, there’s not a lot of evidence on its website. One case study is trumpeted as showing how it will work, but is about a group of GPs who decided they wanted to get more counselling for their patients with personality and eating disorders and worked with a local voluntary organisation to provide it, which eventually got the contract. Here is the link:

http://healthandcare.dh.gov.uk/case-study-integrated-care-commissioning

There’s another case study based in my home town, Sutton, where Care Minister Paul Burstow has his base. This is about local authority and GP commissioning. In this case, the GPs and local councils worked together to keep patients at home rather than admitting them to hospital for three conditions. ‘A six-month pilot, based on just three medical conditions and a trial area of only 25,000 patients, reduced PCT admissions by 29 patients with long-term, high risk conditions and saved approximately £322,000.’ It is now being extended to two more conditions. Again, this is a small-scale project, rather than mass commissioning.

On the web: http://healthandcare.dh.gov.uk/case-study-sutton-integrated-health-and-social-care-pilot-shows-benefits-for-patients

Better integration with social care and local government

GP commissioning is not the only aspect of the reforms. A much greater welcome, across the political spectrum, has been extended to the arrangements for better integration with local authorities. And of course, if you are going to make things work better for an ageing population and a country that can’t afford medical developments, this is one important route to achieving it. One of the pluses is that better integration with local authorities will connect up health and social care services much better, and it builds on long-term attempts to improve relationships and joint work and planning. The minus is that this has been going on for forty years, and conflict and competition is still rife on the ground. One simple reason for this is lack of resources; both sides try to pass the buck as much as they can.

A more high-flown point about the failure to integrate, is that all integration efforts assume that NHS illness care is the most important thing. However, we are not talking about illness, we are talking about long-term care for people with complex social and health care needs as they age. And the NHS has withdrawn from all that, but still demands all the resources for its acute services, starving the much more important long-term care needs of resources.

As a result, healthcare (and DH generally) twists social care into being the mere servant of healthcare priorities. Remember that social work is about promoting social solidarity, resilience and cohesion so that a population can cope with the social pressure on it more effectively. Public health sits well with those priorities, but the NHS is about illness care, not wellbeing. Attempts to merge NHS concerns with public health and wellbeing are prone to disaster because the imperative to treat sick people twists all other social objectives out of kilter. This runs a serious risk of prioritising massive treatment problems instead of equally massive but rather more distant problems of health inequality and social cohesion.

I think of it as rather like the Japanese and their nuclear power industry. The Japanese don’t have reserves of fossil fuel, so if they want to run an advanced industrial society, they have to have lots of nuclear power. However, they also occupy a mountainous set of islands, with minimal coastal plains in which people can live, be industrious and build their nuclear power station, alongside a major geological fault on the earth’s surface which creates large earthquakes and tsunamis. So they keep quiet about the problems, and minimise the difficulties. The recent earthquake and tsunami has found them out.

Because people’s free health care is so important to them, what the DH does, like the Japanese on nucelar power, is run everything they do as subservient to the NHS, and just ignore or keep quiet about any other priorities that might interfere with it. That is why the DH is so bad for social work and social care. It also runs everything as though important care services such as end-of-life care is the same as but less important that acute care in hospitals, so that acute care always seems more important. That is why the DH is so bad for end-of-life care (but seems alright for palliative care, which is really only what the doctors and nurses want to do, and the less important doctors and nurses too, because they’re not concentrating on curing people). It is important not to forget these eternal verities about health care in the UK. Actually, what is more important is mutual social support, prevention and quality care in the long-term that affect everyone as they age. As I said yesterday, we should be aiming to love quality care, but theNHS is set up to love expensive acute care; they love money for treatment rather than less money for quality of life. The whole NHS healthcare system is set up to twist everything so that it fits the fantasy medicine of high-level surgery and heroic medical care.

In some ways, these are points made by the experienced civil servant, social services director and former Labour health minister Lord Warner, in a book: http://www.guardian.co.uk/society/2011/mar/22/nhs-reforms-essential-lord-warner

He argues, according to the Guardian, that Labour failed to ‘…achieve effective commissioning of healthcare, allowing an excessive expansion of the workforce, thus worsening productivity, and ducking the challenge of replacing seriously underperforming and unsustainable hospitals and other care providers.’ He is focused here on the way in which local campaigning often emphasises acute hospital care and the closure of acute hospitals rather than boosting the far more important provision of long-term care in the community.

The reforms aim to use enforced collaboration with local authorities to achieve this. I’m not hopeful, because as I’ve said, it never has achieved any change in the ‘acute-is-best’ NHS scenario yet. The DH trumpets ‘early adopters’ of health and wellbeing boards; these are 132 areas where they have set up shadow boards: http://healthandcare.dh.gov.uk/early-implementers-of-health-and-wellbeing-boards-announced

But if you look carefully, they haven’t actually done much. The DH general statement says:

Many local authorities already have projects in place to integrate services, including:

• combining health and social care support for dementia suffers (sic) to reduce hospital readmissions

• improved communication between health and social care professionals to enhanced the support package offered to vulnerable members of the community
• fast-tracking learning by integrated public health teams in local authorities.

Notice that this is not a brave new world; it talks about local authority projects. I wonder how genuinely collaborative they have been and whether they have been directed to social objectives and health prevention aims, instead of NHS treatment priorities. Notice that the leading achievement is to reduce hospital admissions for dementia sufferers (as I think they meant in their website); this is, it means hospitals don’t have their acute care priorities twisted by actually having to care for people with long-term problems.

This overall impression is supported by another entry on the DH website, the example of effective health and wellbeing board shadowing in Leicestershire: http://healthandcare.dh.gov.uk/leicestershire Again, this is in special project territory, with the aim of getting more health checks for people with learning disabilities. Nice, for example ‘supporting people with learning disabilities to interview Trust Board members about progress’ but not exactly mass commissioning of the full range of NHS services. It’s an important aspect of service, which you would hope to see developing, but a small development project involving a local voluntary organisation for a limited range of patients who are unserved at present is a million miles from commissioning the whole range NHS services. When the big boys of private health want a slice of the action over something that’s important to them, it’s unlikely that a little local group will get a look in, and the GPs would find it hard to resist the pressures of the big professionals.

The website also has a filmed interview with someone described as an early implementer. This is an accolade I’ve often been tempted to seek, and always discretion proved the better part of ambition. You really wonder why the DH decided this innocuous film of someone saying they’ve got an shadow health and wellbeing board was worth putting on their website. The interview is apparently conducted against the background of a conference, no doubt to make it stunningly as of the moment, in that artistic way that only Channel 4 news can really achieve. It features a pink-bespectacled NHS bureaucrat, now working for a County Council. I thought of not bothering to give you the link, since it’s one of the most pointless uses of internet technology I’ve ever seen, but I’ve decided to offer it as a good example of how to say absolutely nothing in 38 seconds – it was edited too, so she was obviously irrelevant to anything important for even longer. Don’t show it to any Tories: this is exactly the sort of unnecessary bureaucracy that they’re keen on killing off and she seems quite nice really: http://healthandcare.dh.gov.uk/early-implementer-cheryl-davenport-nhs-leicestershire-county-and-rutland.

This has a lesson for palliative care. Existing palliative care organisations which are providing services on the ground are quite likely to get their provision supported under the new system. But if extensive developments in palliative care are required in local hospitals, is this going to get priority when they’re fighting tooth and nail with big private providers for more major areas of acute care? Will it fall by the wayside because the big health providers will not be interested? This is likely, because exemplary care for amorphous things like the end of life is not what the big private providers are about. It works in America, I hear you say? Yes, but only because everything is private in the US, so there are financial mechanisms for all sorts of values-based bits of healthcare, and of course, unlike the NHS, they do not have to be responsible for a substantial slice of the population that presents social problems and does not have any personal, family or community resources.

Finding out what’s being said

To add to the more neutral stuff mentioned above (good old BBC), the Guardian’s page on the reforms covers the main points on the reforms well as they were published in January:

http://www.guardian.co.uk/society/2011/jan/19/nhs-health-reforms-unveiled

(with a nice Steve Bell cartoon in which surgeon Lansley bloodily extracts the innards of the NHS:

http://www.guardian.co.uk/commentisfree/cartoon/2011/jan/20/steve-bell-andrew-lansley-nhs-reforms?INTCMP=ILCNETTXT3487)

Why are they in trouble, then? The Guardian account of the BMA meeting which rejected the reforms of behalf of GPs, who are the main protagonists in the new system, is instructive:

http://www.guardian.co.uk/society/2011/mar/15/bma-meeting-rejects-nhs-reforms?INTCMP=ILCNETTXT3487

However, there has been something of a media war and the government tried to put the  positive side. The Guardian also reported on GP supporters of the scheme who turned up at a reception at No 10:

http://www.guardian.co.uk/society/2011/mar/15/nhs-reforms-doctors-accountants

and there was a subsequent exchange of letters, mainly representing opponents of marketisation, in which ‘fantasy economics’ had a part to play:

http://www.guardian.co.uk/society/2011/mar/18/doctors-fantasy-economics-nhs-marketisation?INTCMP=ILCNETTXT3487

What about comment other than in the left-leaning Guardian. I turn to the Telegraph.

A Tory MP and GP says that the reforms will change the NHS ‘beyond recognition’:

http://www.telegraph.co.uk/health/healthnews/8392556/David-Camerons-health-reforms-risk-destroying-the-NHS-says-Tory-doctor.html

Her criticism is that it’s good to get rid of a middle tier of NHS bureaucrats, but NHS planning should not be done by an unelected regulator (Monitor, the much-expanded financial regulator in the plans) and local GPs have too much to do treating their patients. Also, stripping out two tiers of management is really top down, and the Tories are not supposed to be being top down.

If you want to see Conservative official policy on health, this is the link to the election manifesto, which says ‘where we stand’:

http://www.conservatives.com/Policy/Where_we_stand/Health.aspx

But I searched for ‘NHS Reforms’ on the Conservative Party website and in the total returns found only one passing mention by George Osbourne in a party speech in 2011; most of the entries are much earlier. The Party obviously does not keep its website up to date, or else it’s keeping quiet on NHS reforms.

You can’t search the Labour website, I’ve said before that they don’t like you to find out anything they don’t want to tell you (although it is easier to read than when I last assessed it – but I suppose that may be because the NHS has renewed my eyes). They don’t really talk about policy there, but there are one or two items telling you how David Cameron has broken his promises to protect the NHS, but not a lot of detail. I worked hard to find these by ploughing through the site map, so here they are:

http://www.campaignengineroom.org.uk/frontline-nhs

I’ve already mentioned the very good LibDem statement explaining the case for the reforms, but here’s the link again:

http://www.libdems.org.uk/latest_news_detail.aspx?title=Modernising_the_NHS%3a_the_Health_and_Social_Care_Bill&pPK=e73493ce-b0f0-46f8-b83f-c94ffac3ed63

These are the positives that the critics have to argue against.

The Social Enterprise Coalition, whose sector is one of the intended beneficiaries of the reforms enabling non-public providers a chance of getting involved, focused on a concern that NHS staff would find it easiest to go for privatisation because they didn’t know enough about social enterprise to use it properly.

http://www.charitytimes.com/ct/NHS_reforms_must_shield_against_privatisation.php

This is a thoughtful point, and the palliative care sector, along with many voluntary organisations, could draw on their own experience to support this. Most NHS commissioning is done from the perspective of people who mainly only know about the NHS and do not have the time or knowledge to build alliances with small local organisations, or to support them to develop. Privatisation may come about by default.

A good realistic website, which usually contains links to the latest news, is the Royal College of General Practitioners’ commissioning website. They are trying to improve GPs’ skills in commissioning and getting feedback from their members about what’s happening on the ground, so this is a really good site for understanding how GP commissioning is going to work:

http://www.rcgp.org.uk/centre_for_commissioning.aspx?gclid=CJrznKuW9KcCFY0hfAodphr3bQ

This is the daily news update for today:

General practice must embrace change to improve quality of patient care

GP reforms’ leaders on boards of private firms

Why the NHS needs to be reformed

Private firms set to join NHS Board

Consortia must save £4bn by 2014

There could be no better evidence of the likelihood of serious privatisation and reductions of funding than these headlines from just one day.

And here is a broadly supportive comment from a blog, and some of the supportive or critical comments received:

http://bellagerens.com/2011/03/13/those-nhs-reforms

Among the points made are comments that many people involved in health and social care would agree with, that neither central government nor PCT commissioning has been particularly effective, and improvements in effectiveness are certainly needed. There are also some ways in which these reforms might help; whether they do will depend on how they are implemented.

Conclusion

Writing a conclusion sounds a bit like finishing off a student essay, but I feel I should get to some sort of summary of what I think, having looked at this stuff. In a few sentences, it’s this.

It’s clear that reforms of NHS provision are needed, to cope with demographic and medical developments.
I have probably also made it clear over the years of this blog that I yield to nobody in doubting NHS commissioning, which I think is very distant from the priorities of patients and the communities they live in; I have never seen any genuine engagement in the community from NHS commissioners, but I’ve seen a lot of worries about the budget and relationships with big providers; hence I am also doubtful about the value of PCTs as at present constituted. So I’m up for reform, but I want to make sure it improves things and I think the general opinion is that this might not be the right way to go.

Evidence of successful local collaboration is of small-scale projects with limited service user groups, rather than extensive broad service commissioning. This is likely to continue. It’s good to see, but it’s no evidence that GP commsisioning will work for everything.
It looks as though proposals for universal GP commissioning are over-optimistic, but greater bottom-up professional engagement, and not only from GPs but other professionals and from social care and local government, would probably deliver a better system.

Campaigning by critics of privatisation have already achieved some concessions, but it is clear that marketisation will go ahead, because the Conservatives have a majority and believe in it and most people (like me) are not convinced by NHS bureaucracy and are happy to see some change. In this way, I think NHS bureaucrats are a bit like child protection social workers – they have the kind of job where something is bound to go wrong and they’re bound to be blamed for it.

While there are many opportunities for private sector input, there is everything to play for in defending local services against excessive cherry-picking and disruption by private sector companies.

There is broad support for collaboration with local health and wellbeing boards, and some good joint projects: there will have to be a better focus on long-term care, prevention and care policy and away from over-emphasis on local acute hospital provision.

To achieve better end-of-life care, we need to put effort into supporting better integrated long-term care, especially for older people and in dementia services, because that is where most end-of-life care happens, and therefore we need to support the shift from acute hospital care to better community care, more effectively integrated with good palliative care in hospitals so that people’s end-of-life care needs are better met wherever they are.

A Martin Rowson epic, along the lines of the old Giles cartoons, in which hooligan coalition Cabinet members and a fat cat wreck a main street of public sector services.

http://www.guardian.co.uk/commentisfree/cartoon/2011/mar/28/cartoon-steve-bell-tuc-rally

A small cartoon by Tim Sanders in the Independent has two anarchists speculating how they would have done in Fortnum and Masons if they’d had air cover:

http://www.independent.co.uk/opinion/by-tim-sanders-771959.html

The Independent has had a series on the cuts by Dave Brown: this one has Osbourne looking out of the window at anti-cuts marchers and pointing out that the Big Society does exist: while Cameron opens his Fortnum and Mason hamper-style lunch box to find his (red) lobster flourishing a no-cuts sign:

http://www.independent.co.uk/opinion/the-daily-cartoon-760940.html?ino=2

Two days previously, Dave Brown has fireman Osbourne dowsing a public sector on fire with the hose from a petrol pump:

http://www.independent.co.uk/opinion/the-daily-cartoon-760940.html?ino=4

A rather nice Alex Hughes cartoon, in which David Cameron rewrites the public sector as the big society.

http://alexhughescartoons.co.uk/2010/07/big-society

Another Alex Hughes, which social workers might like, of George Osbourne as the child catcher in Chitty Chitty Bang Bang, recast as a child cutter with an axe dripping with the blood of children’s benefits.

http://alexhughescartoons.co.uk/2010/10/the-child-cutter/

There are several small Matt cartoons on various financial matters from the Telegraph: my favourites:

Here a pensioner has renamed his retirement home ‘Dun Eating’.

http://www.telegraph.co.uk/finance/personalfinance/8411166/Matts-money-cartoons-since-David-Cameron-came-to-power.html?image=1

Here, a tanned charitable child in Africa has sponsored the child of a higher rate tax payer in the UK:

http://www.telegraph.co.uk/finance/personalfinance/8411166/Matts-money-cartoons-since-David-Cameron-came-to-power.html?image=9

On the same theme, a Kerber and Black cartoon from the Mirror (for 14th March, scroll along) has two red-nosed African kids collecting to buy the people of Britain some petrol:

http://www.mirror.co.uk/opinion/cartoons

And here, a man suffering the ‘morning after’ receives a warning via his mirror:

http://www.telegraph.co.uk/finance/personalfinance/8411166/Matts-money-cartoons-since-David-Cameron-came-to-power.html?image=8

My favourite Big Society cartoon (from the Independent): the good Samaritan tells the unfortunate victim of the robbery that he should organise his own rescue:

http://www.independent.co.uk/opinion/by-tim-sanders-771959.html?ino=14

…and on the same theme, Kipper Williams in the Guardian shows that in the new Thatcher- and Heseltine-like Enterprise Zones you have to fill your own potholes:

http://www.guardian.co.uk/business/cartoon/2011/mar/23/kipper-williams-budget

…and one on the NHS: Cameron misses out the top-down reform, and just gets rid of the NHS:

http://www.independent.co.uk/opinion/by-tim-sanders-771959.html?ino=19

After the weekend of the large TUC-organised anti-cuts march in London, I suppose I should say that I am not an enthusiast for the ‘cuts’ rhetoric. This starts up in the press, among right-wing enthusiasts for the small state and among people with genuine concerns about public provision whenever an international financial crisis leads to our government retrenching on its financing of public services. I sympathise, but I think we have to look at the bigger picture.

The bigger picture is, first, to understand the role of the economy in balancing the public and private sectors in health and social care provision. Second, the bigger picture involves understanding and achieving the complex balance of professional standards, regulation and economic drivers that maintain good quality care. I’ve said before in the blog that, for me, if I’m up against it, no organised care can ever possibly replace my lovely wife’s care, and this will not be available 24 hours for weeks or years ahead, no matter how hard she tries. So the reality is that all care is not the best we would want. The problem is to make sure that it’s good enough.

Economic drivers: the positives

Look, for example, at Southern Cross, the private sector nursing and care home organisation that has been in trouble for some months. It’s in the news again today, with the chief executive having achieved the honour or ignominy of being interviewed about his troubles on the Today programme, although he was treated very kindly.

What’s the problem here? There are two points, according to the Financial Times. One is that during the good times, they have agreed high rents with their landlords, which they now can’t afford, and are having to renegotiate them. The CEO was sanguine about this on the radio: it’s in the landlords’ interest that Southern Cross doesn’t go bust, so they’ll have to do a deal. His relaxed style on this was probably a bit of show for his worried investors, but nonetheless what you are seeing here is the impact of economic drivers on a private sector company. They did not drive hard bargains in the good times, but they’re now being forced to do so. The FT suggests that good quality providers might replace Southern Cross in some of these homes, if they can make the maths work, so in some cases quality for the residents might actually improve.

You can see a fairly comprehensive diagnosis in the FT: http://www.ft.com/cms/s/0/d550d81c-4e82-11e0-98eb-00144feab49a.html#axzz1HBYad3p9

The second problem is that one of the reasons why the high rents don’t stack up is that local authorities and health trusts have been cutting back on their placements and cutting back on the charges they are prepared to pay. There are also some good points about this. First, it’s the economic drivers again. The public sector commissioners of care did not drive hard enough bargains in the good times, now they’re doing so. Both they and Southern Cross are being forced into doing the job for the minimum possible expenditure.

Second, one of the things the health and social care commissioners are probably doing is providing alternative packages in people’s own homes, rather than shoving people who don’t need it into care homes. Everyone, including the people being cared for, would agree that this is a good outcome. However, there’s a ‘but’ there, which I’m coming to.

Economic drivers: the negatives

There are also some negatives that we should factor in. Ask the question why Southern Cross is in this mess. Some of its troubles have to do with the fact that for several decades running care homes has primarily been a property-oriented business. A lot of money has been made from the properties, rather than giving priority to care. Because of this, it has now hit the buffers as the property bubble has collapsed. If everyone involved (including the landlords) were less concerned with extracting money from the property and more on giving an absolutely first class care service, you can’t help feeling they would not have lumbered themselves with inappropriate property costs, and instead would be focused on how they can provide the best care.

I think of the Railtrack debacle, when the privatised providers of railway track came a cropper because they spent their time extracting money from the property rather than focusing on running a safe railway. Or the numerous high street shops that have gone west because their private equity fund owners were extracting so much money from buying and selling companies and properties that they took on big loans and property costs that, with a retail downturn, they cannot afford. Perfectly good chains of shops have disappeared because of this.

And the lesson from this is not, as our anarchist rioters would have us believe, the evil of capitalism, or at least not directly. The problem is that the people who are doing capitalism these days think it’s only about making money for themselves, instead of the boring old job of running a good service. They get the money to run good shops and care homes, not to line their pockets. I feel I have to mention in passing bankers’ bonuses: there’s another lot of people who think it’s about making money for themselves instead of making the economy run properly by doing their job.

People I know who run businesses, but do not get big bonuses, work very hard to provide a good service. It’s these businesses that people go back to and will survive and build from the recession. But once they are big enough to get into the hands of the money men, their job becomes making money instead of providing a good service. Wrong priorities immediately result. One of my friends who was running an expanding business decided to reduce his expansion so that he didn’t need to get any loans from the banks, because the bank started getting too interested in telling him what he should be doing instead of leaving it to him. Sitting back with no bank loan, he’s living well enough, and nobody interferes with him.

What this tells me is that an overweaning interest in making money is actually a negative in providing all kinds of services, and also I suspect in manufacturing as well.

It’s a bit like Colonel Gadafy, also in the news this week. I can’t help thinking that if he decided to do a really good job of running Libya over the last 40 years, instead of lining his pockets and the pockets of his relatives, he would be generally regarded as an all round good egg and nobody would be wanting to rebel or bomb him.

As the Bible (or at least 1 Timothy 6:10) says: the love of money is the root of all evil. So it is in health and social care. It’s not the economic drivers, but the love of the money that economic drivers bring, that is the problem.

The other negative we should think about is that the downside of pressure from economic drivers, even if they have positive effects, is sometimes to drive down quality. Of course, Southern Cross will have to drive down the rent it pays, but it may also be forced to drive down the quality or amount of care it provides. The people on the streets this weekend, who are concerned about the use of economic drivers in public care, are the most concerned about that and rightly so.

Why economic drivers drive down quality in health and social care

Of course, it does not have to be. You only have to look at John Lewis to realise that people will pay more and flock to an organisation that focuses on providing a reasonable service rather than just the minimum. The problem is that care service users often do not have enough money to go to the John Lewis of care provision. Instead they have to use Poundland health and social care. I go to Poundland a lot, for a look round. It’s efficient at what it does, but a lot of the goods it provides (once you go beyond the small packets of big name goods at the front) are tat; they look glittery and something like what John Lewis offers, but in their manufacture and ingredients, they are cheaper and nastier. I do not want Poundland health and social care. Neither do I want Curry’s health and social care; their products are as good as in John Lewis, but the staff are so ignorant or unpleasant that you positively want to avoid the place.

Quality of care, then, is about the product – in care, the environment and the care processes –  but it’s also about the attitude of the people providing the product. These two aspects interact, in a complex way. Economic drivers do not deal with that complexity: you need other factors.

One problem with economic drivers in the complexity of care is that the people who pay, local health and social care commissioners, are not the people receiving the service, so they have no economic interest in good quality service. That comes from the professional standards of the people providing the service, but the split between commissioner and service provider in health and social care also splits the people who pay from the people who provide the quality. Previous governments have so twisted the organisation of health and social care that ‘effective commissioning’ and similar clap-trap, has become the marker of professional standards in health and social care management rather than the best service. The end product of ‘effective commissioning’ is Poundland health and social care, good if you’re lucky but tat that only looks like good care if you’re not.

The problem of workers’ interests

The second reason for the difficulty over economic drivers in health and social care is that people worry that the definition of quality is too bound up with the personal interests of the professionals. I’m in favour of discretion in applying professional standards for deciding what good care provision ought to be like, because in the end having high professional standards is the only way of ensuring good services in every detail. That has to be alongside genuine rights to decision-making by service users, so that services can be clear what they want and are driven by their choices. However, back to the anti-cuts march this weekend, it is hard to avoid the accusation that trade unions are using the ‘good standards of care’ banner mainly to support good pickings for health and social care staff. I’m one myself, and I think it’s right for us to be paid a fair salary and to have good conditions of work. This ultimately benefits the people we serve, and I’m happy for trade unions to work for improvements.

The problem is that nobody, but nobody (and including me), will believe that focusing on the wish to employ more public sector staff, pay them better and give them good conditions of employment will necessarily lead to improved quality of provision. Lots of very good people aim to provide the best services for service users work in health and social care. In the long run, history shows that if you run down pay and conditions in the public sector as compared with the private sector demoralisation results. People who can will make their exit, while people who can go elsewhere before getting involved in health and socila care never work for the public sector in the first place. But as we’ve seen, there are economic drivers, and they do prodce some benefits. The problem is to mitigate the downside of using economic drivers and boost the upsides.

What does make a difference

Several friends where I live have elderly parents in a local care home – we’re all that age. They were all worried a little while ago when a new manager was appointed and the standards slipped – they all became quite anxious about the safety and quality of life of their parents. The economic drivers didn’t change, the overall management didn’t change. What changed was the skill and professional ability of the manager.  Being middle class, they applied pressure. The regulator seemed suddenly interested. The external management took action, the manager was replaced, standards shot up again. Economic drivers didn’t change, the overall management didn’t change. Checks and balances led to improvements.

You could say this was an example of the Big Society in action. At least, it’s an example of the John Lewis contingent in action. But in Poundland health and social care, services can’t afford enough good people to maintain quality; you get what there is, mostly it’s okish cheap and cheerful, sometimes it’s less good, now and then you’re lucky and it’s great. Economic drivers don’t work because the people who are affected (isolated older people or inexperienced or inarticulate relatives) are not well involved in making caring choices and so don’t have the power of their active engagement in the services.

Would personal budgets make a difference? They are not a good economic driver, because they are about minimalist provision. The aim of introducing personal budgets is to provide the basic; you add to it, if you want a reasonable standard. You cannot use a personal budget to get improvements from an unsatisfactory care home unless you can assess quality of life, negotiate for improvements, and have the self-confidence and choices to move your budget elsewhere. There is just not that much choice in care homes at the lower end of the market, so unless you are rich enough and middle-class enough to add to the basic amount and get extras or you have good negotiating skills, you cannot get improvement or change.

We need to change the culture of our care systems. The only thing that provides good quality care is good quality people trying to achieve the best possible professional standard, well-regulated and, yes, encouraged to be as economical as possible by the economic drivers, because in the end that means more service for more people. And with social workers advocating on behalf of the people who cannot get what they need. Getting the balance between all these factors right is complex, but it’s twisted by an emphasis on economic drivers, because that encourages people to focus on loving money rather than quality. And that’s why cuts rhetoric is also wrong. It also focuses on financial rewards instead of quality of service.

Love quality not money. That will be the basis for my prescription for good palliative health and social care during this week’s series of posts.

On the web at:

http://www.wandsworthguardian.co.uk/news/8832177.Celebrities_celebrate_charity_s_120th_anniversary/

http://www.communitycare.co.uk/blogs/mental-health/2011/01/the-social-work-civil-war-begi.html