This is the definition of ’social value’:

…social value is about seeking to maximise the additional benefit that can be created by procuring or commissioning goods and services, above and beyond the benefit of merely the goods and services themselves.

Under the page on objectives (actually there’s 100% more on their objectives and 50% more on a smarmy message from the Minister than the actual text of the guidance) it says:

We want to encourage public agencies and civil society to collaborate more, including greater involvement for voluntary and community organisations…

None of which leads me to believe that anyone commissioning anything from government will think of anything other than the financial interests of their own organisation. I wonder what the NHS policy is.

You can see the guidance here: http://www.communities.gov.uk/documents/localgovernment/pdf/1976926.pdf (but just you try quoting it to them as they cut you).

I’ve finally got to an overall view of the Palliative Care Funding Review, but inevitably my view of it is affected by the almost simultaneous publication of the Dilnot report on the funding of adult social care, not to mention the fairly recent Law Commission final report on Adult Social Care Law, which looks set to lead to legislation next year. People with a focus on palliative care alone may wonder why I should think these other reports relevant, but constant readers of this social care/palliative care blog will know of its aim to place palliative care within the context of wider social and health care.

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

The Dilnot report on adult social care funding here: https://www.wp.dh.gov.uk/carecommission/files/2011/07/Fairer-Care-Funding-Report.pdf (there are two other volumes: http://www.dilnotcommission.dh.gov.uk/2011/07/04/commission-report).

The Law Commission report of adult social care law here: http://www.justice.gov.uk/lawcommission/docs/lc326_adult_social_care.pdf

The point is that all older people know they are approaching death, so they will be receiving some degree of end-of-life care, mostly by looking after themselves and their own affairs, but also from their families and friends. Mostly, they will continue with their personal aspirations for their lives, supported by the ordinary social and health care they receive. That will be the major element of the formal help they get; specialist palliative care will be a minor element for the few. So, we should really not start from a funding review of a rather specialised, healthcare-focused provision. Instead, what we should be doing is starting from personal aspiration, informal and general social and health care during the period running up to the end of life, and seeing where palliative care for advanced illness fits. But the Review is here and central to the aims of this blog, so here goes, although to compensate for the conception, which comes from the Review’s focused terms of references, I’m going to include some compare and contrast with how I would look at it from a social care point of view.

Palliative care funding, Dilnot’s funding proposals and the future of end-of-life care

Reading the Palliative Care Funding Review alongside the other reports, Dilnot especially, the surprising thing about it is how old-fashioned it seems. The reason for this is, I think, that it is trying to do what nobody else is thinking about, or has thought about for quite a while: get the government to fund a service more. The reason for trying to do this, and for the government having commissioned the report presumably, is that the Conservatives have been fairly upfront in saying they want to fund hospices, particularly children’s hospices, properly. This is largely founded on the same sentiments that get big charitable donations for hospices and other palliative care services such as Macmillan and Marie Curie nurses; it is recognisably a good thing. So there is a bit of a policy impetus and an opportunity there. It seems a sensible move to grab the opportunity and see if we can get a bit further with palliative care funding.

Moreover, the ConDems know that there is a lot of charitable money coming into hospices and they want to encourage services that achieve this; it’s part of the big society agenda. So you could argue that palliative care is getting the reward for its big society achievements over the decades. However, knowing that the money is there probably means that the government don’t want to spend any more on them; rather they would like to get more out of them; that is also the big society agenda.

I don’t think it is an unmitigated political good that the government has recognised the amount of charitable money coming into palliative care. If I were Andrew Lansley, I’d be looking at how I could get that money transferred into funding my mainstream healthcare services. After all, people are usually happy to donate charitably to a hospital or a local healthcare service that they find useful: I don’t know that they particularly care whether their local hospice or home nursing service is run by an independent organisation so long as it is doing the job. Some years ago I remember giving a donation on the retirement of my GP for a new local hospice that, it turned out, was actually part of the local general hospital. It got its funding with no problem, and I suspect the same would be true if the NHS went all-out to define extra end-of-life care bits in its mainstream services and get charitable donations for them.

So there is a risk that moving along the path of greater involvement in the mainstream NHS will lead to greater incorporation of independent provision into a dominating NHS commissioning process. In the end that might vitiate the independence that has served palliative care so well in maintaining its creativity and lightness of foot. The social work historian in me is reminded of the ‘cause and function’ debate in social work in the 1930s: once you’ve stopped being a movement to achieve something innovative, you shift into becoming part of the functions of the state, and a bit of pizzazz is lost in favour broader security of provision.

But, I hear you say, isn’t Dilnot also trying to get the government to pay more for a service? Hasn’t the main criticism been that it will cost the government billions when austerity is the order of the day? Yes, but Dilnot is addressing an issue that is widely recognised as a major social issue of the day, that the government has to do something about. Although, as I’ve already said in a previous post, the real problems will still not be here for a decade or more, so the government can follow the grand tradition in dealing with difficult issues and frisbee Dilnot into the long grass without difficulty.

Another thing about Dilnot, that’s not true for the palliative care funding review, is that it’s helping the government’s money problems because although Dilnot will cost more, it will tie co-payment into the social care system, so that it will become the publicly-accepted norm that people will make contributions for their care. This would be a great political achievement. They already make contributions of course, but Dilnot’s research shows that it is not widely accepted. The political gain in implementing Dilnot will be that the whole adult social care system would be set up to achieve public recognition that we as individuals have all got to pay for our social care, and, on top of that, we’ve all got to pay more than we have been assuming we are going to pay. And as the years go on, I have no doubt that the system will be tightened so that we will all have to pay even more as individuals; that process has been going on since the mid-1980s, when the care home system was privatised.

The palliative care funding review is not offering that to the government: it wants to incorporate free social care into palliative care, when Dilnot is taking social care the other way into people paying more for what they get. The fear must be that if Dilnot is implemented, tying social care funding into palliative care provision will lead to creeping acceptance of social-care-style co-payment for end-of-life care services, rather than the NHS assumption for free at the point of delivery. So it’s understandable that the palliative care funding review is trying to be very clear that this should all be done on an NHS basis. However, I think there is an opportunity open to the government here of saying: ‘Well, we’re moving into end-of-life care here, not specialist palliative care, so it’s more appropriate for it to be like social care’. My suspicion is that such a view might eventually (after the next election, say) not only be applied to end-of-life care but to all sorts of what is currently community healthcare provision: ‘It’s all a bit like social care, isn’t it? No reason that people couldn’t pay something towards it.’ I hope not, but I suspect so; the more so because I hear from the financial pages of my newspaper about the possibility of an L-shaped recession (austerity is going to go on for ever).

Moreover, the palliative care funding review is saying that there is wide inequity in the provision, so that the whole thing should be more coordinated and coherent. We can all agree with that, but any astute civil servant will know that making everything coordinated and coherent will probably mean that there will have to be more of it. This is because places that have not got much will have to be brought up to the more usual level of provision. The ‘more of it’ will cost money, and so there will be upward quality creep – very desirable from the point of view of patients and palliative care services that want to improve their offering (the ‘Review’s’ perspective), but not so good if you’re George Osborne and trying to save money.

Balanced against this, the ‘Review’ offers some possibilities to meet the government’s present preoccupations. First, by coordinating effectively it has been made clear by some of the Marie Curie projects used here as case studies that you can do a lot to provide a more comprehensive service in an area without too much cost push, by facilitating more efficient delivery of care. However, if I were an NHS commissioning group, I’d be worrying about stimulating too much demand that I couldn’t meet in straitened times. Second, and I think the major advantage that the ‘Review’ can offer the Chancellor as he views the Olympic volleyball finals from his study window in number 11, if you can really get palliative care going well in home care and other community settings, you can take some financial heat off the hospitals because it’s absolutely clear that effective community end-of-life care more or less stops the unnecessary emergency admission of dying people to hospital care.

Which brings us back to social care, because a lot of that community provision is going to be in residential care homes and require integration in community social care provision, and I think the detail of how social care will knit with what the Review proposes is unclear.

One of the important aspects of that is that the Review mixes together palliative care for people with advanced illness (a relatively limited provision) and broader end-of-life care (a universal requirement) with the aim of getting end-of-life care more accepted into the mainstream of community social and health care. The problem is that these are fundamentally different animals: what I think we should be about is knowledge and skill transfer. We need to transfer knowledge and skill from palliative care, so that end-of-life care can build up its knowledge and skill resources to provide what in many areas is a fundamentally new aspect of their generalised services. This is less about service funding and more about development work. Doing this will take away the resource pressure that arises from unnecessary hospital admission, as the Review rightly says.

But it should also reduce the need for palliative care services, because better general end-of-life care provision in social and health care will reduce the need for specialised palliative care except where there are complex advanced illnesses and complex social circumstances to deal with. Putting these two together, as the Review does, makes clear the connections, but I think it does not make the argument that palliative care is the senior service. It is currently the service with the expertise, but as a service once it transfers its expertise, the need for the specialist resource has to be looked at in relation to its more limited specialist role within the wider non-specialist provision.

So to some more detail.

Trying to get more for palliative care

What, then are the detailed arguments in the Review for developing end-of-life and palliative care?

-         Postcode lottery: there is wide variation in the funding, so that the minimum spend in PCTs is about £0.2m, the average spend is £3.1m and the maximum £21m. the cheapo PCT spent about £181 per death in their area, while the Rolls Royce PCT spent £6213. The average spends less that £1000 a death. I’m a bit doubtful about the extreme variation of these figures: while I believe the average, I suspect that there may be variations in what is being counted in different PCTs.

-         Complicated and variable funding mechanisms for hospices mean that there’s a block grant in many areas, spot purchasing sometimes and 97% of independent hospices thought that the NHS did not pay fully for their patients. All too true, but if an NHS commissioning body looked anew at that, they might decide that they would prefer to stop funding beds in hospices and spend more in the community, in care homes and in hospital palliative care, where the major lacunae are. As a result, it might be able to reduce a lot of demand on and criticism of its emergency services by having a more secure universal end-of-life service. More rational funding does not mean more for beds in hospices, although their part in community services might be secured.

-         Funding is further complicated. Palliative care is done in hospitals, hospices, people’s own homes (using GP and community nursing services) and care homes, and they are all funded through different processes. Not to mention the major (and largely unfunded) contribution of self-care and informal caregiving by friends and family. The Law Commission on adult social care law is recommending a reform of the rights of informal carers to assessment and service provision to improve their own well-being. If more government money is going on them, an NHS commissioning body might find it beneficial to focus on supporting informal carers and general community services. Again, simplification does not necessarily mean more beds in specialist palliative care, or a funding priority to palliative care responsibilities.

-         Crucially, there is a chance of saving money – always a good move to say this to governments…

-         …and it is because too many people are being admitted to accident and emergency units inappropriately, when if they were properly cared for in their own homes and in care homes they would not consume expensive NHS resources at the end of life and, even more wonderfully from a politician’s point of view, they would prefer it.

The last two items point to a virtuous circle: we could save money if we did what people like: better than a slap in the face with a wet gurnard (you’re supposed to be enjoying unfamiliar fish dishes so as to preserve endangered fish stocks; get the behind me codfish, and look with favour – but according to BBC Good Food, not with flavour – on scorpaeniform fishes in the family triglidae).

What is not clear is that savings in accident and emergency would pass to fund better end-of-life care: they are more likely to pass into the hands of Mr Osborne. So better end-of-life care might have to be funded from existing resources in palliative care.

Proposed new funding system

The last time work was done on this, we got to a system of paying for each patient for a period (perhaps about 12 days) in a hospice. This Review had research which has come up with a much more sophisticated model. Basically, the idea is that bits of the NHS that are treating people for a medical condition get the money for doing that, and when it is decided that they are also dying, they get another bit for palliative care services. It’s a bit like James Bond and the man from Smersh in a struggle on the clifftop: they sway to and fro between the condition money and the palliative care money, until they fall off the cliff, the man from Smersh dies (and so the money stops) and James meets a nurse and sails off in a rubber dinghy into the sunset. There’s a diagram of this – a wavy line goes up and down with more condition money giving way to more palliative care funding and then back again, as the patient’s needs change.

The amount of money is worked out on patients’ needs. These in turn are calculated by allocating patients to a category. The main thing is the stage of the disease (stable, unstable, deteriorating, dying); but added to this is whether they have a specialist or non-specialist provider, low or severe problems, their functional status (can they walk or sit up?) and age (over or under 60). This produces 13 classifications for adults. The same principles are applied to children, but I won’t go into the detail.

The first stage is that it is decided that the patients require palliative care; this means that they get the money for that added to their disease money. Every time they enter a new stage of the disease (pay attention: from stable to unstable, unstable to deteriorating or deteriorating to dying and so on), their service provider gets another slice of money.

There are two things about this: one is that the healthcare system is much more used to doing this sort of thing than social care. The decision about whether you require palliative care is the ‘surprise’ question (would you be surprised if this patient died within the next – whatever period you decide – perhaps 12 months?). Care homes and adult social care staff tend to ask that sort of question about their clients even less than healthcare staff (because they generally don’t have a focus on people’s overall physical condition) and they tend not to have the kind of good evidence that would mean that you can trust the decision, as you would trust a GP or district nurse thinking about it. In particular, it’s easier to ask if you have a clear medical condition and even more so if, as in palliative care, you have an advanced illness, where the stages of progression are well mapped out. I wonder if this will mean that people who are getting frailer in the community and mainly being looked after in social care will not get the palliative care money because nobody will be thinking clearly about their end of life. There is evidence that many people in care homes who pay for themselves do not get a lot of attention from professionals; for example social workers do not review them regularly because the local authority is not paying. So they might not get assessed. Alternatively, what may happen is that there will be a demand from adult social care departments for GPs to make this assessment, or ticklists will be set up for social care staff to go through to do the assessment. This could mean that the decision-making for people outside healthcare will be more rocky and inconsistent than the Review assumes. This feeds into my next point.

This system is a big incentive to put people on the palliative care money as soon as possible in their illness career. I reckon there will be phasing drift. Social workers, care home managers, and other commissioners will put people on this extra money as soon as they can. Who will the commissioners be? GPs and their friendly local hospital doctors and other healthcare professionals will be running the commissioning show, so there will be a financial incentive to get their hands on the palliative care money, and speed up the shifts to the later and more lucrative stages of the palliative care money. This means that people might be progressed up the levels of care quicker than necessary; not a good outcome for the psychology of patients in my view. Care home proprietors and social care staff will realise that if they can get someone on the palliative care money they will get enhanced funding and, if the Review’s recommendations are accepted, anyone they get onto palliative care funding will get free social care for which they would otherwise have to pay.

The report specifies various scales that will have to be completed for assessing the funding group, but as I frequently point out, scales are just forms filled in by human beings; they are not evidence. The people filling in these forms, and the people they are filling them in about, will have a strong financial incentive to look for reasons for extra funding for this patient.

Social care in the new system

Following on from the previous points, how social care is funded and organised is clearly going to be a big issue for many people moving into this end-of-life care system. The proposal is that social care will be a ‘clip-on’ to the palliative care money. Once someone is defined as ‘end-of-life’, all their social care would be paid for by the NHS.

The effect of this is that people defined as at the end of life would be accepted as being eligible for what is currently NHS continuing care funding. It’s a nice idea that people should get social care within their NHS services and indeed my experience of dealing with continuing care applications is that most people feel this is fair. Although the system distinguishes between healthcare needs and social care needs, most social care needs are off-shoots of health problems, and people find the distinction drawn by the present system non-intuitive. It is also true, as the Review rightly argues, that most people are beyond social care once they are receiving palliative care, so there should not be a massively increased cost to the NHS.  However, while I think this argument is right, I don’t think it is how continuing care is played by most commissioners at the moment. I know civil servants are rather gung-ho about their wonderful rational national assessment system for continuing care, but many people who are applying for it find that commissioners tend to resist very strongly too much drift onto full funding. Therefore, although if you look at the criteria, most palliative care patients should get it, and so the extra cost of this proposal is not great, the reality of how it is allocated means that actually many people are not treated as eligible and phasing drift and the increased comprehensiveness of a universal end-of-life care service may mean much greater demand to deal with. Moreover – back to the point that most people pay for their social care, and particularly for their care homes – this proposal will be very much at odds with the way in which the government wants to take the social care funding system, which is to get people to pay more, not less. I would be very surprised if the government will go along with allowing people to opt out of their own contributions and shift the burden onto the NHS; that’s not the signal that they want to give the public about being responsible for your own care.

Reading the document, I do not get a clear sense of what ‘clip-on’ means; the implication is that an extra sum to fund social care will be added to the palliative care money. But where is this money going to come from? NHS continuing care budgets? Or will it simply be a call on the palliative care money that you get at the different stages of your progression towards the dying phase. If so, money could actually be taken away from palliative care funding for, say, hospices, to fund social care costs. More likely, the whole thing will be lost in a translucent general budget allocation, which over time will be increasingly squeezed, so we will not be quite clear how much money is being allocated for each patient at all; it will all become very discretionary. Which goes against what the Review is trying to achieve.

Finally, the main focus of the Review is on funding the end-of-life care system, but just a question about social work (which,m as opposed to social care, is little mentioned in the Review), because it is not clear to me how psychosocial and social work needs will be met within a system like this. I think the intention is that formally assessed needs will be met in a coordinated system commissioned by an end-of-life coordinator from adult social care departments. When someone is defined as ‘end-of-life care’, the palliative care money will snap in, paid presumably to an end-of-life care coordination body in the area, commissioned through the healthcare system because that’s the focus of the report. So where a frail older person is receiving a continuing adult social care service, for example regular reassessment in their care home or community setting, will this be pulled out in favour of a new palliative care service? I suspect an adult social care department will ask for money and if they don’t get it, they’ll be over the hills and far away, because, the report says that social care is being paid for by a clip-on to the palliative care money, although not (in alignment with Dilnot) accommodation costs. The Review reports that stakeholder views saw social care, along with other non-healthcare elements of multiprofessional palliative care as it is currently conceived as something that should be ‘supported by a combination of the state and society’ (p 17). It’s not quite clear what that society might be or how much might not be funded by the state: presumably social care and related things would not be an NHS-funded provision, but resources would be recruited from elsewhere and coordinated by the NHS service, including the voluntary sector and adult social care departments. But if this is not funded, it may well be hard to integrate comprehensively. I don’t say this can’t be organised, but I don’t think the working together can be left to organise itself and I suspect it will mean money from the extra palliative element of the payment.

Well-being in end-of-life care

Which brings me finally to my concern about the way in which the Review rather elides major differences between the direction of the adult social care system as a part of a universal end-of-life care system and palliative care as a specialised service for people with clearly identifiable advanced illness.

As I look at the Law Commission on adult social care law, I see the proposal that there should be a legal focus on wellbeing in social care provision. It is also proposed that provision should come from a legal duty on local authorities to provide both a service user and carer assessment. It is not clear how this would interact with the single assessment for palliative care. The outcomes proposed for the legislation that an adult social care department will have to achieve are:

(1)   health and emotional well-being

(2)   protection from harm and neglect

(3)   education, training and recreation

(4)   the contribution made by them to society

(5)   social and economic well-being; and

(6)   securing their rights.

These are very broadly phrased and include some aspects which would be unexpected in health care or palliative care. Many of the broader outcomes would also tend towards the things that the palliative care funding review would see as provided by ‘society’ rather than the state (although this distinction is reported from stakeholders rather than pursued by the Review). However, note the inclusion of rights. The Law Commission points out that under the Human Rights legislation, people receiving care services under a well-being principle are entitled to demand their rights as follows:

Among other matters, it emphasises that the Article 8 rights of disabled people to participate in the life of the community and to have “access to essential economic and social activities and to an appropriate range of recreational and cultural activities”.

This is a quotation from a legal judgement. If we are to include social care into a palliative care service that respects patients’ human rights as defined in the proposed social care legislation, it will need to respond to needs very much broader than a healthcare definition of what should be provided in end-of-life care, while the Review, presumably because of its terms of reference, rather focuses on such a healthcare definition. The Law Commission assumes that a necessary outcome of a social care service is the provision of ‘social, leisure, communication, education and training activities’ for patients. While some palliative care services, St Christopher’s pre-eminent among them, have made great strides in including arts and personal development into what they provide in hospices, care homes and in the community, this is not generally what the NHS sees itself as there to provide, and what Mr Osborne will see himself paying for.

The end-of-life care provision proposed in the Review is firmly focused on financing healthcare objectives in alliance with broader NHS provision and commissioning. It is not clear that this is going to allow for the broad understanding of social care that human rights legislation and the proposed social care legislation requires, not to mention fulfilment of the aspirations of many in social care, and I believe also many in palliative care.

And here, quoted on page 51, is a hospice chief executive still living in the dark ages:

‘While actual care components may be delivered in a variety of settings, provided by a range of organisations and funded from multiple sources, the assessment of needs and coordination of the care plan must sit within statutory funded services and be the responsibility of an NHS key worker’ Hospice Chief Executive

You have to ask: why? Two whys – why statutory and why NHS?

There is considerable research evidence worldwide that you can commission and provide assessment and coordination outside the state. In fact, it has advantages, because you then have an independent view of needs, and can develop advocacy on behalf of the service user and carer for their needs, as I was arguing with carers’  services last week: July 8th or search for ‘carers’.

Then in many areas the person with the skills and access to a coordinated view of palliative care services is sitting in a voluntary sector hospice. It’s perfectly possible for that planning and coordination to be commissioned in a voluntary sector organisation, no need for it to be an NHS person. And actually the people with experience and trained in skill in coordination are social workers, so you could think about the local authority as well, since the NHS is supposed to be working with them.

Wake up at the back there: the government is trying to make the NHS more flexible.

You can just imagine Clare in the Community, Harry Venning’s comic strip social worker setting up a social enterprise to run her local child protection or learning disability social work service can’t you? However, the government is keen on this, and Le Grand has had some experience with pilot projects helping social work teams to do it. You can see why they might want to do this; a group that wants to provide a quality social work service can get out from under the more stupid excrescences of local government management. As he says: ‘We developed five pilot projects with the Labour government, which involved social workers spinning out into independent practices, and we discovered that they had more flexibility and were able to make better decisions. It has worked well so far.’

However, they foundsome problems.

Social workers don’t like getting into business planning, he says; that is, working out their decisions according to what people will pay for rather than what they think as professionals should be done, and selling what they think social services agencies should pay for, like quality and well-trained staff. I think this is not where social workers are now, but as soon as you start up the greasy pole in local government or voluntary organisations nowadays, you soon get into business planning anyway. And when as professionals they can see greater influence on the quality of what they do coming through independence, many more imaginative social workers will leap at the chance. You can business plan for quality . GPs have never had trouble persuading the public to pay for a good quality service, and people will value social work more as they see practitioners getting a grasp on a flexible response, instead of a local authority ‘no’.

I recently edited a very interesting article by a private care home operator who was reviewing her experience over 20 years or so. She was very clearly focused on financial and business planning, but had the same sort of professional aims as most social workers would have and had achieved them, even though her approach to what she was doing was very much: what makes business sense. We can all learn from this kind of experience. One of the benefits of this sort of business approach is when a ’small is beautiful’ philosophy is possible, because this leads to good influence for service users and flexibility for staff. To her, and to me, a strong focus on training and staff development is crucial to good quality, and you can provide for this is you plan a business effectively. Thinking about it as a business quality issue is just as valuable as thinking about it as a local authority policy issue and small business operatos are closer to people’s real care needs that a lot of policy-makers, who are only intereeested in political ideas.

The article: Patricia Prior (2011) developing srervices, knowledge and skillls; the 21st century challenge. in Brągiel, J., Dąbrowska-Jabłońska, I. and Payne, M. (eds) Social work in adult services in the European Union. London: College publications: 21-8. http://www.collegepublications.co.uk/other/?00018 or from Amazon.

However, we will lose this benefit if we go into giant businesses like the troubled Southern Cross care home group, where the motivation is financial manipulation rather than concern for the people who need care. So I’m up for the mutual social enterprise model if it stays small-scale.

Another of Le Grand’s problems is that unions and management oppose it. Le Grand says this is because of self-interest (on the part of unions, they lose membership and can’t use collective power so easily) and management (they are into telling people what to do, not commissioning them for flexibility). I think this is wrong. I’m sure some people in trade unions are concerned about maintaining their influence, but the main reason most people are opposed to this move is that they are opposed in principle to the break-down of state responsibility for the people most in need in our societies. A crucial requirement of developing mutual social enterprises as providers of social care is to set up the system so that it is absolutely clear that this is a way of providing a comprehensive public service, responding to democratic decision-making.

As for management, my thirty years or so experience of management is that a lot of it is about being relaxed when people do things in ways different from the way in which you would do it. while trying to help them. Only sometimes do you need to say, that won’t do, and that’s ususally about quality of response most social workers don;t start out from a ‘can’t be bothered’ attitude that you get from servers in low-budget cafes. Social work is a personal thing and needs to respond to the personalities, practitioners and clients, involved in it, otherwise it won’t work.

He also comments on pensions: staff won’t be able to pay for expensive, defined benefit local authority pensions with them. I think you have to accept that a lot of people come into social work because it provides a secure local authority job – society is always going to want social workers and we’ve never produced enough of them, it’s an interesting, stimulating job and it’s reasonably flexible when you have child care responsibilities. As an academic, I’ve seen a lot of people going through social work courses for these reasons, not for reasons of dedication to the public sector or social concern; nothing wrong with that. So you do have to respect people who want to make sure they and their families are properly looked after. But most people in the voluntary sector have not had a defined benefit pension scheme for years. And most people have a collection of pensions from a variety of places. If you have a reasonable start in a defined benefit scheme from your period of local authority work and you pay a sensible sum into a money-payment pension scheme, you’ll still get a reasonable outcome. The crucial thing is paying in a reasonable sum. Le Grand should be making a start on his task force that by ensuring that it is accepted that a good employer contribution is paid into staff pension schemes by mutual social enterprises. Because if not, he’s not going to get very far. And quite right too.

The interview here: http://www.thirdsector.co.uk/news/Article/1075751/Interview-Julian-Le-Grand/

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?

Like most people, I’ve spent a bit of time struggling with BigSoc (this is what I call it), and you can see my struggle represented in my BigSoc blog (http://bigsoccommsw.blogspot.com/). I keep this separate from my St Christopher’s blog, partly because it deals more directly with party political issues (which is a no-no for St C’s). Also, it includes a lot of detail unrelated to end-of-life care and blogs need to stay with one main subject, so that people know what they’re getting. Hence the separation. However, struggling with BigSoc elsewhere does mean that I have a stash of material to ground my thinking in relation to palliative care. That’s what I’m doing in this post.

The contradictions in BigSoc policy

Why is BigSoc a struggle? For two main reasons. One is because its political focus and objectives are claimed to be unclear, by political commentators in the press. My stance in my BigSoc blog is ‘details tell all’: that is, if you dig around in what people actually say and do in some detail, you can get a picture of the whole, because what they are doing in practice informs you about the big ideas behind it. The picture reflects Conservative ways of thinking: they want a more private sector ethos in public services.

The other reason is that the BigSoc idea seems attractive to those of us who have always been committed to community work. Community work is the practice (sometimes it’s  an element of social work and sometimes broader) which seeks to facilitate people from communities, both local communities and communities of people who share interests, to come together, work collectively on issues that they share and create solutions that they put into action themselves. BigSoc seems to want to encourage this; groups of local people are encouraged to find their own solutions.However, the engagement with people at the grass-roots that is typical of community workdoes not usually produce the kinds of initiatives and engagements that can be presented as colourful, imaginative developments demonstrating an important political idea likfe BigSoc. Consequently, activities selected to represent BigSoc, in order to promote the policy, are often quite untypical of what is actually done in community work and of what local government will achieve by decentralising and localising decision-making.

Therefore, contradictions seem to grow out of how the ConDem coalition has tried to implement BigSoc. I have pointed out before in this blog and elsewhere that the history of attempts to encourage community endeavour through government action is littered with government finding out that community action often leads very rapidly to protest about what government is doing, and rapid squashing of what communities want. It often also leads to communities creating responses that government does not expect. Governments (or the politicians in them) tend to think that their political views are widely shared, whereas they are often only shared by the people those politicians meet. The people who come together to share views and work on things together often find that their views and what they want to do about them differ from the political assumptions. Their public response is often protest or resistance, rather than imaginative development, or development of local services which do not offer a lot of zip-zap for someone who wants to promote a new BigSoc policy.

The main aims of BigSoc policy

BigSoc seems to have two main drivers. One is a conception that government is too big. There are at least two elements to this: one is that it is too large as part of the UK economic system, and that if you reduced its economic role, it would leave space for non-government sectors of the economy to be creative, expand and get us out of economic problems. The second element is that government looms too large in people’s minds as the solution to social problems and that if you reduced its role in providing services and responding to social issues, people would sort out answers on their own. These are broad objectives for cultural change, based in broad political philosophies. Can encouraging local engagement in quite prosaic local government decisions or developing responses to small-scale local issues achieve such change?

The first concern driving the policy is that government is too big in the economy, leads to an economic policy which reduces government expenditure and tax, and associated political policies such as the ‘bonfire of the quangos’ and the ‘bonfire of red tape’, with the aim of reducing the burden that government places on the economic capacity of other sectors of the economy to innovate and expand.

The second driver, people should be enabled to become more active in resolving social issues, rather than relying on government, leads to attempts to reduce the role that government takes in providing many services and encouraging citizen activism.

Both these diagnoses and prescriptions might be questioned in serious economics and sociology, but I leave that aside. Also, critics from the left would say that these are just new formulations of a conventional liberal position, which argues on economic grounds for a small state. I’m leaving that on one side, too. The ConDem government has given these ideas importance in BigSoc, and so that is what we are playing with. In ConDem policy they are connected because reducing government expenditure and activity inevitably means present services or activities disappearing altogether, or being replaced by something less extensive. Making space for non-government enterprise at the level of the whole economy can also mean making space for individual activism in responding to social issues.

In a speech reported by the BBC, David Cameron, the UK Prime Minister, connects these two things: ‘My mission is social recovery as well as economic recovery’.

The BBC report, including a clip of Cameron speaking: http://www.bbc.co.uk/news/uk-politics-12443396

Another good political report from the BBC looks more comprehensively at the concept: http://www.bbc.co.uk/news/uk-politics-12163624 , and includes a lot of comments from viewers and listeners.

Existing activism and BigSoc?

As this report makes clear, virtually anything that has to do with activism, such as volunteering or people demonstrating commitment to and involvement in their locality or some other social interest, may be seen as BigSoc. Since in the UK a lot of such activism goes on, the government might be able to claim wide support for its concept and the press might be able to identify lots of BigSoc activity. In one of my BigSoc blog posts, I looked at the claimed evidence for ‘broken Britain’ and the need for greater volunteering, and came to the conclusion that the government was overstating its case: a lot of community involvement and volunteering goes on, more than the government claims. This post is at: http://bigsoccommsw.blogspot.com/2011/03/good-evidence-exists-for-strong.html

Similarly, an earlier post looking at stated Conservative Party policy on BigSoc found that this rather naively seemed to be unaware of a lot that goes on in local community activity:

http://bigsoccommsw.blogspot.com/2011/03/bigsoc-minnie-mouse-policy-minimal-and.html.

The problem with this approach to BigSoc is twofold. First, it demonstrates a general ignorance and naivety or, alternatively, complete denial about what valuable things are going on in local communities and suggests that the policy is based on ignorance and denial. Second, it will allow Conservatives to claim all sorts of activities as the product of its policy initiative, when they were there anyway.

Palliative care organisations such as hospices fall into this category: they are there, they are successful, they substantially fund themselves. They are therefore a good example of what BigSoc policy might achieve. However, as I argue below, hospices are rather unusual voluntary organisations, and their size and funding cannot transfer all that easily to other comunity activties. So people in hospices should not be too forward in claiming either that what they do can be replicated elsewhere, or that they are some wonderful example to others: that is calculated to irritate lots of local government and the voluntary sector, who do not have the same advantages.

Claims that BigSoc is everywhere are already happening. In another BigSoc blog post, I examined all the projects that had received a BigSoc award from the Cabinet Office, at the time twelve, although the details of one of these was missing from the Cabinet Office website http://bigsoccommsw.blogspot.com/2011/03/details-tell-all-analysis-of-number-10.html. There were, of course, a variety. But an interesting feature was that many of them were for really rather ordinary community activities, carried out with pizzazz. In my later post, I listed the top ten words for putting into your applications for a BigSoc award, things like inspiration, passion, life-changing: the whole list here: http://bigsoccommsw.blogspot.com/2011/03/top-10-words-for-getting-number-10.html.

BigSoc as chutzpah

In many respects then, the government is treating BigSoc as a marketing tool for things that it wants to encourage. You’ll have gathered from many comments in this blog that I’m unhappy about marketing as an approach to health and social care. In another BigSoc blog post (http://bigsoccommsw.blogspot.com/2011/02/bigsoc-is-not-pr-message-it-demands.html), I pointed to a PR wonk’s take on BigSoc; she was saying that people in government were treating it as a way of conveying a warm friendly image, in the face of criticism about cuts.

I connect this with Steve Burghardt’s recently published book on macro social work (Macro Practice in Social Wokr for the 21st Century Los Angeles, Sage, 2011), in which he describes community work as being ‘chutzpah meets humility’. The point is: if you are going to facilitate people to come together and make their own decisions, you have to take a step back out of the limelight and help them to work things through in their own way. One the other hand, you also have to have a certain amount of zip-a-dee-doo-dah to promote new ideas, get people engaged and push things along. It’s a difficult balance to achieve, and one of the skills of community work is achieving this.

I think the Conservatives understand the chutzpah bit, but not the humility. You can see this in the kinds of things that they support as BigSoc.

BigSoc is (in the Conservative mind)…

So what is BigSoc as the government sees it? Cameron has made a number of attempts to describe this.

The first general presentation of the ideas is the Hugo Young lecture in 2009: http://www.conservatives.com/News/Speeches/2009/11/David_Cameron_The_Big_Society.aspx

The conclusion of my analysis on this in the BigSoc blog (http://bit.ly/i3pD3L) is as follows.

To sum up the argument, Cameron is arguing that the size of the state leeches away personal and shared social responsibility. BigSoc policy aims to provide government to action to reverse that. Subsidiarity is the thing, giving responsibility to the lowest possible level in society. They will try to give individuals the responsibility and capacity for helping themselves, through family, education and welfare reforms. Where that is inappropriate, they will encourage shared action in neighbourhoods, and when that is not possible they will make the lowest level of government, local government responsible, and make it more transparent, accessible and responsive to active citizens.

In an article in the Observer, after some criticism of BigSoc, he says:

The big society is about changing the way our country is run. No more of a government treating everyone like children who are incapable of taking their own decisions. Instead, let’s treat adults like adults and give them more responsibility over their lives. That’s why, in reality, this is quite different from what politicians have offered in the past.

This is not another government initiative – it’s about giving you the initiative to take control of your life and work with those around you to improve things. It has the power to transform our country. That’s why the big society is here to stay.

The article here: http://www.guardian.co.uk/commentisfree/2011/feb/12/david-cameron-big-society-good

An article in the Observer recently claimed that some of Cameron’s ideas are from Schumacher’s famous book of the 1970s, ‘Small is Beautiful’. Quoting extensively from the book, I argued in the BigSoc blog http://bit.ly/dN1rvU , that, if so, it is a complete misunderstanding of Schumacher’s point. He is arguing that a policy of pursuing economic growth to achieve larger economies, with larger economic units consuming larger finite natural resources, is unsustainable. The outcomes of this growth model are the increasing use of finite natural resources to achieve merely transitory consumption. Present Conservative policies clearly aim at this kind of economic growth, which Schumacher criticises. Conservative BigSoc policy is completely antithetical to Schumacher’s position. It seeks to reduce constraints on big business in order to achieve higher economic growth. It sees the main constraint as big government, and so it wants to remove big government in favour of localism, because it thinks this will release economic growth. Schumacher does not talk about localism so much as the small and the human.

The BigSoc critics

In his Observer article, Cameron notes, fairly accurately, the criticism of the concept, and these are his answers:

It’s too vague: he rejects this because he is against creating one central design

It’s a cover for cuts: he says supporting social responsibility is a different matter and he has supported that for a long time; anyway, greater social responsibility will benefit society.

It will work in rich areas, but not where there are no resources: he rejects this because there is evidence of activism in poor communities.

It’s not new: yes, but he wants to encourage more of it.

Voluntary bodies are being squeezed: no, they will be restructured because the Conservatives will open up opportunities for voluntary bodies to bid for contracts for public sector activities. (To the extent, I would say, that they demonstrate emterprise thinking and chutzpah.)

Polly Toynbee and a range of commentators on her article cover most of the issues about cuts to voluntary groups. She distinguishes between small very local social groups and the organisations providing services, often under contract from the government already, although it may limit their preparedness to criticise government.  The fact that small groups fund themselves is irrelevant to support for that part of the voluntary sector that provide useful serviecs. She also criticises the concept of the BigSoc bank, providing development loans at commercial rates to help voluntary organisations compete for government contracts as part of her argument that government support is central to succesfsul voluntary endeavour.

http://www.guardian.co.uk/commentisfree/2011/feb/14/david-cameron-big-society-charities?intcmp=239

Similarly, a Jackie Ashley article sums up well the critics who say you cannot achieve BigSoc if you simultaneously cut funding to charities and voluntary organisations, because they are the major existing aspect of BigSoc. If you cut local government, those cuts will have a disproportionate effect on voluntary organisations, since local government will priorities its own staff and services.

http://www.guardian.co.uk/commentisfree/2011/feb/13/big-society-destruction-david-cameron?intcmp=239

BigSoc in practice

So what does BigSoc seem to involve in practice? To work that out I looked at a number of policies and practices, and you can follow the detail in the following  BigSoc blog posts.

What’s happening in the three continuing BigSoc ‘vanguard’ local authorities (one, Liverpool, gave up in a shower of sparks because local government cuts was preventing it from developing BigSoc policies and had reducing funding for voluntary sector BigSoc activities):

Sutton, in south London: http://bigsoccommsw.blogspot.com/2011/02/suttons-bigsoc-vanguard-tells-us-what.html

Windsor and Maidenhead, to the west of London: http://bigsoccommsw.blogspot.com/2011/02/details-tell-all-windsor-maidenhead.html

Eden, in the Lake District: http://bigsoccommsw.blogspot.com/2011/02/details-tell-all-windsor-maidenhead.html

Overall, what is going on in local government is not very impressive and not very imaginative – no chutzpah there. First, most of what they were doing they were doing anyway, they were just relabelling it BigSoc. sometimes openly. Second, many of the initiatives were about local involvement in planning; nice, but probably they should have been doing that anyway. The problem with participation in decision-making is that it is not very attractive to local politicians, because they feel they have been elected to make decisions and achieve their political objectives, not have them questioned by every Tom, Dick and Harry that turns up to public meetings.  Third, there were meetings with local citizens or with voluntary organisations to discuss what BigSoc might mean. These seemed to be part of getting more volunteers for things, especially if it meant reduced local council costs.

Another important aspect of BigSoc policy is what I call ‘enterprise’ thinking, and I have sometimes called it ‘businessification’, following John Harris’s critique of treating social work as though it was a business activity.  In many Conservative eyes, an important objective of BigSoc is that it is a local arm of the government’s aim to encourage the private sector to be engaged in what is now public sector activity; this is inherent in many of the government’s policies. Part of the reasoning for this is an opposition to bureaucratisation, by which Conservatives often mean unimaginative thinking which opposes change of the kind that Conservative politians would like to achieve. The answer to this is being enterprising, imaginative, creative and all these traits are assumed to be associated with the private sector, rather than the public sector. To the extent that voluntary organisations emulate that, they are good and not part of the public sector. To the extent that they just take government money for providing government services, they are bad, and just another aspect of the public sector.

It’s back to chutzpah again.  Conservatives like to see community activity that demonstrates chutzpah; humility and participation are not enterprising; they do not understand why you would need it. So only particular kinds of community activity are required, therefore, and activities such as continuing to build and provide end-of-life care through professional integrated community services (to give one example) do not have it.

Much of the rest of my blog has been about the debate on voluntary organisations. Here, the pattern is quite clear. Conservative commentary is anti the ‘establishment’ of the voluntary sector, which receives government money for providing services (http://bigsoccommsw.blogspot.com/2011/03/tories-reject-establishment-charities.html) they are really hoping for radical, enterprise oriented voluntary organisations with right-leaning policies enabling disabled people and single mothers into employment, for example. And chutzpah. A ‘society of the second chance’ is an Iain Duncan Smith phrase which seems to mean forcing people to take whatever second chances they can get, instead of staying comfortably on social security benefits.

BigSoc and palliative care

What does all this mean for palliative care? It’s a complicated picture. Most palliative care is in hospices in the UK, whereas a lot of non-specialist end-of-life care is with GPs and general health and social care services and BigSoc policy is different in these two areas.

Hospices are talked up by the Conservatives, including Cameron. I have commented before in this blog that this seems to be for two reasons. First, hospices raise a high proportion of their own funding, so they are not ‘establishment’ charities, in the sense that the government supports all their activities. However, they are not enterprising; they do not have chutzpah. The need for chutzpah if you want to appeal to the government is the reason for the success of organisations such as Marie Curie and Macmillan: they employ high-profile senior staff who trumpet successes in a glossy, businesslike way with lots of advertising and image. Solid service provision from your local hospice is a lesser priority.

Second, there is a sentimentality about end-of-life care, which politicians pick up from general public attitudes. Most people have little to do with the end of life, don’t like to think about it and support organisations that make them feel that it’s all going to be handled very nicely and kept out of their way.

On these two counts, BigSoc will have little impact on hospices, for so long as they are able to continue raising their own funding and put up some people with chutzpah. This means that the government does not actually have to make clear decisions about the extent to which they support end-of-life care as against other priorities, and it all sounds jolly good. I suspect that if they did have to think about it, they might not be so supportive, and might in particular want to see a reduction in the high costs of quality palliative care. The distance means that everyone can feel a warm glow of doing something nice with a little bit of funding and expressing support.

End-of-life care is not much involved in local authority and voluntary sector funding cuts, so it neither irritates government supporters by whingeing about cuts nor engages with the problems of local health and social care organisations. That will last until local service changes begin to affect hospices’ capacity to achieve home care.

Another factor is that most hospices, although theoretically voluntary organisations, and locally committed, are really part of the health service, and BigSoc does not talk a lot about the NHS. Health promotion and well-being are good things, but actual services are part of the public sector bureaucracy. Hospices do not generally have a lot to do with the local voluntary sector establishment, or with local government, and are much more affected by NHS policy. The more generous funding of the health sector tends to insulate them from the debates about BigSoc, at the same time as being a potentially desirable element of BigSoc.

So BigSoc is not a big deal for palliative care yet, but BigSoc policy is going to permeate lots of thinking about public services. This will have a particular impact on palliative care as the health and social care reforms that I discussed on Tuesday begin to affect palliative care. My next post will try to bring together health and social care reform, BigSoc thinking and end-of-life care.

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.

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.

Writing this post from my ‘Social work around the world’ blog: http://intsw.blogspot.com/ about my adventures on the less touristy streets of this lovely central European city caused me to wonder how much attention we are paying to homeless people in palliative care everywhere. People die on the streets and their dying weeks, days and hours must be miserable. The young men who took me out, as social work students of Comenius University who therefore have to put up with my lectures, were well aware of palliative care; I wonder how many of the volunteers of our homelessness charities are. I’ve no doubt that in Britain the Commander would get sensitive attentions from young people running similar organisations to Nota Bene (the streetwork arm of the local ‘Big Issue’) and some healthcare. But a good death?

Two former students working for Nota Bene, the Slovakian equivalent of St Mungo’s, take me out on a ‘finding’ evening (as opposed to a static evening, where they serve soup at a known location and people come to them). they translated this as street-walking – I said that had other impolications. Nota Bene was founded some years ago from the Comenius University school of social work (which I am visiting) as a practical project, operating alongside their project for drug users.
Link to the Nota Bene streetwork site: http://www.notabene.sk/?streetwork

Hefting a giant medical kit, and rucksacks with flasks of hot soup and other possible needs, we find the Commander and his female friend nesting behind a barrage of large dustbins in a covered area surrounded by flats. A radio is quietly playing. Shouting ‘Good evening, Nota Bene’, as a warning several times, Pauli wheels a dustbin away to reveal them camped on the ground under a hot air vent from a restaurant.
I am introduced. ‘Ah, English’, says the Commander, remembering his smattering of many languages from a long gone sea-going career. He announces he will play a serenade for me, and a passable harmonica rendition of ‘She’ll be coming round the mountain’ assails the night air. Various local residents come by to drop in their rubbish, or walk their dogs, while Sergio unpacks the medical kit. A lady in a blue coat hovers.
Helping the Commander to pull off his boots, Sergio unpicks soiled bandaging, and re-dresses the Commander’s ulcerated legs, spraying with antiseptic and smoothing in paraffin cream, while Pauli hands a mug of soup to the lady. A cheerful conversation ensues throughout the long period of dressing. Trainers are produced from a rucksack, softer than the sodden boots, which are left to dry by the air vent. They ask for a new coat, but only a sweater is offered. Nota Bene does not get enough clothes donated: the Commander already has a coat, so a new one is not a priority.
We wheel the dustbin barrage back, and the blue-coated lady engages us in conversation. She is a local resident who sometimes helps the two rough-sleepers, wanted to know what we were doing. It’s good she is positive, not everyone agrees with helping homeless people.
The Commander apparently, is a fixture with his harmonica in a local food market, making enough money to get by. They will be back in a few days to check on his legs again.
A drive through the outskirts of the capital brings us to an area of semi-derelict garages by a railway line. The laptop is extracted from its concealment, and checked: every known living site in the City for homeless people is noted with multicoloured flags in Google Earth, which gives an overhead photography view guiding them to the exact garage. the new social worker uses technology. The garage is occupied by a family who own this property, but no house or flat. A number of possibly aggressive dogs wander around, Sergio emerges from the van cautiously, morsel in hand to tempt a canine appetite.
But no, the dogs are in the control of various members of the family. A visitor from another town tries to extract a donation, but they are all drinking and invading their territory seems unwise.
Another drive, and we park nose forward for a quick getaway about 50 metres from a thriving main road, in some fields by a derelict house. Conversation is audible from an upstairs room, but the people living here do not respond to cheerful calls of ‘Nota Bene’. They are perhaps in the midst of drug-taking or glue-sniffing.
A passer-by has alerted their control centre to possible incursions in a redundant school in a nice area of town. It is in darkness when we get there, and local residents do not answer their doorbells. Eventually, Sergio and Pauli clamber over a fence, more calls of ‘Good evening, Nota Bene’, and, powerful torches in hand, search around the building, then go in. Nothing; perhaps a homeless occupant has moved on, or lies doggo or drunk.
Driving back to the main road, we see some more garage blocks, backing on to some derelict land by another railway. These are unknown to them: ‘Just the sort of place for us’. So we get out and wander round. But these garages are well-kept and locked, we progress on to some abandoned gardens, but there are no signs of nest-making.That’s it for today: no time to visit a pregnant woman, often abused by her partner and living under railway arches some way away. She is slated for a visit tomorrow.
Bratislava has only limited hostel accommodation, prioritised for people who have had medical treatment. There is little opportunity to get people off the streets. Housing is expensive compared with local wages and the hand out of state housing at the end of the communist regime has led to a shortage of public housing.

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?